Presentation
Disabled patient, fell at home. Blood tests sent from the ER. Results remarkable for elevated liver enzymes and a CRP of 150.
Patient Data
Liver of normal dimensions, fatty. Several hypoechoic lesions in both its lobes; the largest is in the right lobe, measuring 6.5 cm across.
Nondisplaced fracture in anterior arch of right ribs 5-8. Adjacent mild subcutaneous emphysema around intercostal muscles. Basal subsegmental atelectasis in right lower lobe.
Exophytic mass in greater gastric curvature measuring approximately 9.5 x 6.0 x 4.1 cm; part of its extragastric extension is probably isodense omental-gastrosplenic ligament implants. Several smaller infragastric omental implants left of midline.
Elongated, slightly isodense mass in pancreatic body and tail measuring ~10 cm in length and 3.6 cm at thickest part, insinuating into the gastrosplenic ligament.
Rounded hypodense masses in both hepatic lobes, showing thin mildly hyperenhancing margins; the largest is subcapsular, between segments 7 and 8, and measures 5.5 x 7.2 x 5.2 cm. Hypodense heterogeneous splenic mass measuring 7.4 x 6.0 x 8.6 cm.
No axillary, mediastinal or hilar lymphadenopathy, nor in the abdominopelvic cavity or the inguinal region.
Status post sternotomy, coronary artery bypass grafting (CABG), aortic valve replacement (AVR), and mitral valve repair. The aorta is of normal diameter, showing calcified and soft plaque.
In summary:
- large exophytic gastric mass, large pancreatic mass - difficult to determine which is the primary mass but the gastric mass seems more likely
- hypodense hepatic and splenic masses, compatible with metastatic spread
- omental-gastrosplenic ligament implants
A biopsy is required and can be obtained either from the stomach via gastroscopy or from a hepatic metastasis.
Ulcerated mass at greater curvature of stomach. Biopsies obtained.
Case Discussion
Case of diffuse large B-cell lymphoma with spread to the upper abdomen but no obvious lymph node involvement. The primary was probably the gastric mass. The pancreatic mass, although large, was a less likely candidate mainly due to its being much rarer.
Pathology report - biopsy from the gastric mass:
Malignant lymphoma, large B cell diffuse. CD20 strongly positive, pankeratin negative,
Ki67 index very high.