University of Hawaii, John A. Burns School of Medicine Honolulu, HI
Arvin Jeremy Tan, MD1, Jennie Zhang, MD2, Giancarlo Colon Rosa, MD2, Raymond Janowski, MD2, Marie L.. Borum, MD, MPH, FACG2, Samuel A.. Schueler, MD2 1University of Hawaii, John A. Burns School of Medicine, Honolulu, HI; 2George Washington University School of Medicine and Health Sciences, Washington, DC
Introduction: Primary gastric lymphoma is rare, accounting for approximately 5% of primary gastric cancers. They more commonly present in males and in the 5th decade. The clinical presentation is nonspecific and typically mimics gastritis. We present a young female patient with gastric diffuse large B-cell lymphoma (DLBCL) presenting as acute pancreatitis.
Case Description/Methods: A 26-year-old female presented to the emergency department (ED) with three-weeks of new-onset abdominal pain. Her pain was initially 2/10 severity, persistent, and worse with meals. Two days prior to admission, her pain became sharp, 7/10 severity and radiating to her back. She tested positive for Helicobacter pylori (H. pylori) infection and started on quadruple therapy. Due to high lipase, she was sent to the ED. There, she was tachycardic to 127 and lipase was 3754 units/Liter (U/L). Computed tomography (CT) showed a 15.3-centimeter (cm) infiltrative mass arising from the lesser curvature of the stomach with invasion of the left hepatic lobe, spleen, and pancreas (Image 1A-1B). Peritoneal metastatic disease was noted. Esophagogastroduodenoscopy revealed a 5-cm ulcerated and fungating mass (Image 1C-1D). Endoscopic ultrasound with fine needle biopsy showed heterogeneous, hypoechoic mass in the cardia and lesser curvature with poorly defined borders and invasion into the liver and pancreas (Image 1E-1G). Positron emission tomography/CT confirmed peritoneal and lymph node metastases. Pathology revealed high-grade B-cell lymphoma. She was found positive for Epstein Barr Virus (EBV) Immunoglobulin G (IgG), suggesting prior infection. She started intrathecal chemotherapy with R-EPOCH and continued H. pylori therapy.
Discussion: Primary gastric lymphomas are largely broken down into DLBCL (~60%) and mucosa-associated lymphoid tissue (MALT) (~40%). H. pylori, EBV, hepatitis B, human immunodeficiency virus (HIV), and human T-cell lymphotrophic virus 1 are risk factors. Treatment includes chemotherapy and H. pylori eradication with surgery limited to cases of perforation, bleeding, or obstruction. There is no survival difference between DLBCL and MALT due to chemotherapy advancements. Our patient was positive for both H. pylori and EBV and was asymptomatic until she developed symptoms of pancreatitis due to invasion of the mass. This case highlights the variable presentation of primary gastric lymphoma, and underscores the importance of identifying and modifying predisposing factors.
Figure: 1A-1B: CT imaging showing a large, homogenous, ill-defined gastric mass arising from the lesser curvature measuring 9.3 x 12.0 x 15.3 cm with ulceration of the lesser curvature (1A), diffuse infiltration of the pancreatic body and tail, and loss of fat plane at the superomedial aspect of the spleen (1B). 1C-1D: EGD revealing a large, fungating, and ulcerated non-circumferential mass of approximately 5 cm. 1E-1G: EUS showing a hypoechoic and heterogeneous irregular mass in the cardia and lesser curvature 4 cm from the GE junction, measuring 10 mm x 6 mm in cross-sectional diameter with poorly defined borders (1E) and invasion into the liver (1F) and pancreas (1G).
Disclosures:
Arvin Jeremy Tan indicated no relevant financial relationships.
Jennie Zhang indicated no relevant financial relationships.
Giancarlo Colon Rosa indicated no relevant financial relationships.
Raymond Janowski indicated no relevant financial relationships.
Marie Borum: Takeda Pharmaceuticals – Consultant, Speakers Bureau.
Samuel Schueler indicated no relevant financial relationships.
Arvin Jeremy Tan, MD1, Jennie Zhang, MD2, Giancarlo Colon Rosa, MD2, Raymond Janowski, MD2, Marie L.. Borum, MD, MPH, FACG2, Samuel A.. Schueler, MD2. P5094 - Beyond Gastritis: A Case of Gastric Diffuse Large B-cell Lymphoma Presenting as Acute Pancreatitis, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
