2. PRESENTATION OF CASE
An 84-year-old man complained with an intermittent colicky abdominal
pain, dyspnea, orthopnea, fatigue, pallor looking, and progressive
generalized edema for one month. On admission, vital signs were BT:
37.5°C, PR:98/min, RR:19/min, BP: 86/64mmHg. Laboratory data included
Hgb: 4.4 g/dl, Hct: 15.1%, MCV: 71.6 fl, MCH: 20.9 pg, MCHC: 29.1 g/dl,
neutrophils: 78.9%, lymphocytes: 87.7%, monocyte: 12.2%, NT-proBNP
(PBNP): 3260 pg/mL, Na+: 123mmol/L, albumin: 2.39 g/dL, and urine
protein was trace. Tumor marker (CEA, PSA, CA199 and AFP) levels were
within normal limits. Microcytic anemia, hypoalbuminemia, and
hyponatremia were firstly considered. He had BPH post-operation and
denied of allergy history. He had BPH post-operation and denied of
allergy history. He was negative for hepatitis B and human
immunodeficiency virus (HIV) tests. Esophagogastroduodenoscopy revealed
reflux esophagitis of Los Angeles classification grade A and gastric
polyp over middle body was found. Chest x-ray showed bilateral pleural
effusions (Figure 1A). Chest CT scan exhibited atelactasis of LUL and
LLL with bilateral pleural effusions (Figure 1B). Some small lymph nodes
with less than 1 cm at mediastinum and no bony destruction of thoracic
cage was detected. CT scan of abdomen and pelvis demonstrated two
segments of small bowel intussusception (Figure 1C-D), and one presented
abnormal enhancement of the leading point with regional small lymph
nodes and small bowel tumor was considered (Figure 1C-D). No peritoneal
effusion or ascites was found. Suspected jejunal tumor related to JJ
intussusception. Enlargement of left para-aortic and peri-portal lymph
nodes were noted. Clinical and imaging examinations showed highly
suspected of jejunal intussusception and intestinal obstruction. He
underwent the diagnostic laparoscopy assisted laparotomy and two areas
of JJ intussusception with manual reduction of intussusception.
Subsequent segmental resection of the jejunum with lymph nodes
dissection were also performed.
Histopathologic examination, the resected specimen submitted was a
segmental jejunum with two separated protruding ulcerative polypoid
masses between 10 cm in distances were identified, measured up to 3 by 2
by 2 cm (T1) and 2.5 by 1.5 by 1 cm (T2) (Figure 2). Microscopically,
both T1 and T2 intestinal polypoid masses revealed diffuse loosely
cohesive sheets and nodules, marked diffuse monotonous lymphoid elements
with mixtures medium to large cells displayed vesicular nuclei with
prominent nucleoli. Nuclear pleomorphic or large with obscure cytoplasm
seen (Figure 3A-D). Sections showed homogeneous infiltrative lymphoma
cells separating fibers through the intestinal wall and periserosal
adipose tissue. The lymphoma cells reached up to the serosa and was
accompanied by perforation of peritonitis. Analysis of dissected lymph
nodes indicated 12 out of 16 mesenteric regional lymph nodes were
involved by the lymphoma and displayed similar morphology suggesting
high grade lymphoid malignancy. Immunohistochemical (IHC) staining,
these lymphoma cells (T1 and T2) demonstrated diffusely positive
immunoreactivity for CD20 (strongly diffuse membranous staining) (Figure
4A-B), increase expression for proliferative Ki-67-labeling index with
approximately 90% of involved lymphoma cells (Figure 4C-D). Lymphoma
cells also presented positive for Bcl-2, MUM-1/ IRF (multiple myeloma
oncogene 1, post-germinal center or activated B-like), and focal
positive for Bcl-6 (B-cell lymphoma 6, germinal center marker). In
contrast, tumor cells showed negative for CD3 (T-cell marker) with
positive in background small lymphocytes, and negative for CD-10
(germinal center marker), pan-CK, NSE, CD30, CD4 and cyclin-D1. The
feature of synchronous high-grade DLBCLs of the jejunum was diagnosed.
Subsequently pleural effusion cytopathology illustrated detection of
lymphoma cells. Bronchoscopy brush cytology and sputum cytology showed
negative for malignant cells. Trephine needle core biopsy for bone
marrow examination showed negative for lymphoma involvement. The final
pathological diagnosis prompted a diagnosis of synchronous DLBCLs of the
jejunum with mesenteric lymph nodal and pleural metastasis associated
intestinal obstruction with perforation was concluded. The pathological
TNM stage indicated, AJCC, 8thed stage, pT3N2M1, Stage IV (associated
with primary GI lymphoma stage: pT3N2M1B0).