Mantle Cell Lymphoma Presenting with Severe Upper GI Bleeding.

Mantle Cell Lymphoma Presenting with Severe Upper GI Bleeding. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Mantle Cell Lymphoma Presenting with Severe Upper GI Bleeding. Khaled Ali, Mhd Baraa Habib, Ferial Alloush, Mohamed A. Yassin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-439768/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Although it usually involves extra-nodal sites such as gastrointestinal tract in more than 80% of case, Mantle cell lymphoma is considered a rare cause of gastrointestinal bleeding, especially a severe and life-threatening bleeding. We are reporting a 60 year old man, known to have peptic ulcer disease, who presented with a severe upper GI bleeding and found to have large gastric ulcer, which diagnosed as primary gastric mantle cell lymphoma. Clinical Pharmacology Scientific Communication Mantle cell lymphoma GI bleeding gastrointestinal tract Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction One of the mature B cell non-Hodgkin lymphomas (NHL) is mantle cell lymphoma (MCL). Although it is often discussed alongside clinically indolent types of NHL, its behavior is more often that of a disease that is aggressive 1 . In the United States and Europe, MCL accounts for about 7% of adult non-Hodgkin lymphomas, with an annual occurrence of 4 to 8 cases per million people 1 . MCL may affect any part of the digestive tract, with lymphomatous intestinal polyposis being an occasional presenting 2 . The stomach (57 percent), duodenum (52 percent), jejunum/ileum (87 percent), colon (90 percent), and rectum (69 percent) were all included in a prospective clinicopathologic review of 31 cases of gastrointestinal tract involvement 3 . Patients with gastric lymphoma have nonspecific symptoms that are close to those seen in more common gastric conditions like peptic ulcer disease, gastric adenocarcinoma, and non-ulcer dyspepsia. Occult gastrointestinal bleeding constitutes around 19 percent of the presenting symptoms of all gastric lymphomas 4 . We present a case of mantle cell lymphoma initially presenting with unusual massive upper gastrointestinal bleeding. Case Presentation A 60-year-old, Pakistani gentleman, previously healthy apart from history of peptic ulcer disease which was diagnosed four months prior to the admission in his home country by endoscopy and treated medically with antibiotics as per the patient. He presented to our hospital with a few days’ history of recurrent episodes of black tarry stool, with mild nausea and heartburn, but no vomiting or frank abdominal pain. The patient denied any history of consuming alcohol, painkillers, or herbals. On admission, blood pressure was 115/67 mmHg and heart rate 115 beats per minute. Physical examination otherwise was unremarkable. Initial blood test showed Hb 6.6 g/dl (Table 1). He was admitted under short stay and taken to Esophagogastroduodenoscopy (EGD). EGD showed Large Rolled Edges Greater Curvature ulcer with eccentric blood vessel (Fig. 1). Endoclip was deployed but the vessel started oozing heavily after that. the patient was shifted to intensive care unit for stabilization and monitoring. Table 1 laboratory tests upon admission. Detail Value w/Units Normal Range Beta 2 Microglobulin 2.21 mg/L 0.80-2.20 WBC 10.2 x10^3/uL 4.0-10.0 Hgb 6.3 gm/dL 13.0-17.0 MCV 87.0 fL 83.0-101.0 Platelet 233 x10^3/uL 150-400 INR 1.1 APTT 21.9 seconds 24.6-31.2 Urea 17.0 mmol/L 2.5-7.8 Creatinine 68 umol/L 62-106 ALT 13 U/L 0-41 Retic # 144.8 x10^3/uL 50.0-100.0 Retic % 6.2 % 0.5-2.5 Interventional radiology team was contacted for embolization. There was no contrast extravasation during CT angio by interventional radiology, so no embolization done. CT abdomen with contrast showed features of gastric carcinoma with cervical peri gastric and possibly left paraaortic metastatic lymph nodes and suspected transverse mesocolon peritoneal nodules. During hospitalization, the patient developed multiple episodes of symptomatic anemia and melena. He was treated conservatively by blood transfusion and started on Traneximic acid for 3 days. Biopsy revealed Mantel cell