Primary diffuse large b-cell lymphoma of the stomach presenting as acute pancreatitis

¹Gastroenterology and Proctology, Medicine B Department, Ibn Sina University Hospital, Mohammed V University, Faculty of Medicine and Pharmacy of Rabat, Rabat, Morocco

^&Corresponding author
Sara Ghani, Hepato-Gastroenterology and Proctology, Medicine B, Department, Ibn Sina University Hospital, Mohammed V University, Faculty of Medicine and Pharmacy of Rabat, Rabat, Morocco

Introduction    

Primary gastric lymphoma presents 1-5% of all gastric malignancies diseases, and it´s the most frequent type of extranodal lymphoma [1]. Diffuse Large B Cell Lymphoma (DLBCL) presents 31% of all non-Hodgkin´s Lymphoma (NHL) [2]. Clinical presentations are nonspecific; such as abdominal pain, dyspepsia or appearance of diabetes, and diagnosis is often delayed [3]. Pancreatic tumors like adenocarcinoma, pancreatic lymphoma, and metastases have been implicated in the etiologies of acute pancreatitis [4]. We describe a case of gastric primary diffuse large B lymphoma presenting as acute pancreatitis.

Patient and observation     

A 45-year-old man with recent diabetes presented at emergency with epigastric pain and vomiting. There was no history of biliary colic or abdominal trauma. Patient reports recent weight loss a deterioration of the general setting. His pulse rate was 98/min, blood pressure 110/80 mmHg, respiratory rate 18/min, temperature 98.4°F (36.9°C). The patient presented a pallor without icterus and peripheral edema. The abdominal examination showed a mass in the epigastrium tender on palpation. The rest of the examination was normal. He was initially treated as acute pancreatitis based on elevated levels of lipase (1593 U/L) and CRP. The renal function, serum calcium and triglycerides levels, hemogram and liver function tests were normal. Abdominal ultrasound showed a heterogeneous mass in the region of the head and the body of the pancreas. Gallbladder, common bile duct, pancreatic duct and liver were normal. After initial stabilization, abdominal CT scan was done after 72h. It revealed a gastric mass (17 mm) infiltrating the head and the body of the pancreas with ganglionic metastasis. The carbohydrate antigen 19-9 (CA 19-9) level was normal. Upper endoscopy showed an ulcerated mass in the proximal and distal stomach (Figure 1). Biopsies of the gastric mass revealed diffuse large lymphoid cells (Figure 2). Immunohistochemistry confirmed the diffused large B cell lymphoma with CD20 (++ +), (Figure 3). Bone marrow cytological examination showed a marrow infiltrated with 5% of large cell B cells. The patient was ready to be transferred to the clinical hematology for chemotherapy. A therapeutic regimen of R-CHOP (Rituximab+cyclophosphamide+doxorubicin+Vincristine+prednisolone) was developed for him. Subsequently, the patient developed a massive upper gastrointestinal bleeding leading to death before the start of treatment.

Discussion     

Gastric lymphoma presents 1% to 5% of all gastrointestinal malignancies and 40% of extranodal NHL [5]. Biopsies of the lesion and immunohistochemistry analysis are mandatory. A few cases of pancreatitis revealed by B-cell lymphoma had been reported [6]. Abdominal pain and dyspepsia are the most common symptoms of primary gastric lymphoma. The pancreatic duct infiltration by the tumor leads to acute pancreatitis. Cytokines and hypercalcemia released from the tumor can produce pancreatitis [7]. The treatment of DLBCL should be urgently. It relies mainly on R-CHOP chemotherapy, combining rituximab with CHOP (doxorubicin, cyclophosphamide, vincristine, prednisone) for 6 or 8 cycles every 3 weeks with systematic eradication of H. pylori to treat small cell proliferation of associated Mucosa-Associated Lymphoid (MALT) type. It has been demonstrated in ganglionic lymphomas but not in gastric lymphoma, that the combination of rituximab with chemotherapy (“R-CHOP” protocol) leads to superior survival compared to CHOP alone. In the case of a relapse, autologous stem cell transplantation is the only chance of cure for patients under 60 years old. For these patients, allograft results are promising [8]. Upper endoscopy after three courses will be done to judge the efficacy of the treatment [9]. Clinical monitoring is essential every 3 months during the first year, then every 6 months the second year, then 1 time per year with clinical examination, endoscopy, and LDH level. The time of follow-up is around 5-10 years. No imaging or CT scan or Fluorodeoxyglucose -Positron Emission Tomography (FDG-PET) scan is recommended. The optimal frequency of endoscopic controls is undetermined [10].

Conclusion     

In our case, pancreatitis was the initial presentation of primary gastric lymphoma, however, a good and timely evaluation can be effective in early diagnosis and successful treatment.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All the authors have read and agreed to the final manuscript.

Figures     

Figure 1: upper endoscopy revealed a tumor in the fundus and antrum with bleeding

Figure 2: histology revealed gastric infiltration by large atypical lymphoid cells

Figure 3: immunohistochemistry confirmed the diagnosis of diffuse large B cell lymphoma by the positivity of CD20 (+++)

References