Patient Complaining of Abdominal Pain Found to Have Unusual Case of DLBCL

Patients with diffuse large B-cell lymphoma (DLBCL) most commonly present with masses involving the lymph nodes in the neck, abdomen, or mediastinum, and with symptoms that include weight loss and night sweats.

However, a new case report underscores the variability of the disease. In the case, a patient was found to have a large cystic left retroperitoneal mass that was later diagnosed as DLBCL. The report was published in Cureus.

The World Health Organization has recognized a “relatively rare” subtype of DLBCL in which patients present with a mass in the setting of chronic inflammation or in the growth wall of a preexisting cyst, noted the study authors. Yet, the patient described in the report had neither chronic inflammation nor a preexisting cyst.

“To our knowledge, this is the first case to be reported adding to the already diverse presentation of the disease,” the authors wrote.

The patient was a 53-year-old Black woman with several preexisting health conditions, including chronic iron deficiency anemia, asthma, hypertension, and type 2 diabetes. When she arrived at the hospital, she complained about fatigue, shortness of breath, and pain on the left side of her abdomen. Those symptoms had been going on for a month, but now the patient was also experiencing fever and diarrhea.

Upon examination, her physicians noted a large soft palpable mass in the left upper abdominal quadrant. A subsequent CT scan showed a large mass measuring 21 by 15.5 by 22 cm. It was a predominantly cystic, left retroperitoneal mass with thickened, enhancing walls that was so large it had displaced her left kidney and stomach. The scan also showed multiple enlarged retroperitoneal/para-aortic lymph nodes, the authors said.

After a meeting of a multidisciplinary team, the patient underwent a biopsy, during which surgeons also drained 1.4 L of fluid from the cystic component of the mass. The drainage led to a marked improvement of the patient’s symptoms, the authors said.

The biopsy and cytology confirmed that the patient had large B-cell lymphoma, but because the drainage had relieved her symptoms, her physicians decided to refer the patient for chemotherapy instead of performing surgery to remove the mass.

The patient completed her first cycle of chemotherapy, but then she suffered a fall at home during which she hit the left upper quadrant of her abdomen. A CT scan at the hospital suggested splenic rupture. At that point, the patient underwent surgery to remove both her spleen and the cystic mass. The patient was discharged 7 days later and at the study’s writing, was continuing to undergo outpatient chemotherapy.

The authors said their case shows that, even though rare, hematological cancers should be considered when encountering cystic masses of unknown origin. They said a thorough evaluation with a biopsy is also necessary before surgery is warranted.

“Ultimately, these patients will require chemotherapy which remains the standard of care and surgery may still be required for symptomatic relief for some patients,” they said.

Reference

Genualdi J, Orach T, Gumbs S, Ausqui G, Donaldson B, Ramcharan A. Traumatic rupture of cystic left retroperitoneal mass: an atypical presentation of diffuse large B-cell lymphoma. Cureus. Published online April 18, 2023. doi:10.7759/cureus.37797