lymphoma. Therefore, the patient underwent urgent hemostatic Radiotherapy. Histopathology Sections from the gastric biopsy (Fig. 2) show expansion of the lamina propria with sheets of small monotonous lymphocytes with small nuclei and perinuclear clearing artifact. No large cells or lymphoepithelial lesions identified. There are adjacent areas of ulceration and intestinal metaplasia (not shown). By immunohistochemical stains, the neoplastic cells are of B-cell nature which stained positive with CD20 (Fig. 3), and co-express CD5 (Fig. 4), cyclin-D1 (Fig. 5) and SOX-11 (not shown). They are also positive for BCL2. The proliferation marker Ki-67 is positive in 20% of cells (not shown). The neoplastic cells are negative for CD10 and CD23 (not shown). The non-neoplastic T cells are highlighted with CD3 (not shown). The morphologic and immuno-phenotypical features are consistent with mantle cell lymphoma. Discussion At the time of diagnosis, the majority of MCL patients are in an advanced stage of the disease (70 percent). While lymphadenopathy is the primary symptom in around 75% of patients, extranodal disease is the primary clinical manifestation in the remaining 25% 5 . The lymph nodes, spleen (45 to 60 percent), Waldeyer's ring, bone marrow (> 60 percent), blood (13 to 77 percent), and extranodal sites like the gastrointestinal tract, breast, pleura, and orbit are all common sites of involvement 56 . The explanation for mantle cell lymphoma's affinity for the gastrointestinal tract is unknown 6 . Patients with mantle cell lymphoma that has spread to the gastrointestinal tract may be asymptomatic, or experience a variety of symptoms, including abdominal pain, obstruction, diarrhea, melena, and hematochezia. The ileocecal region is the most common site of gastrointestinal tract involvement, but any area from the stomach to the rectum could be affected. In a study published by Romaguera et al., up to 26% of patients had gastrointestinal symptoms at the time of diagnosis 6 . Endoscopy can reveal MCL involvement in the gastrointestinal tract that is not visible on radiological imaging. During the staging process and during the follow-up period for MCL patients, endoscopic examinations are recommended 7 . Moreover, chemotherapy for primary gastrointestinal mantle lymphomas might result in potentially fatal gastrointestinal bleeding. Much attention should be paid to the prevention and treatment of PGIL gastrointestinal bleeding while receiving chemotherapy 8 . Conclusions MCL should be kept in mind when assessing massive upper GI bleeding, as an unusual cause of bleeding gastric ulcer. Also, predict the advancement of bleeding or onset of new bleeding after initiation of chemotherapy in patients with MCL. Declarations i. Funding: Not applicable. ii. Conflicts of interest/Competing interests: The authors report no conflict of interest. iii. Ethics approval: Not applicable. iv. Consent to participate: Due to the COVID-19 situation and its impact on direct patient contact, only verbal consent was obtained to publish this case. v. Consent for publication: Due to the COVID-19 situation and its impact on direct patient contact, only verbal consent was obtained to publish this case. vi. Availability of data and material (data transparency): Not applicable. vii. Code availability (software application or custom code): Not applicable. viii. Authors' contributions: K.A. wrote the initial draft of the manuscript and literature review, M.B.H. participated in literature review and editing the manuscript, F.A. Description of pathological findings, M.A.Y. Editing and revising. References Armitage JO, Weisenburger DD. New approach to classifying non-Hodgkin’s lymphomas: clinical features of the major histologic subtypes. Non-Hodgkin’s Lymphoma Classification Project. Journal of clinical oncology: official journal of the American Society of Clinical Oncology. 1998;16(8):2780–95. doi: 10.1200/JCO.1998.16.8.2780 . Isaacson PG, MacLennan KA, Subbuswamy SG. Multiple lymphomatous polyposis of the gastrointestinal tract. Histopathology. 