Jejunal plasmablastic lymphoma presenting as obscure overt...
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1130-0108/2015/107/567-568 REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS COPYRIGHT © 2015 ARÁN EDICIONES, S. L. REV ESP ENFERM DIG (Madrid Vol. 107, N.º 9, pp. 567-568, 2015 PICTURES IN DIGESTIVE PATHOLOGY Jejunal plasmablastic lymphoma presenting as obscure overt gastrointestinal bleeding: Diagnosis by wireless capsule endoscopy Pedro Magalhães-Costa, Miguel Bispo, Leopoldo Matos and Cristina Chagas Gastroenterology Department. Hospital Egas Moniz. Centro Hospitalar Lisboa Ocidental. Lisboa, Portugal CASE REPORT A 43 year-old male, diagnosed with acquired immune de- ficiency syndrome (under highly active antiretroviral therapy), presented with intermittent and recurrent melena. Physical ex- amination was unremarkable. Labs revealed a severe microcytic anemia –serum hemoglobin (Hb) = 5.1 g/dL. Upper gastroin- testinal endoscopy and ileocolonoscopy disregarded any poten- tially bleeding lesion. In the ward the patient kept the clinical picture, thus a wireless capsule endoscopy (WCE) was per- formed. The examiner noted in the mid-jejunum, a circumfer- ential, stricturing and ulcerated lesion (Fig. 1A and C), with ac- tive oozing bleeding (Fig. 1B). An abdomino-pelvic computed tomography (CT) (Fig. 2A and B) scan revealed a small-bowel mass in the pelvic cavity. Also, a round and hyperintense im- age with many artefactual effects associated with the previous- ly described mass was noted (the retained WCE device). The patient developed severe obstructive symptoms and an urgent surgical approach was deemed necessary. The resected speci- men consisted of a 16 cm long segment of jejunum centered by a neoplastic mass, stricturing and ulcerated with 8 cm of larger longitudinal axis. Mesenteric ganglia were not committed and the surgical margins were free (R0 resection). Microscopy (Fig. 3A-E) visualized a diffuse lymphoma with large cell nucleus. The immunohistochemistry stain (IHQ) profile was positive for (cluster of differentiation) CD138 and CD79a; negative for CD30, CD20, CD19, CD10, (B-cell lymphoma) BCL2, BCL6, anaplastic lymphoma kinase (ALK), CD3, EMA (MUC1): Ep- ithelial membrane antigen (AE1AE3) and EMA. On the basis of these morphologic and IHQ characteristics, the pathological diagnosis of plasmablastic lymphoma was made. The patient re- ceived 6 cycles of cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) and, after 32 months of follow-up, his disease is in remission. DISCUSSION There are few case reports of plasmablastic lymphoma (PBL) which had occurred in extra-oral locations like the small-bowel (1-3). Although PBL is usually typified as being an high-grade malignant lymphoma and known by their diffuse infiltrative growth, high mitotic rate and a dismal prognosis, in this case, an appropriate multidisciplinary approach allowed to an early diagnosis and subsequent treatment of the neoplasm. ACKNOWLEDGMENTS Presented as a poster at RICE 2013 (XI Reunión Ibérica de Cápsula Endoscópica), 12 January 2013, Valencia, Spain. Fig. 1. Capsule endoscopy findings. A and C. A circumferential, stricturing and ulcerated lesion was found. B. Oozing active bleeding from the lesion. A B C
Transcript of Jejunal plasmablastic lymphoma presenting as obscure overt...
1130-0108/2015/107/567-568Revista española de enfeRmedades digestivasCopyRight © 2015 aRán ediCiones, s. l.
