Adult abdominal Burkitt lymphoma with isolated peritoneal involvement

Abstract

Burkitt lymphoma is a fast-growing high grade B-cell neoplasm that rarely affects adults. Three clinical variants are described in the World Health Organization classification: endemic, sporadic, and immunodeficiency-associated. The non-endemic form typically presents as an abdominal mass in children. Symptoms usually occur due to mass effect or direct intestinal involvement. We describe a very unusual presentation of a sporadic Burkitt lymphoma case in a 61-year-old male with diffuse peritoneal and omental involvement, without lymphadenopathies, mimicking peritoneal carcinomatosis.

Keywords: Burkitt lymphoma; multidetector computed tomography; omental caking; peritoneal neoplasm.

Figure 1

Sixty-one-year-old male with Burkitt lymphoma. Upper abdominal ultrasound using a curve probe (3–5 MHz). a) Longitudinal scan of the right hypochondrium shows peritoneal anechoic effusion in the Morison pouch (asterisk); b) Transversal scan of the epigastric region demonstrates heterogeneous nodular thickening of the anterior abdominal wall.

Figure 2

Sixty-one-year-old male with Burkitt lymphoma. Plain and contrast enhanced CT of the abdomen (Scanner: Multidetector CT Philips Brilliance 16-slices®. Protocol: 250mAs, 120kV, 5mm slice thickness, 100ml iobitridol Xenetix® (350 mg Iodine/ml)). a) Axial plain CT shows diffuse nodular thickening of the peritoneum in the lesser sac (arrows). At the same level, axial contrast enhanced CT in the arterial b) and portal phase c) shows heterogeneous enhancement of the nodular peritoneal thickening (arrows); d) Axial contrast enhanced CT, at a more cranial level, demonstrates low attenuation free peritoneal effusion also filling the lesser sac (asterisk).

Figure 3

Sixty-one-year-old male with Burkitt lymphoma. Axial and plain contrast enhanced CT of the abdomen (Scanner: Multidetector CT Philips Brilliance 16-slices®. Protocol: 250mAs, 120kV, 5mm slice thickness, 100ml iobitridol Xenetix® (350 mg Iodine/ml)); a) Plain axial CT demonstrates diffuse thickening of the greater omentum resulting in a large mass-like appearance with caking effect (arrows). Contrast enhanced CT in the arterial phase at different levels b), c) and d) reveals heterogeneous enhancement and a diffuse vascular net (arrows).

Figure 4

Sixty-one-year-old male with Burkitt lymphoma. Multiplanar reconstruction in the coronal a) and sagittal b) plan of a contrast enhanced CT of the abdomen and pelvis in the portal phase (Scanner: Multidetector CT Philips Brilliance 16-slices®. Protocol: 250mAs, 120kV, 5mm slice thickness, 100ml iobitridol Xenetix® (350 mg Iodine/ml)). There is a diffuse nodular heterogeneous thickening of the peritoneum (arrows) and low attenuation free peritoneal effusion; no enlarged lymph nodes were noted.

Figure 5

Hematoxylin & Eosin high power view (x400) of the peritoneal thickening biopsy shows sheets and cords of intermediate size lymphocytes. They have round nuclei and small nucleoli with high nuclear/cytoplasm ratio, hyperchromasia and apoptotic bodies. Several mitotic figures were identified as well as numerous macrophages containing cellular debris giving ‘starry sky’ appearance, a typical feature of Burkitt lymphoma.

Figure 6

Immunorreactivity high power view (x400) of the peritoneal thickening biopsy. a) Using antibody against CD20 - there was intense positive immunoreactivity; b) Using antibody against BCL6 - positive immunorreactivity occurred in about 50% of the neoplastic cells c) Using antibody against Ki-67 - there is intense positive immunorreactivity in the neoplastic cells (expressed in >90%), characteristic features of Burkitt lymphoma.