1984;8(4):641–56. doi: 10.1111/j.1365-2559.1984.tb02377.x . Ruskoné-Fourmestraux A, Delmer A, Lavergne A, et al. Multiple lymphomatous polyposis of the gastrointestinal tract: prospective clinicopathologic study of 31 cases. Groupe D’étude des Lymphomes Digestifs. Gastroenterology. 1997;112(1):7–16. doi: 10.1016/s0016-5085(97)70212-9 . Wang T, Gui W, Shen Q. Primary gastrointestinal non-Hodgkin’s lymphoma: clinicopathological and prognostic analysis. Medical oncology (Northwood, London, England) . 2010;27(3):661–666. doi: 10.1007/s12032-009-9265-1 . Argatoff LH, Connors JM, Klasa RJ, Horsman DE, Gascoyne RD. Mantle cell lymphoma: a clinicopathologic study of 80 cases. Blood. 1997;89(6):2067–78. Romaguera JE, Medeiros LJ, Hagemeister FB, et al. Frequency of gastrointestinal involvement and its clinical significance in mantle cell lymphoma. Cancer. 2003;97(3):586–91. doi: 10.1002/cncr.11096 . Lee HH, Cho S-G, Lee IS, et al. Mantle cell lymphoma with gastrointestinal involvement and the role of endoscopic examinations. PLOS ONE. 2020;15(9):e0239740. Zheng W, Song Y, Lin N, Tu M, Liu W, Zhu J. Primary gastrointestinal mantle lymphoma with massive bleeding: a case report and literature review. Chinese journal of cancer research = Chung-kuo yen cheng yen chiu. 2013;25(2):250–3. doi: 10.3978/j.issn.1000-9604.2012.12.05 . Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-439768","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":33672836,"identity":"3436157e-fa72-4cd4-9789-3dfddf327f2b","order_by":0,"name":"Khaled Ali","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAv0lEQVRIiWNgGAWjYBACCQbmhgOJf2wSIBzitDA2HHjYkEaiFsaHDYdJ0CLZfrDxQOKO83n80w4/vMFQZkdYizRPItAvZ24XS9xOM7ZgOJdMWIscA1BLAtvtxIbbCWYSjG3MRGjhfwjSci5x/u30b0At9UQ4TALksLYDiRtu54BsOUxYi+QMkC1nkhM33s4ptkg4d5ywFonzyYc//qiwS5x3O33jjQ9l1YS1oIIENlJ1MDCQoWUUjIJRMAqGPwAAtxRDlP8QK4EAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-8073-4375","institution":"Hamad Medical Corporation","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Khaled","middleName":"","lastName":"Ali","suffix":""},{"id":33672837,"identity":"c6795a81-7cf7-4f3a-adfb-333a4c804f33","order_by":1,"name":"Mhd Baraa Habib","email":"","orcid":"","institution":"Hamad Medical Corporation","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mhd","middleName":"Baraa","lastName":"Habib","suffix":""},{"id":33672838,"identity":"1a334587-a239-4d87-b548-e98556e7af2c","order_by":2,"name":"Ferial Alloush","email":"","orcid":"","institution":"Hamad Medical Corporation","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ferial","middleName":"","lastName":"Alloush","suffix":""},{"id":33672839,"identity":"1d00a066-eead-40c9-9d41-3b6f102517e1","order_by":3,"name":"Mohamed A. Yassin","email":"","orcid":"","institution":"Hamad Medical Corporation","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"A.","lastName":"Yassin","suffix":""}],"badges":[],"createdAt":"2021-04-19 12:22:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-439768/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-439768/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":10529482,"identity":"ad371bdb-4b96-4567-894a-a2f6993968bd","added_by":"auto","created_at":"2021-06-18 14:19:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":885748,"visible":true,"origin":"","legend":"A, B: Large Rolled Edges Greater Curvature Ulcer.\nC, D: Bleeding during attempt to deploy Endoclip.\n","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-439768/v1/aa817313349894ef29cff62e.png"},{"id":10529655,"identity":"02ca2fa3-c852-4b05-ab1f-04d88b4d0a25","added_by":"auto","created_at":"2021-06-18 14:22:47","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":839550,"visible":true,"origin":"","legend":"Low magnification H\u0026E photo of the gastric biopsy.\nThere is a dense lymphocytic infiltrate in the lamina propria\n","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-439768/v1/3d35bd5867565dd33d342f47.jpeg"},{"id":10529656,"identity":"de0790ea-d591-4627-88e2-fb55e743b272","added_by":"auto","created_at":"2021-06-18 14:22:47","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":659002,"visible":true,"origin":"","legend":"CD20 immunohistochemical stain is positive in\nthe neoplastic lymphocytes, confirming the B cell nature.