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).