HIV. PR bleeding, distended abdomen, US showed multiple hepatic lesions. Colorectal cancer?
CT Abdomen and pelvis
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There is a 6 cm x 4 cm mass in the right atrium consistent with tumour thrombus. A small pericardial effusion is noted. Incompletely imaged there is an expansion of a left lower lobe pulmonary vessel by a low density filling defect, also consistent with tumour thrombus. As this vessel is located next to the left interior pulmonary vein, the tumour thrombus is almost certainly located within a pulmonary artery. Urgent echocardiography recommended
Multiple mass lesions are demonstrated within the hepatic parenchyma with the largest lying in segment 2 and this appears to have several associated mass lesions adjacent to it. The largest mass has an area of central hypodensity whereas the other mass lesions do not. This may represent evidence of central necrosis.
There is significant enlargement of the adrenals bilaterally. Vessels are seen extending through the bilateral adrenal masses.
There is poor enhancement of the right kidney in comparison to the left. This appears to be secondary to compression of the right renal artery at the level of the renal hilum secondary to the presence of a mass lesion. There is dilatation of the renal collecting system. Multiple renal mass lesions are demonstrated with enlargement of the right kidney.
There is significant enlargement of the prostate. The bladder is unremarkable in its appearance with inflammation secondary to the significant prostatic enlargement.The Prostatic mass lesion appears to be causing obstruction of the distal right ureter.
There is poor enhancement of the anterior and medial aspect of the left kidney at the level of the renal hilum with the presence of a mass lesion. This appears to be extending down the left ureter with marked enlargement of the left ureter proximally.There is no significant dilatation of the renal collecting system. Multiple mass lesions are seen associated with the left kidney with enlargement of the left kidney.There is satisfactory enhancement of the left kidney in its mid and lower pole sections.
Note is made of a filling defect within the left renal vein. It is difficult to ascertain if this enhances but has the appearance of tumour thrombus rather than vascular thrombus. It is difficult to visualise the right renal vein and this appears to be occluded secondary to the presence of a mass lesion and likely tumour thrombus.
There is significant compression of the IVC secondary to the large right adrenal mass lesion. A filling defect is present within the intrahepatic IVC which may represent the presence of thrombus.
There appears to be a large mass lesion associated with the pancreas. There is a satisfactory appearance to the pancreaticuncinate process head and neck. No pancreatic ductal dilatation is identified with no significant intra or extrahepatic biliary duct dilatation present.
There appear to the omental metastases associated with a mass lesion at the inferior pole of the liver.
There is wall thickening of the ascending colon and hepatic flexure and the bowel is collapsed down. The possibility that this represents the presence of a mass is difficult to exclude. There is no obstruction to the small or large bowel loops with contrast seen extending throughout to the level of the splenic flexure. There is a slightly dysplastic appearance to the loops of small bowel within the midabdomen to the left of midline with some clumping present. It is difficult to clearly delineate a definite mass lesion.
A soft tissue mass lesion is present within the ischiorectal fat on the left.
MICROSCOPIC DESCRIPTION: Sections show multiple cores of tissue which shows a diffuse population of large atypical cells. The cells have large irregular nuclei with small nucleoli and a moderate amount of eosinophilic cytoplasm. The cell nuclei are irregular and folded. Mitotic figures are present. There is prominent apoptosis.
- Immunohistochemistry shows cells stain:
- positive with CD20, CD10, Bcl-6, c-myc and p53.
- negative with Bcl-2, Cyclin- D1,MUM-1, CD23, CD5 andCD3.
- Ki67 >95%.
- EBER-CISH positive. EBV-LMP focal positive. HHV-8 and TdT negative.
DIAGNOSIS: Features support the diagnosis of a Burkitt Lymphoma.
The differential diagnosis lies between lymphoma and disseminated metastatic disease.
Acknowledge risk factors for Burkitt's lymphoma include:
- post-transplant immunosuppression
Burkitt lymphoma is an aggressive tumour with a doubling time of 24 hours. It can present in a wide variety of locations:
- head and neck, e.g. facial bones, Waldeyer's ring
- pleural space (~70%)
- gastrointestinal tract, especially ileocaecal region
- mesentery, peritoneum, retroperitoneum
- gonads (~75%)
Nodal involvement is more common in adults than in children.