Presentation
Lower abdominal pain and mass for two months. History of low grade fever, anorexia, and weight loss.
Patient Data
Findings: Scan demonstrates marked circumferential mural thickening and aneurysmal dilatation of a segment of the distal ileum. Morphology of the proximal small bowel loops as well as the colon is within normal limits. Multiple large mesenteric lymph nodes are seen in central and lower abdominal cavity, with the largest lymph node measuring approximately 38 x 38 mm. No significant paraaortic, pelvic, or inguinal lymphadenopathy is seen.
Conclusion: Marked circumferential mural thickening and aneurysmal dilatation of a segment of the distal ileum with multiple enlarged mesenteric lymph nodes and no bowel obstruction; these radiological features are suggestive of small bowel lymphoma. Possibility of the small bowel adenocarcinoma is less likely.
A focal area of significantly increased gallium uptake is seen in the pelvic region. Another focal area of increased gallium uptake is seen in the posterior left upper abdomen.
There is interval resolution of the previously noted gallium-avid disease in the pelvis and left upper abdomen.
Case Discussion
Procedure: Laparotomy with excision of the distal small bowel mass and anastomosis.
Diagnosis: High grade primary diffuse large B-cell lymphoma (Mediterranean-type), related to mucosa associated lymphoid tissue (MALT).
Immunohistochemistry: The tumor cells stain uniformly positive for CD45 and CD20 and shows a negative reaction for CD3, CD10, CD30, MUM-1 and CK AE1/3. More than 70% of the tumor cells stain positively for Ki-67.