\n","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-439768/v1/7795014906fc0ce7029035cb.jpeg"},{"id":10530517,"identity":"7034c675-ef8a-4da4-ae7f-c45f617679aa","added_by":"auto","created_at":"2021-06-18 14:28:47","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":564242,"visible":true,"origin":"","legend":"CD5 immunohistochemical stain is expressed in\nthe non-neoplastic T cells in addition to the neoplastic B cells\n","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-439768/v1/fac5de30ab152fd96071ae38.jpeg"},{"id":10530181,"identity":"fd7c05f9-fe0c-480b-8df6-39178c08ee56","added_by":"auto","created_at":"2021-06-18 14:25:47","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":539614,"visible":true,"origin":"","legend":"Cyclin-D1 immunohistochemical stain is expressed in the neoplastic B cells\nconfirming the diagnosis of mantle cell lymphoma.\n","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-439768/v1/265af38fecee8c89c7230e83.jpeg"},{"id":16992481,"identity":"21e45300-53b7-42ff-9d23-bf2a566ce2a4","added_by":"auto","created_at":"2022-01-04 21:30:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2869819,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-439768/v1/10f4ba4e-ad1b-4230-a504-2f14a6429053.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eMantle Cell Lymphoma Presenting with Severe Upper GI Bleeding.\u003c/p\u003e","fulltext":[{"header":"Introduction","content":" \u003cp\u003eOne of the mature B cell non-Hodgkin lymphomas (NHL) is mantle cell lymphoma (MCL). Although it is often discussed alongside clinically indolent types of NHL, its behavior is more often that of a disease that is aggressive\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. In the United States and Europe, MCL accounts for about 7% of adult non-Hodgkin lymphomas, with an annual occurrence of 4 to 8 cases per million people\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. MCL may affect any part of the digestive tract, with lymphomatous intestinal polyposis being an occasional presenting\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. The stomach (57 percent), duodenum (52 percent), jejunum/ileum (87 percent), colon (90 percent), and rectum (69 percent) were all included in a prospective clinicopathologic review of 31 cases of gastrointestinal tract involvement\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePatients with gastric lymphoma have nonspecific symptoms that are close to those seen in more common gastric conditions like peptic ulcer disease, gastric adenocarcinoma, and non-ulcer dyspepsia. Occult gastrointestinal bleeding constitutes around 19 percent of the presenting symptoms of all gastric lymphomas\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe present a case of mantle cell lymphoma initially presenting with unusual massive upper gastrointestinal bleeding.\u003c/p\u003e "},{"header":"Case Presentation","content":"\u003cp\u003eA 60-year-old, Pakistani gentleman, previously healthy apart from history of peptic ulcer disease which was diagnosed four months prior to the admission in his home country by endoscopy and treated medically with antibiotics as per the patient. He presented to our hospital with a few days\u0026rsquo; history of recurrent episodes of black tarry stool, with mild nausea and heartburn, but no vomiting or frank abdominal pain. The patient denied any history of consuming alcohol, painkillers, or herbals.\u003c/p\u003e\n\u003cp\u003eOn admission, blood pressure was 115/67 mmHg and heart rate 115 beats per minute. Physical examination otherwise was unremarkable. Initial blood test showed Hb 6.6 g/dl (Table\u0026nbsp;1). He was admitted under short stay and taken to Esophagogastroduodenoscopy (EGD). EGD showed Large Rolled Edges Greater Curvature ulcer with eccentric blood vessel (Fig.\u0026nbsp;1). Endoclip was deployed but the vessel started oozing heavily after that. the patient was shifted to intensive care unit for stabilization and monitoring.\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003eTable 1\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003elaboratory tests upon admission.