Case 004: 79 Year Old Male with a Small Bowel Ulcer

Contributed by Andre Thompson, M.D. and Kaori Saito, M.D. Supervised by Nadeem Zafar, M.D.

Clinical History

A 79 year old Caucasian male with history of coronary artery disease and prostate cancer presents with diffuse abdominal pain x6 weeks. Abdominal CT reveals a large mass centered around the small bowel loops and extensive intra-abdominal and retrocrural lymphadenopathy. At exploratory laparotomy, a large ulcerating mass in the ileum, a mass in the root of the mesentery (peritoneal implant), and multiple enlarged abdominal lymph nodes were observed and excised.

Gross Findings

  1. "Peritoneal implant": a 0.3 X 0.3 X 0.2 cm tan-white soft tissue fragment; received fresh for frozen section.
  2. "Abdominal Lymph Node ": 2.8 X1.8 X 0.9 cm soft tissue mass; received fresh for frozen section.
  3. "Segment of ileum": a portion of small intestine measuring 6.5 X 5.0 X 2.8 cm and containing an ulcerated, nodular tumor measuring 5.0 X 3.5 cm with 1.2 cm invasion into the bowel wall.

Microscopic Findings

(Click a photo to view a larger image.)

Image (1) H&E, 4x - Ileal ulcer Image (2) H&E, 4x - Abdominal lymph node Image (3) H&E, 20x - Ileal ulcer Image (4) H&E, 20x - Abdominal lymph node Image (5) H&E, 40x - Ileal ulcer Image (6) H&E, 40x - Abdominal lymph node Image (7) CD79a, 20x - Ileal ulcer Image (8) BCL2, 20x - Ileal ulcer Image (9) Gross image - The ileal ulcer

Diagnosis

Diffuse Large B-cell Lymphoma. The tumor cells are essentially large and include many giant/multinucleated forms. The cells show very brisk mitotic activity and cellular necrosis. The tumor cells are positive for CD20, CD79a, BCL2, and LCA and negative for CD3, CD30, EMA, and CD10, with kappa and lambda light chains non-contributory. The flowcytometry study was limited by extremely low (14%) viability of the sample; the majority of cells evaluated were B cells expressing CD19, FMC-7 and bright CD20. CD10, CD23, HLA-DR, and light chains were either dim or absent.