Diffuse Large B-cell Lymphoma Presenting as Gastrointestinal Bleeding and Breast Mass

Abstract

Introduction: Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoid neoplasm accounting for approximately 25% of all non-Hodgkin lymphomas (NHLs). The gastrointestinal (GI) tract is the predominant extranodal site involved but the disease can arise in virtually any tissue. Herein, we describe one such case where patient presented with simultaneous involvement of two extranodal sites, namely the upper GI tract and breast. Case Report: A 56-year-old Hispanic female presented with lightheadedness, malaise, dyspnea, palpitations and near syncope. She had night sweats, unquantified weight loss, mild epigastric pain and melena for three weeks prior to admission. In the emergency room, she was afebrile; blood pressure 118/71 and pulse of 108 with orthostatic changes. On examination, there was a left breast mass located in the right upper quadrant (Figure A) and right inguinal lymphadenopathy. Fecal occult blood testing was positive. Hemoglobin was 6.4 with low iron indices. Blood transfusions were given. Upper endoscopy revealed multiple gastric and duodenal ulcers with volcano-like appearance (Figure B). The left breast mass was biopsied. The pathology findings on both the ulcers and breast mass showed DLBCL with high proliferative index. Bone marrow examination was normal. The patient was subsequently started on a chemotherapeutic regimen in view of disseminated DLBCL. Discussion: Patients with DLBCL typically present with a rapidly enlarging symptomatic nodal mass, usually in the neck or abdomen but extranodal extramedullary disease occurs in up to 40% of cases and can be the presenting symptom. In the GI tract, the stomach is most commonly involved (70%) followed by the small bowel, colon, rectum, and esophagus. Our case was unusual in that there were two extranodal sites involved at presentation.Figure: A shows 3.5 cms left breast mass located in the right upper quadrant; Figure B shows gastric ulcers with volcano-like appearance.