EP143 - Burkitt Lymphoma Presenting As Gastrointestinal Bleeding And Partial Colonic Obstruction

Purpose/Background: Burkitt lymphoma is an aggressive high-grade B-cell lymphoma that typically presents as a growing mass and rarely in adults (1,2). We present an unusual case of an older patient who presented with a partially obstructing transverse colon mass resulting in gastrointestinal bleeding.

Methods/Interventions: This is a case of a 64-year-old male with history of epithelioid hemangioendothelioma of T7, status post decompressive laminectomy and adjuvant radiation 20 years prior to presentation, who presented with abdominal pain and symptomatic anemia. Past medical history included iron deficiency anemia, hypertension, diabetes mellitus, coronary artery disease, gastroesophageal reflux and Barrett’s esophagus. At the time of presentation, hemoglobin was 7.6 from a baseline of 13. The patient reported a one month duration of melanotic stools. An upper endoscopy two years prior demonstrated distal esophageal Barrett’s, moderate diffuse gastritis and biopsy was negative for H pylori. Colonoscopy five years prior demonstrated diverticulosis and a single tubular adenoma in the cecum.

Upper and lower endoscopic evaluation were performed shortly after admission. Upper endoscopy demonstrated moderate chronic focal active gastritis with focal intestinal metaplasia. Colonoscopy was significant for a partially obstructing and friable mass in the transverse colon. Pathology demonstrated distorted lymphoid aggregates. CT scan of the abdomen and pelvis revealed a near obstructing mid transverse colon mass measuring approximately 11.4 x 8.3 cm (Figure 1). CEA was 1.0. CT scan of the chest was negative for evidence of metastatic disease.

The patient underwent exploratory laparotomy, extended ascending colectomy with en bloc partial gastrectomy, greater omentectomy, end ileostomy with distal transverse colon mucous fistula.

Results/Outcomes: Pathology demonstrated high-grade large B-cell lymphoma with a high proliferation rate. It was noted that the mass had invaded through colon wall into the pericolic tissue with serosal involvement and direct extension to the gastric muscularis propria. Lymphovascular and perineural invasion were present with 25 mitoses per 10-HPF. All margins were negative and 1 out of 15 lymph nodes were positive.

Postoperatively, the patient developed an ileus which resolved with supportive care, and he recovered well with cessation of gastrointestinal bleeding. PET CT scan was performed following surgery and demonstrated numerous intraperitoneal soft tissue deposits with significant FDG avidity consistent with malignancy. The patient was started on chemotherapy with plans to receive 6 cycles of R-EPOCH (3).

Conclusion/Discussion: As only a handful of cases in the literature describe similar presentations, it is crucial to consider the diagnosis of Burkitt Lymphoma even in atypical locations given the aggressive nature of the disease process.

Figure 1
(A) Axial and (B) coronal CT scan images demonstrating a large mass lesion of the mid transverse colon resulting in near complete obstruction with moderate distention of the proximal transverse and ascending colon.