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A 75-year-old gentleman with a medical history of glaucoma and hypertension was presented to the acute medical admissions unit with insidious weight loss over 18 months and more rapid weight loss of 4kg in the preceding 2 weeks. He had also been complaining of anorexia, lower back pain, general malaise, and increased urinary frequency and urgency. He underwent investigation with blood tests, upper gastrointestinal (GI) endoscopy, and cross-sectional imaging.
The blood results were as follows:
|WCC||3.6 x 109/L||(4‒10)|
|Plat||94 x 109/L||(150‒450)|
During the endoscopy, lesions were found on the gastric greater curve, as well as in the second part of the duodenum (Figures 1 and 2). A CT was subsequently organised (Figure 3).
Figure 1: Lesion on the lower gastric greater curve
Figure 2: Lesions in the second part of the duodenum
Figure 3: Coronal slice from CT of the neck, chest, abdomen, and pelvis
1. What diagnosis would explain these findings?
- Zollinger-Ellison syndrome
- An early gastric cancer and a duodenal adenoma
- Cholangiocarcinoma with metastases to stomach and duodenum
- Gastric cancer with a duodenal metastasis
- Multifocal lymphoma
2. What does the gastric biopsy show?
- Low-grade T lymphocytes
- Low-grade B lymphocytes
- High-grade T lymphocytes
- High-grade B lymphocytes
- Undifferentiated lymphocytes
3. What additional investigation is not recommended as standard for this condition?
- Contrast-enhanced CT scan of neck, chest, abdomen, and pelvis
- Baseline bloods, including LDH, HIV, HBV and HCV
- MRI of the brain, orbits, and sinuses
- PET-CT scan
4. Which of the following is a GOOD prognostic indicator?
- Involvement of the central nervous system
- No involvement outside lymph nodes
- Patient performance level 3
- Patient is older than 60 years
- Larger amount of disease
Answer is e.
The gastric lesion showed the typical appearance of GI lymphoma with engorged red mucosal folds and ulceration, and the duodenal lesion was well demarcated, depressed, fissured, and contained blunted white tipped villi. The CT scan demonstrated marked splenomegaly, retroperitoneal, axillary and cervical lymphadenopathy. The GI tract is the commonest site of extra-nodal non-Hodgkin lymphoma, accounting for 30‒40% of cases.1 Of these, 60‒70% are found in the stomach and 20‒35% in the small bowel; only 5‒10% occur in the colorectum.2 GI lymphomas are more common in males and typically present in the sixth decade of life. They can manifest with a multitude of symptoms, such as dyspepsia, nausea, pain, bloating, diarrhoea, bleeding, obstruction, and weight loss.3
Figure 4: Gastric biopsy stained with H&E, CD-20, and Ki67 stains
Dr John Jacob is a Consultant Gastroenterologist and Therapeutic Endoscopist at University Hospital North Tees & Hartlepool NHS Foundation Trust.
Dr Bjorn Rembacken is a Consultant Gastroenterologist and Specialist Endoscopist at Leeds Teaching Hospitals NHS Trust.
Dr Chris Bacon is a Senior Lecturer in Haematopathology at Newcastle University and an Honorary Consultant Haematopathologist at Newcastle upon Tyne Hospitals NHS Foundation Trust.
- Thomas A, Schwartz M, Quigley E. Gastrointestinal lymphoma: the new mimic. BMJ Open Gastro 2019;6:e000320.
- Barakat M. Endoscopic features of primary small bowel lymphoma: a proposed endoscopic classification. Gut 1982;23:36-41.
- Vetro C, Romano A, Amico I, et.al. Endoscopic features of gastrointestinal lymphomas: From diagnosis to follow up. World J Gastroenterol 2014;20:12993-13005.
- Tilly H, Vitolo U, Walewski J, et al. Diffuse large B-cell lymphoma (DLBCL): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow up. Annals of Oncology 26 (Supplement 5): v116-v125, 2015.
- Chaganti S, Illidge T, Barrington S, et al. Guidelines for the management of diffuse large B-cell lymphoma. Br J Haematol 2016;174:43-56.
- McKay P, Wilson MR, Chaganti S, et al. The prevention of central nervous system relapse in diffuse large B-cell lymphoma: a British Society for Haematology good practice paper. Br J Haematol 2020:190;708-714.