University of Connecticut Health Center Farmington, CT
Sheena Mago, DO1, Perry K. Pratt, Jr., MD2, Houman Rezaizadeh, MD1; 1University of Connecticut Health Center, Farmington, CT; 2University of Connecticut, Farmington, CT
Introduction: Extranodal lymphomas are less prevalent, with only 30% of non-Hodgkin lymphomas arising from sites other than the lymph nodes, spleen, or bone marrow. The gastrointestinal tract has been found to be a predominant site of extranodal lymphoma – specifically B cell lymphoma. Though exceedingly rare, extranodal lymphoma stemming from a primary ampullary origin can present with non-specific symptoms and be challenging to diagnose.
Methods: An 85-year-old male with a history of melanoma (stage IIC; treated with wide excision), basal cell carcinoma (treated with Mohs surgery), provoked PE and atrial fibrillation on Apixiban 2.5mg twice a day was evaluated for non-specific symptoms of chronic anemia, dyspepsia, and weight loss. Recent PET scan demonstrated an FDG-avid left lower lobe lung nodule not able to be biopsied due to size and labs were notable for hemoglobin of 12.5g/dL with normal iron studies. Endoscopic evaluation was notable for a medium-sized non-bleeding villous mass in the ampulla (Figure 1) which was biopsied and showed atypical lymphoid infiltration suspicious for a lymphoma. An endoscopic ultrasound (EUS) was performed for better characterization and flow cytometry but due to the presence of a large paraesophageal hernia, the ampulla could not be evaluated. Instead, abnormal lymph nodes < 10mm in the gastrohepatic and peripancreatic region were noted and localized wall thickening in the fundus of the stomach was seen with targeted biopsies performed. Histopathologic and immunohistochemical evaluation showed atypical lymphoid infiltrates located mainly in the lamina propria which stained positive for CD-20, BCL-2, and Kappa, confirming the diagnosis of B-cell non-Hodgkin’s lymphoma. Discussion: While the majority of B-cell non-Hodgkin’s lymphoma have an indolent course, some cases are far more aggressive and are associated with a poor prognosis and high mortality if undiagnosed and untreated. Given the low incidence of extranodal gastric lymphoma and even rarer occurrence of ampullary lymphoma, a standardized diagnostic work-up and management - including endoscopic evaluation - has not been formulated. We presented a case of primary extranodal ampullary B cell non-Hodgkin’s lymphoma. As demonstrated in this case, the presence of extranodal lymphoma can be missed on PET scan. This stresses the importance of high clinical suspicion for early diagnosis, when non-specific gastrointestinal symptoms are present.
Ampullar mass seen en face
Disclosures: Sheena Mago indicated no relevant financial relationships. Perry Pratt indicated no relevant financial relationships. Houman Rezaizadeh indicated no relevant financial relationships.