Rev esp enfeRm dig (MadridVol. 107, N.º 9, pp. 567-568, 2015
PICTURES IN DIGESTIVE PATHOLOGY
Jejunal plasmablastic lymphoma presenting as obscure overt gastrointestinal bleeding: Diagnosis by wireless capsule endoscopyPedro Magalhães-Costa, Miguel Bispo, Leopoldo Matos and Cristina Chagas
Gastroenterology Department. Hospital Egas Moniz. Centro Hospitalar Lisboa Ocidental. Lisboa, Portugal
CASE REPORT
A 43 year-old male, diagnosed with acquired immune de-ficiency syndrome (under highly active antiretroviral therapy), presented with intermittent and recurrent melena. Physical ex-amination was unremarkable. Labs revealed a severe microcytic anemia –serum hemoglobin (Hb) = 5.1 g/dL. Upper gastroin-testinal endoscopy and ileocolonoscopy disregarded any poten-tially bleeding lesion. In the ward the patient kept the clinical picture, thus a wireless capsule endoscopy (WCE) was per-formed. The examiner noted in the mid-jejunum, a circumfer-ential, stricturing and ulcerated lesion (Fig. 1A and C), with ac-tive oozing bleeding (Fig. 1B). An abdomino-pelvic computed tomography (CT) (Fig. 2A and B) scan revealed a small-bowel mass in the pelvic cavity. Also, a round and hyperintense im-age with many artefactual effects associated with the previous-ly described mass was noted (the retained WCE device). The patient developed severe obstructive symptoms and an urgent surgical approach was deemed necessary. The resected speci-men consisted of a 16 cm long segment of jejunum centered by a neoplastic mass, stricturing and ulcerated with 8 cm of larger longitudinal axis. Mesenteric ganglia were not committed and the surgical margins were free (R0 resection). Microscopy (Fig. 3A-E) visualized a diffuse lymphoma with large cell nucleus. The immunohistochemistry stain (IHQ) profile was positive for (cluster of differentiation) CD138 and CD79a; negative for CD30, CD20, CD19, CD10, (B-cell lymphoma) BCL2, BCL6, anaplastic lymphoma kinase (ALK), CD3, EMA (MUC1): Ep-ithelial membrane antigen (AE1AE3) and EMA. On the basis of these morphologic and IHQ characteristics, the pathological diagnosis of plasmablastic lymphoma was made. The patient re-ceived 6 cycles of cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) and, after 32 months of follow-up, his disease is in remission.
DISCUSSION
There are few case reports of plasmablastic lymphoma (PBL) which had occurred in extra-oral loca tions like the small-bowel (1-3). Although PBL is usually typified as being an high-grade malignant lymphoma and known by their diffuse infiltrative growth, high mitotic rate and a dismal prognosis, in this case, an appropriate multidisciplinary approach allowed to an early diagnosis and subsequent treatment of the neoplasm.
ACKNOWLEDGMENTS
Presented as a poster at RICE 2013 (XI Reunión Ibérica de Cápsula Endoscópica), 12 January 2013, Valencia, Spain.
Fig. 1. Capsule endoscopy findings. A and C. A circumferential, stricturing and ulcerated lesion was found. B. Oozing active bleeding from the lesion.
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B C
568 P. MAGALHÃES-COSTA ET AL. Rev esp enfeRm Dig (maDRiD)
Rev esp enfeRm Dig 2015; 107 (9): 567-568
REFERENCES
1. Cha JM, Lee J Il, Joo KR, Jung SW, Shin HP, Lee JJ, et al. A case report with plasmablastic lymphoma of the jejunum. J Korean Med Sci 2010;25:496-500.
2. Bahari A, Jahantigh M, Mashhadi A, Bari Z, Bari A. Plasmablastic lymphoma presenting as small intestinal polyposis: A case-report. Iran Red Crescent Med J 2012;14:669-75.
3. Wang H-W, Yang W, Sun J-Z, Lu J-Y, Li M, Sun L. Plasmablastic lymphoma of the small intestine: Case report and literature review. World J Gastroenterol. 2012;18:6677-81.
Fig. 2. Radiological images of a jejunal mass. A. CT scan (transverse plan): Small-bowel mass in the pelvic cavity. The retained capsule endoscopy device (hollow arrow). B. CT scan (coronal plan): Small-bowel mass in the pelvic cavity (6.9x6.7 cm) with cleavage plan with the surrounding structures.
Fig. 3. Histopathology of plasmablastic lymphoma. A. (H&E, 40x). Diffuse infiltration in the mucosa of the small-bowel by monotonous large atypical lymphoid cells. B. (H&E, 400x). These cells displayed a large nucleus, a prominent centrally located nucleoli, abundant basophilic cytoplasm and high mitotic index. C. IHQ (CD138): Positive (plasmocytic differentiation). D. IHQ (CD79a): Positive (B-cell lineage). E. IHQ (CD20): Negative (typical B-cell antigen).
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