An 81-year-old-man was admitted to the emergency department on August 2, 2010 for an acute onset of abdominal pain. Loss of appetite and general weakness had started a few weeks earlier, getting worse recently. No fever was noted at home. Physical examination showed multiple purpura on the trunk and both lower extremities with gum bleeding. There was no enlargement of lymph nodes and organomegaly by palpation. In his medical records, he underwent right hemicolectomy and partial duodenopancreatectomy with splenectomy for stage IIIC (pT4bN2aM0, restaging by the American Joint Committee on Cancer staging system, 7 th edition) ascending colon cancer in July 2006. He received adjuvant chemotherapy and was regularly followed as recommended by the National Comprehensive Cancer Network practice guidelines and was free of disease until March 2010.
Under the impression of colon cancer recurrence, an abdominal CT scan was performed. The CT scan revealed massive ascites and thickening of peritoneum and bowel walls, which was compatible with peritoneal carcinomatosis. (Figure 1) His complete blood cell counts showed hemoglobin level of 12.5 g/dL, total leukocyte count of 15 × 109/L with 70% neutrophils, 15% lymphocytes, 9% monocytes, 4% eosinophils; and platelet count of 11 × 109/L. Blood biochemical test results were unremarkable. While evaluating the evidence of recurrence, ascites tapping was performed for both diagnostic and palliative purposes, with the following results: ascites white blood cell count of 52,210/mm3, protein level of 2,600 mg/dL, albumin level of 2.5 g/dL (serum albumin, 3.5 g/dL) and serum-ascites albumin gradient of 1.0 g/dL. The patient was diagnosed with peritoneal carcinomatosis and was transferred to a local hospital for palliative care.
After 7 days, cytology of ascites showed atypical lymphoid cells. Additional lymphocyte surface markers by immunohistochemical and molecular studies revealed positive results for CD79a, CD20 and Ki-67 (80%), but negative for CD3, suggesting a malignant lymphoma of B-cell lineage. (Figure 2) LDH levels of his serum and ascites were elevated up to 1,866 U/L and 2,200 U/L, respectively (normal value, 101-202 U/L). Based on these findings, he was diagnosed with diffuse large B-cell lymphoma presenting with peritoneal lymphomatosis and ascites.
After informing the patient and his family of the final diagnosis and the possibility that diffuse large B cell lymphoma may better respond to chemotherapy, the patient visited the ER once again. One day after his admission to ER, he had refractory metabolic acidosis due to tumor lysis syndrome, and he began continuous renal replacement therapy. Because of difficulties in patient positioning and the family's concern about possible bleeding complication, bone marrow biopsy could not be performed. The patient underwent dexamethasone treatment followed by R-CVP considering his poor performance status, but he died due to respiratory complications and multi-organ failure one month after he was diagnosed with peritoneal lymphomatosis. An autopsy could not be performed due to family's refusal. The refractory thrombocytopenia was thought to be the result of bone marrow involvement. If we had suspected the possibility of peritoneal lymphomatosis and closely communicated with pathologist, 3 to 4 days might have been saved and an appropriate therapeutic intervention could have begun before the patient's condition deteriorated.