Ulcerated Gastric Large Diffuse B-Cell Lymphoma In A 95-Year-Old Female

INTRODUCTION: Gastric lesions are commonly benign and include mucosal or mesenchymal tumors. Malignant lesions include adenocarcinoma, lymphoma, stromal and neuroendocrine tumors. Primary gastric lymphomas are an uncommon etiology for gastric lesions. We describe a case of primary gastric Diffuse large B-Cell lymphoma in a patient with concomitant myelodysplastic syndrome. CASE DESCRIPTION/METHODS: The patient is a 95 year old female with a history of myelodysplastic syndrome that presented to the hospital for syncope. Labs on presentation showed a hemoglobin of 5.4, WBC 15.4, platelet 837, BUN 56, and Creatinine 1.36. The patient was transfused two units of packed red blood cells and her hemoglobin increased to 8.3. Rectal exam was performed revealing heme-positive stool with reported episodes of melena at home. Twice daily pantoprazole was initiated. She underwent endoscopic evaluation demonstrating an ulcerated gastric lesion within the stomach body. Biopsy was performed resulting in atypical/neoplastic lymphocytes infiltrating the gastric lamina propria consistent with diffuse large B cell lymphoma. Immunostains were positive for CD45, CD20, PAX5, MUM1, BCL2, c-myc, BCL6 and CD30. The patient’s hemoglobin remained stable and she was discharged to follow up with oncology. One month after discharge, the patient denied wanting to pursue systemic therapy and underwent external beam radiation. The patient required multiple blood transfusions in the following months and ultimately pursued chemotherapy with R-CHOP five months following her diagnosis. DISCUSSION: Primary gastric lymphomas are rare, representing 0.9% of gastrointestinal tumors and up to 5% of gastric malignancies. It is considered an extranodal form of Non-Hodgkin's lymphoma. Large diffuse B-cell lymphoma is one common subtype and according to the National Cancer Institute, at time of diagnosis, the majority of patients have stage 4 disease severity with a corresponding 5 year survival rate of 52.7%. Presenting symptoms may be nonspecific and can mimic other disorders such as peptic ulcer disease or gastritis. Up to 30% of patients report gastrointestinal bleeding as a presenting or associated symptom. Mainstay treatment is 3–4 rounds of R-CHOP therapy with or without radiation. Surgery is reserved for patients with perforation, hemorrhage or obstruction. Our patient presented with symptomatic anemia inducing a syncopal episode likely form gastrointestinal blood loss. As of now, the patient has had a total of 2 cycles of R-CHOP therapy.Figure 1.: Ulcerated mass in the stomach body.Figure 2