CASE N°39 – PERIGASTRIC LYMPHOMA
EUS: Endoscopic gastric cavity presents the lumen reduced by extrinsic compression on the gastric wall. EUS confirms the presence of solid perigastric mass (size> 8 cm), with mixed pattern elastosonographic (areas with higher and lower rigidity). This mass grows between the posterior gastric wall (no clear signs of origin from itself), spleen and pancreas. The latter appears undamaged, with a regular caliber and course of Wirsung. Around the main mass are observed nodular rounded formations (size from 10 mm to about 25 mm), compatible with adenopathy. The major vascular structures are dislocated, without signs of infiltration.
Conclusion: suspicious for lymphoma
CT-SCAN: In the left iliac fossa is present focal lesion that occupies the mesentery having transverse extensions of up to 14x 9 cm in correspondence of the lower pole of the left kidney. Multiple nodular images in the mesentery with characteristics of lymph node (size from a few millimeters to 2 cm.).
cytological speciemen: EUS-FNA
histological speciemen: peritoneal nodule excision
Presence of numerous malignant tumor cells of lymphoid origin, isolated and sometimes of a large size. Cytological findings suggest the presence of lymphoproliferative process.
Non-Hodgkin’s B Lymphoma, with aspects of diffuse large cell type. Are associated foci of fibrosclerosis.
Immunophenotype: CD20 +, CLA +, Bcl6 +, MUM1 +/-, Bcl2 +, CD10 + (weak focus), PAX8 +/-, CD15-, CD30-, CD3-, CD5-, ALK-, CD138-
Proliferation index (Ki67): about 70%.
Cytologically the presence of tumor cells with high nucleo-cytoplasmic ratio, macronucleolate, the absence of necrosis and cellular aggregates effectively suggest the presence of a lymphoproliferative process. The histological diagnosis supported by immunohistochemistry effectively confirms the presence of a B cell lymphoma.
The stomach is the site most commonly involved by extranodal lymphomas, and in 15–20% of diffuse non-Hodgkin`s lymphomas involvement of the stomach has been described.
… In 30% of the cases the lesions are larger than 10 cm. Usually the serosa is invaded first followed by the mucosa. Regional lymph node metastasis (63%) precedes the involvement of distant organs.
… The disease is most common in the sixth decade, men are affected more often than women, and Caucasians more than individuals of Afro-American origin. Most patients show symptoms of the upper GI tract resembling gastritis up to peptic ulcer syndrome. Only a small number of patients in the series were asymptomatic (3%) while the most frequently occurring symptoms were epigastric or diffuse abdominal pain (60–95%), weight loss of more than 2 kg (15–40%), nausea (12–14%), vomiting (14–32%), bleeding (8–30%), dysphagia (4–9%), anorexia (6–10%), perforation (3%) and lymphadenopathy (10–15%).
…To date, many aspects of primary gastric lymphoma need to be stated: preoperative diagnosis is improving and this is very important not only for staging but also to plan a correct therapy. In fact, the prognosis is better than for other gastric tumors (12),
…Stage of the disease and grade of the lesion are the most important prognostic factors. In fact, depth of the invasion of the wall and size of the tumor measured at the intervention are important survival factors, as reported in previous studies (1) (80.8% of five-year survival for tumors smaller than 5 cm vs. 44.4% for larger lesions, p < 0.05).
…Management of gastric lymphoma is still being discussed and as yet the value of the respective treatment modalities is not well defined. Actually, results from the literature support both, chemo- or radiotherapy, and surgery (1, 4, 14–19).
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12.Dworkin B, Lightdale C J, Weingrad D N. et al. Primary gastric lymphoma. A review of 50 cases. Dig Dis Sci. (1982);27(11):986–992. [PubMed: 7140495]
14.Gobbi P G, Dionigi P, Barbieri F. et al. The role of surgery in the multimodal treatment of primary gastric non-Hodgkin lymphomas. A report of 76 cases and review of the literature. Cancer. (1990);65:2528–2536. [PubMed: 2186852]
19.Weingrad D N, Decosse J L, Sherlock P. et al. Primary gastric lymphoma: a 30 year review. Cancer. (1982);49:1258–1265. [PubMed: 7059947]