Gastric diffuse large B-cell lymphoma

Case contributed by Dr Michael P Hartung

Presentation

Abdominal pain, early satiety, weight loss.

Patient Data

Age: 45 years
Gender: Male

Thick-walled, enhancing, ulcerative mass projecting from the anterior gastric antrum. 

Lower-attenuation submucosal thickening of the remainder of the lower gastric body and antrum. Mucosal hyperenhancement diffusely. 

Few borderline enlarged lymph nodes about the antral mass. No other metastases. 

ENDOSCOPY AND ENDOSONOGRAPHY:

IMPRESSION: 

  •  Non-bleeding large cratered gastric ulcer. Biopsied.
  • A mass was found in the antrum of the stomach. This was staged T3. The staging applies if malignancy is confirmed.

ENDOSCOPIC FINDING: One non-bleeding cratered gastric ulcer was found in the gastric antrum. It appeared to encompass the entire antrum. Biopsies were taken with a cold forceps for histology. The ulcer resulted in antral deformity and the pylorus was not able to be found.   

ENDOSONOGRAPHIC FINDING: :A hypoechoic mass was identified endosonographically in the antrum of the stomach. The endosonographic borders were well-defined. There was sonographic evidence suggesting invasion into the muscularis propria (Layer 4). 

PATHOLOGY:

FINAL DIAGNOSIS: 

A. Mass, Stomach: Biopsy:

Diffuse large B cell lymphoma, ABC type, double expressing MYC and BCL-2

H. Pylori-like organisms identified.

The sections show gastric mucosa with readily identifiable H. Pylori-like organisms on H and E.  There is an infiltrate of large atypical cells in the mucosa and underlying tissue with associated necrosis.  The large cells are positive for CD20, MUM-1, BCL-6, BCL-2, and >90% for Ki-67.  They are negative for AE1/3, CD10, and CD5.

Case Discussion

In this case, gastric wall thickening is related to BOTH lymphomatous infiltration (in the ulcer crater) and submucosal edema (elsewhere in the lower body and antrum). This serves as a great side-by-side comparison of these important and often-confusing imaging findings. 

Tumor can be differentiated from edema due to the "soft-tissue/intermediate" attenuation, rather than the lower attenuation of edema. Enhancing soft-tissue thickening can raise the concern of infiltrative or ulcerative neoplasm, and can appropriately prepare the endoscopist prior to EGD. 

In summary this case has a combination of gastritis, submucosal edema, and malignant ulceration. 

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Case information

rID: 65369
Published: 6th Jan 2019
Last edited: 7th Jan 2019
Inclusion in quiz mode: Included

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