Gastric Ulcer Masquerading as Mantle Cell Lymphoma

Abstract

Mantle cell lymphoma (MCL) is a rare and generally aggressive form of B cell non-Hodgkin lymphoma (NHL) comprising 3-10% of all NHL. MCL arises from a pre-germinal center cells in primary follicles or in the mantle region of secondary follicles. WHO criteria for diagnosing MCL comprises morphologic, immunophenotypic, and genetic features including overexpression of Cyclin D1 by immunohistochemistry and / or detection of t(11:14) (q31:q32) by genetic testing. Most patients present with systemic disease including lymphadenopathy and/or involvement of extra-nodal sites. A 77 year old Caucasian male with history of nodal MCL had undergone 4 cycles of treatment with R-CHOP (Rituximab, Cytoxan, Adriamycin, Vincristine and Prednisone) and had no major complaints except feeling weak. A post chemotherapy surveillance CT of abdomen / pelvis, revealed a gastric antrum lesser curvature focal out pouching. On further investigation with esophagogastroduodenoscopy (EGD) a large, clean base gastric ulcer was seen. The biopsy showed H. Pylori chronic active gastritis as well as a B-cell lymphoid infiltrate positive for Cyclin D1. The cyclin D1 expression distinguishes MCL from mucosa-associated lymphoid tissue (MALT) lymphoma. The patient continued with 2 cycles of R-CHOP leading to a partial but good response along with a standard H. Pylori treatment. He was then put on maintenance q3 months Rituximab injections. MCL with gastrointestinal (GI) tract involvement is reported to be at 15-30 %. It can present either as a primary or a secondary systemic spread (more common). MCL can involve any part of the GI tract, but colon is more commonly involved after abdominal lymph nodes. Colonic involvement presents as micropolyps or ‘multiple lymphomatous polyposis', whereas upper GI a manifestation of MCL is usually a non-specific mild gastritis, a large gastric ulcer as seen in our patient is a rare but reported occurrence. Due to a frequently normal appearing gastric mucosa in MCL with standard endoscopy the reported GI tract prevalence may be underestimated. However, this may have very little impact on Ann Arbor staging, treatment and overall outcomes.Figure 1Figure 2