Introduction: A massive upper GI bleed is a life threatening emergency which requires urgent intervention. Some causes of upper GI bleeding include gastric/duodenal ulcers, esophagogastric varices with or without portal hypertension, and Dieulafoy’s lesions. Hematologic malignancies are very rare causes of GI bleeds and most often originate from the duodenum. We present a rare case of acute upper GIB in the setting of metastatic DLBCL leading to a diagnosis of concurrent primary lung adenocarcinoma.
Case Description/Methods: An 84 year old female with medical history of stage II SCC of the anal canal status post chemotherapy and radiation, stage II SCC of the right lower lung status post resection presented to the emergency department with several days of melena and hematochezia. Laboratory studies were significant for worsening anemia with hemoglobin of 7.4 (from 8.4). Patient underwent EGD/colonoscopy with findings of a non-bleeding gastric body ulcer on EGD and diverticulosis without bleeding on colonoscopy. Biopsy of the gastric body ulcer returned with Diffuse Large B-Cell Lymphoma. Patient was discharged home with oncology follow up. Outpatient imaging confirmed Stage IV DLBCL with diffuse lymphadenopathy and evidence of metastatic disease to the spleen and gastric body. The patient was initiated on R-CHOP with prophylactic intrathecal methotrexate. Interval PET Scan showed resolution of hypermetabolic lymph nodes, but with increased uptake of left adrenal nodule. The patient underwent IR guided biopsy of left adrenal mass which showed poorly differentiated adenocarcinoma of lung origin consistent with new primary lung cancer given no prior diagnosis of adenocarcinoma. Repeat imaging showed new liver and kidney lesions, and a decision was made to undergo surgical resection of liver lesion which confirmed moderately differentiated adenocarcinoma with neuroendocrine features consistent with metastasis from pulmonary origin. The patient was started on chemotherapy for stage IV primary lung adenocarcinoma, but passed away several months later from bacteremia.
Discussion: DLBCL can have various presentations, but symptoms of nodal involvement are the most frequent. Gastric mucosa is involved in most of the cases with extra nodal involvement, and can lead to GI bleeds. Two concurrent hematologic and solid tumor malignancies are extremely rare, but should be kept on the differential if imaging shows conflicting areas of disease stability vs. progression.
