Diffuse Large B-cell Lymphoma Presenting as Upper Gastrointestinal Bleeding

Abstract

Gastric lymphoma is a rare cause of GI bleeding. We hereby report a case of diffuse large B-cell lymphoma that extensively invaded the stomach, spleen and pancreatic tail and demonstrates the aggressive nature of the disease and our diagnostic and therapeutic approach. A 74-year-old woman with a history of peptic ulcer disease presented with dark output from her nasogastric tube and melena. CT without contrast two months ago showed a large necrotic mass invading the spleen, for which she underwent a non-diagnostic CT-guided para-aortic lymph node biopsy as well as laparoscopic biopsy of greater curvature lymph node and retroperitoneal mass that was suspicious for lymphoma. On presentation, she was febrile, hypotensive and tachycardic. She was intubated and sedated. Labs revealed a Hgb of 7.9 g/dL, WBC 33.8 K/mm, AST 125 IU/L, ALP 186 U/L, alb 1.6 g/dL, T bili 2.4 mg/dL. CT scan on admission showed heterogeneous neoplasm involving the pancreatic tail, gastric body, spleen and metastatic upper abdominal lymphadenopathy (Figure 1). PET demonstrated an intensely FDG-avid confluent mass involving the pancreatic tail, spleen and greater curvature of the stomach with FDG-avid abdominal adenopathy (Figure 2). EGD showed a nonbleeding, large infiltrative non-circumferential mass on the lesser curvature of the stomach (Figure 3). A review of the prior laparoscopic biopsies showed large atypical cells of B-cell origin based on PAX5, CD19 and CD79a expression, diagnosis of a diffuse large B-cell lymphoma was made. Results of EGD with biopsy and laparoscopic biopsy were consistent. Given recurrent active bleeding requiring vasopressors and transfusions, IR was consulted and hemostasis achieved with embolization of left gastric and splenic artery. However, she died soon after discharge due to the diffuse nature of the disease. Diffuse large B-cell lymphoma is the most common type of non-Hodgkin lymphoma. Since DLBCL can advance quickly, it usually requires immediate chemotherapeutic treatment once the diagnosis is established. Surgery is considered as second-line treatment for severe perforation, bleeding, or a need for palliative treatment. An EGD can help confirm the diagnosis and rule out other sources of bleeding. In this setting, EGD biopsy could have obviated the need for a laparoscopic biopsy. Given the extent of tumor involvement in our case, endoscopic hemostasis is rarely successful and IR is necessary for hemostasis.Figure: A large mass inseparable from the pancreatic tail and gastric antrum inferiorly was seen on CT abdomen/pelvis. This appears to invade the spleen at the splenic hilum and the largest component of the mass measures up to 11 x 7.2 x 12 cm.Figure: Intensely FDG-avid confluent mass with central necrosis is noted involving the pancreatic tail, spleen and greater curvature of the stomach, correlating to hypoenhancing mass noted on CT measuring approximately 11.5 x 7.2 cm.Figure: EGD showed a large, infiltrative mass with oozing and stigmata of recent bleed.