Dysphagia as Inaugural Presentation of Lymphoma: a Diagnosis Hard to Swallow

Aims

Methods

Results An 18-year-old woman, with no relevant medical history, presented at the Emergency Department for progressive dysphagia, initially for solids and later for liquids, associated with weight loss of 10 kg within 9 months. She had a mild increase in C-reactive protein (3.18 mg/dL; N <0.5). A stenosis of the middle third of the esophagus was identified in esophagogastroduodenoscopy, patent only to the ultra-thin endoscope with normal mucosa, suggesting extrinsic compression. Biopsies of the stenosis showed nonspecific infiltration of the mucosa by normal B lymphocytes. Cervicothoracic CT scan revealed thickening of the upper half of the esophagus, densification of the mediastinal fat and lung parenchyma, and peri-tracheal and hilar adenopathies. The 18-FDG-PET-scan revealed hypermetabolic uptake of the esophagus, supra-diaphragmatic lymph nodes, pleuropulmonary tissue, muscle and bone marrow, suggestive of high-grade malignancy. Days later, the patient developed right cervicobraquial paraesthesia in relation to a growing cervical mass causing spinal compression from C5 to D1 vertebrae. A guided-ultrasound biopsy followed by a first surgical biopsy of this mass were also inconclusive, so we performed a second surgical macrobiopsy, which finally allowed the definitive diagnosis of an unclassifiable non-Hodgkin B-cell lymphoma, after an extensive workup excluding infectious, autoimmune, immunodeficiency or other malignancy causes. The patient started chemotherapy regimen with R-CHOP followed by R-EPOCH, with symptomatic remission and complete response on 1-month 18-FDG-PET-scan after completion of therapeutic protocol.

Conclusions Less than 1 % of lymphomas involve the esophagus, and even rarer are the reports of dysphagia as its presentation, being the 2^nd case in which dysphagia resulted from extrinsic compression/infiltration of the esophageal wall without mucosa macroscopic involvement. Although a young patient, the concomitance of constitutional symptoms with dysphagia should raise lymphoma hypothesis in the differential diagnosis. Additionally, this case highlights the challenging histopathological diagnosis often requiring multiple biopsies. Endoscopic, imaging and histological iconography is presented.

Citation: Bento-Miranda M, João M, Gravito-Soares E et al. eP24 DYSPHAGIA AS INAUGURAL PRESENTATION OF LYMPHOMA: A DIAGNOSIS HARD TO SWALLOW. Endoscopy 2021; 53: S104.

Publication History

Article published online:
19 March 2021