Non Hodgkin lymphoma with peritoneal localization: case report

Abstract

INTRODUCTION: The gastrointestinal tract is the most common extranodal site involved by lymphoma and its affection usually is a result of a widespread nodal disease. The majority of the extranodal lymphomas are Non-Hodgkin type, they are characterized by an intermediate or high grade dysplasia, and the extranodal involvement is considered a poor prognostic factor. Any organ or tissue can be affected, but diffuse and extensive peritoneal cavity involvement is rare. CASE REPORT: A 57-year-old woman was admitted to the Clinic of gastroenterohepatology because of ascites. The performed examinations (abdominal ultrasound and CT, digestive tract endoscopy) did not discover any pathological findings affecting parenchymal organs or digestive tract, except for diffusely thickened peritoneum. Peripheral, mediastinal or retroperitoneal lymphadenopathy was not registered. A small unilateral pleural effusion was diagnosed. Laboratory tests found elevated leukocyte count (from 9.8х109 before admission to 16.7х109 during the stay) with granulocytes predominance (80%). The peripheral blood smear did not discover immature blood cells. The biochemistry test showed remarkable values of LDH-3194 U/L, uric acid-1068 μmol/L, creatinin-227μmol/L. Among the tumor markers CA 125 was elevated (597.9 U/ml), and CEA, CA 19-9 and CA 72-4 were within the normal range. The peritoneal fluid was chylous, with high levels of CA 125-4221 U/ml, LDH-32585 U/L and ADA-122.9 U/L. The cytology from the peritoneal and pleural fluid did not show presence of malignant cells (cytology class I). The investigations towards diagnosing specific peritonitis (acid-fast staining, Lowenstein-Jensen culture and Mauntoux test) were negative. The diagnostic laparoscopy performed at the Clinic of gastroenterohepatology revealed only thickened peritoneum, and the histology of the peritoneal biopsies did not reveal the nature of the findings. The histology of the biopsy taken during the surgical laparoscopy discovered diffuse neoplastic lymphoid peritoneal and omental infiltration as part of an aggressive type of B cell Non-Hodgkin lymphoma. The immunohistochemical study showed CD 20+ expression with proliferative fraction higher than 80%, proving diffuse large B cell lymphoma. During the diagnostic process the patient developed progressive cardiorespiratory deterioration which soon led to a lethal outcome. CONCLUSION: The gastrointestinal lymphoma and especially the peritoneal lymphomatosis is very rare, does not have specific clinical presentation and can resemble to other neoplastic or inflammatory conditions, which makes the diagnosis difficult. In cases of ascites of unknown origin laparoscopy with peritoneal biopsy is the only procedure that can differentiate lymphoma with peritoneal localization. Accurate and early diagnosis enables the application of an appropriate treatment.