P1260 - A Rare Case of Diffuse Large B-cell Lymphoma Presenting as a Malignant Mass in Both Duodenum and Ascending Colon

Hossam Abed, MD, Dema Shamoon, MD, Iyad Farouji, MD, Theodore Dacosta, DO, Siva Prasad Maruboyina, MD, Theodore Dacosta Jr., MD, Andre Fedida, MD
Saint Michael's Medical Center, Newark, NJ

Introduction: We are reporting a very unique case of diffuse large B-cell lymphoma found to affect two different locations in the GI tract; the duodenum and the ascending colon, which unfortunately led to perforation of the bowel and the patient passed away.

Case Description/Methods: A 61-year-old female presented with complaints of nausea, vomiting and diarrhea for 3 days, the physical exam revealed diffuse abdominal tenderness. Labs showed Lactic acid of 2.8 mmol/L, Hemoglobin 11.4 g/dl. Lactate dehydrogenase 260 U/L. White count 2/mm3. ESR 55 mm/hr. Computerized tomography (CT) showed a large heterogeneous necrotic mass in the right small bowel measuring 9.5 x 15 cm. Right colonic wall thickening and suggestion of a small fistula originating from the right ascending colon into the mass. Esophagogastroduodenoscopy showed a large ulcerated necrotic mass in the third portion of the duodenum. Colonoscopy revealed a fungating, ulcerated mass at the hepatic flexure, 10 cm in length. Biopsies were consistent with diffuse large B-cell lymphoma. She was started on CHOP chemotherapy. Afterwards, she started to complain of severe abdominal pain. A repeat CT scan showed malignant perforation of the right upper retroperitoneal mass that is closely associated with the duodenal C loop and the hepatic flexure. She underwent ileostomy with an exploratory laparotomy with right hemicolectomy, enterostomy, and gastrostomy. Post-op CT scan showed extraluminal extravasation of the contrast, possibly from the second and third portion of the duodenal area. Open abdominal wound was debrided. Unfortunately, she had cardiac arrest with pulseless electrical activity and she passed away after unsuccessful resuscitation efforts.

Discussion: Primary colorectal lymphoma is a rare malignancy accounting for 3% of all GI lymphomas and 0.1-0.5% of all colorectal malignancies. In the colon, the lymphatic tissue is more prominent in the cecum, making it the most common site for GI lymphoma. To our knowledge, a patient with GI lymphoma involving two different locations in the GI tract has not been discussed in the literature making this case very rare. Perforation of the GI tract in lymphomas is an important clinical complication. This complication was reported in around 10% of patients who have GI lymphoma and may represent the initial presentation of this tumor. In other patients perforation may occur after starting chemotherapy, especially after the first cycle. Both inflammation and tumor necrosis are blamed to be the cause of perforation.


Figure: Figure 1: Endoscopic picture showing a malignant mass in the third part of duodenum.
Figure 2: Endoscopic picture showing a malignant mass in the colon hepatic flexure.
Figure 3: High power view showing normal colon glands and malignant lymphocytes
Figure 4: CD20+ B-cells
Figure 5: CD79a + B-cells
Figure 6: Ki-67; High Proliferative Index consistent with high grade lymphoma


Disclosures:
Hossam Abed indicated no relevant financial relationships.
Dema Shamoon indicated no relevant financial relationships.
Iyad Farouji indicated no relevant financial relationships.
Theodore Dacosta indicated no relevant financial relationships.
Siva Prasad Maruboyina indicated no relevant financial relationships.
Theodore Dacosta Jr. indicated no relevant financial relationships.
Andre Fedida indicated no relevant financial relationships.


Hossam Abed, MD, Dema Shamoon, MD, Iyad Farouji, MD, Theodore Dacosta, DO, Siva Prasad Maruboyina, MD, Theodore Dacosta Jr., MD, Andre Fedida, MD. P1260 - A Rare Case of Diffuse Large B-cell Lymphoma Presenting as a Malignant Mass in Both Duodenum and Ascending Colon, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.