S3701 Necrotic Ulcer From Diffuse Large B-Cell Lymphoma

Abstract

Introduction: Diffuse B cell lymphoma is a non-Hodgkin’s lymphoma that mainly occurs within the lymph nodes. However, about 40% of the time it occurs in extranodal sites. The most common sites are within the gastrointestinal tract, especially within the stomach and ileocecal regions. We present a case of a patient with diffuse large B Cell lymphoma within the cardia of the stomach. Case Description/Methods: A 69-year-old male with a past medical history of diffuse large B cell lymphoma was admitted for active melena. Further workup revealed a hemoglobin of 5.6 g/dL with a baseline around 10 g/dL, as well as a BUN of 67 mg/dL. Aside from mild tachycardia the patient was otherwise hemodynamically stable. He had received K Centra and one unit of blood in the emergency room. A CT angiogram of the abdomen showed recurrence of diffuse large B cell lymphoma with multiple lymph node stations in the pancreas, left kidney, and associated vasculature. Ultimately, the patient underwent an endoscopy. A necrotic ulcer measuring 5 cm in the cardia of the stomach with pigmented material on the surface indicating recent bleeding. Multiple biopsies were taken of each of these ulcers to rule out underlying malignancy. The pathology report revealed that the chronic ulcer in the cardia of the stomach was diffuse large B cell lymphoma and no evidence of Helicobacter pylori. The patient was treated with pantoprazole and Carafate. Their hemoglobin remained stable after 3 units of packed red blood cells and the patient was discharged. However, it was advised for them to follow up outpatient with hematology and oncology however he has since elected for hospice (Figure 1). Discussion: Diffuse large B cell lymphoma is the most common type of non-Hodgkin's lymphoma. The stomach is the most common extranodal site involved in non-Hodgkin's lymphoma representing up to 65% of all GI lymphomas. In these patients, symptoms may include dyspepsia, nausea, and vomiting. Primary gastric lymphoma is the most common extranodal lymphoma but only accounts for 2-8% of all stomach cancer. Thus, our case of diffuse large B lymphoma in the cardia of the stomach is a rare entity. Most patients are treated with conservative management like chemotherapy or immunotherapy. One retrospective study showed the use of R-CHOP to have a high remission rate. Surgical intervention is usually reserved for lesions that cause perforation, obstruction, or intractable bleeding. Our case would have required surgical intervention had the bleeding continued.Figure 1.: 5 cm necrotic ulcer found on retroflexion in gastric cardia.