VPS Lakeshore Hospital & Research Centre Kochi, Kerala, India
Kiran U. Revankar, MBBS, MD1, Roy j. Mukkada, MBBS, MD, DNB, MNAMS, FRCP2, Sreevidya B. Pillai, MBBS, MD3, Jerry Abraham, MBBS, MD2 1VPS Lakeshore Hospital & Research Centre, Kochi, Kerala, India; 2VPS Lakeshore Hospital & Research Centre, Cochin, Kerala, India; 3VPS Lakeshore Hospital, Cochin, Kerala, India
Introduction: Diffuse Large B-Cell Lymphoma (DLBCL) is the most common subtype of Non-Hodgkin's Lymphoma which has variable clinical presentation, the most common being lymphadenopathy. Though obstructive jaundice is seen in the late phase of the disease, it is rarely a presenting symptom. DLBCL usually mimics Cholangiocarcinoma in imaging studies, however, their treatment and prognosis are radically different, hence it’s important to differentiate these two conditions at an early stage.
Case Description/Methods: A 42-year-old gentleman presented to the OPD with yellowish discoloration of eyes, pruritus, and high-colored urine, associated with anorexia and significant weight loss for one month. He was on herbal medications for the last 3 months for his lower backache and was also diagnosed with Hepatitis B in the past. On examination, there was axillary and inguinal lymphadenopathy with moderate splenomegaly. His Liver Function Test (LFT) was suggestive of obstructive jaundice with an elevation of CA 19-9 (51.80). His Hepatitis B workup was reactive to only total Anti-HBc. USG abdomen showed Intra Hepatic Biliary Radicle Dilatation with the prominent proximal common bile duct. CT abdomen revealed a hypodense heterogeneous area in the portal hilar region suggestive of Cholangiocarcinoma with multiple lytic bony lesions and erosive masses suggestive of metastasis. He underwent ERCP with brush biopsy which revealed tight hilar stricture for which stent was placed only in the right biliary duct as the left biliary duct couldn’t be cannulated. His LFT improved significantly post-procedure. He was subjected to PET CT which showed features suggestive of lymphoma with solid organ (liver, spleen) and bony metastasis. CT-guided right iliac bone lesion biopsy and Tru-Cut biopsy of left axillary lymph node were suggestive of B-cell lymphoma and Immunohistochemistry results (positive for CD10, CD20, Bcl 2, Ki 67) were consistent with DLBCL.
Discussion: DLBCL is an aggressive form of B cell lymphoma, however, it has a good response to chemotherapeutic agents. Involvement of the biliary system in the NHL is a rare phenomenon and its radiological appearance usually mimics Cholangiocarcinoma. As the treatment approach and prognosis are fundamentally different, NHL should be kept as a differential diagnosis in patients presenting as malignant obstructive jaundice especially when it's associated with lymphadenopathy and splenomegaly. This case report even raises the question of the association of NHL with the Hepatitis B virus.
Figure: Figure 1: Radiological and Histopathological images of a 42-year-old male presented as metastatic Cholangiocarcinoma. A) CT Abdomen showing heterogenous hypodense lesion at portal hilar region suggestive of Cholangiocarcinoma(Yellow Star) with vertebral lytic lesions(Red Arrow) suggestive of metastasis. Moderate IHBRD can be noted (white arrowhead) and gross splenomegaly (asterixis). B &C, PET CT imaging suggestive of infiltration into liver and spleen (black arrows), and bone involvement (green arrowhead showing infiltrating erosive masses at the right iliac bone).D)Cholangiogram suggestive of the hilar stricture with right IHBRD, Left biliary duct couldn't be canulated. Brush biopsy was negative for Cholangiocarcinoma. E) Iliac bone biopsy showing marrow infiltrated by sheets of medium to large atypical mononuclear cells, inset showing IHC marker Ki 67 positive for more than 70% of the tumour cells. F) Immunohistochemistry showing cells are positive for CD 10, CD20, and BCL2 suggestive of DLBCL.
Disclosures: Kiran Revankar indicated no relevant financial relationships. Roy Mukkada indicated no relevant financial relationships. Sreevidya Pillai indicated no relevant financial relationships. Jerry Abraham indicated no relevant financial relationships.
Kiran U. Revankar, MBBS, MD1, Roy j. Mukkada, MBBS, MD, DNB, MNAMS, FRCP2, Sreevidya B. Pillai, MBBS, MD3, Jerry Abraham, MBBS, MD2. P2146 - A Rare Case of Non-Hodgkin's Lymphoma Presenting as Metastatic Cholangiocarcinoma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.