\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" style=\"border-collapse: collapse; margin: 0px auto;\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30.7165%;\" valign=\"top\" width=\"39.93399339933993%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDetail\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2485%;\" valign=\"top\" width=\"35.478547854785475%\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue w/Units\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 18.8262%;\" valign=\"top\" width=\"24.422442244224424%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNormal Range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30.7165%;\" valign=\"top\" width=\"39.93399339933993%\"\u003e\n \u003cp\u003eBeta 2 Microglobulin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2485%;\" valign=\"top\" width=\"35.478547854785475%\"\u003e\n \u003cp\u003e2.21 mg/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 18.8262%;\" valign=\"top\" width=\"24.422442244224424%\"\u003e\n \u003cp\u003e0.80-2.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30.7165%;\" valign=\"top\" width=\"39.93399339933993%\"\u003e\n \u003cp\u003eWBC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2485%;\" valign=\"top\" width=\"35.478547854785475%\"\u003e\n \u003cp\u003e10.2 x10^3/uL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 18.8262%;\" valign=\"top\" width=\"24.422442244224424%\"\u003e\n \u003cp\u003e4.0-10.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30.7165%;\" valign=\"top\" width=\"39.93399339933993%\"\u003e\n \u003cp\u003eHgb\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2485%;\" valign=\"top\" width=\"35.478547854785475%\"\u003e\n \u003cp\u003e6.3 gm/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 18.8262%;\" valign=\"top\" width=\"24.422442244224424%\"\u003e\n \u003cp\u003e13.0-17.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30.7165%;\" valign=\"top\" width=\"39.93399339933993%\"\u003e\n \u003cp\u003eMCV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2485%;\" valign=\"top\" width=\"35.478547854785475%\"\u003e\n \u003cp\u003e87.0 fL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 18.8262%;\" valign=\"top\" width=\"24.422442244224424%\"\u003e\n \u003cp\u003e83.0-101.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30.7165%;\" valign=\"top\" width=\"39.93399339933993%\"\u003e\n \u003cp\u003ePlatelet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2485%;\" valign=\"top\" width=\"35.478547854785475%\"\u003e\n \u003cp\u003e233 x10^3/uL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 18.8262%;\" valign=\"top\" width=\"24.422442244224424%\"\u003e\n \u003cp\u003e150-400\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30.7165%;\" valign=\"top\" width=\"39.93399339933993%\"\u003e\n \u003cp\u003eINR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2485%;\" valign=\"top\" width=\"35.478547854785475%\"\u003e\n \u003cp\u003e1.1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 18.8262%;\" valign=\"top\" width=\"24.422442244224424%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30.7165%;\" valign=\"top\" width=\"39.93399339933993%\"\u003e\n \u003cp\u003eAPTT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2485%;\" valign=\"top\" width=\"35.478547854785475%\"\u003e\n \u003cp\u003e21.9 seconds\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 18.8262%;\" valign=\"top\" width=\"24.422442244224424%\"\u003e\n \u003cp\u003e24.6-31.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30.7165%;\" valign=\"top\" width=\"39.93399339933993%\"\u003e\n \u003cp\u003eUrea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2485%;\" valign=\"top\" width=\"35.478547854785475%\"\u003e\n \u003cp\u003e17.0 mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 18.8262%;\" valign=\"top\" width=\"24.422442244224424%\"\u003e\n \u003cp\u003e2.5-7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30.7165%;\" valign=\"top\" width=\"39.93399339933993%\"\u003e\n \u003cp\u003eCreatinine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2485%;\" valign=\"top\" width=\"35.478547854785475%\"\u003e\n \u003cp\u003e68 umol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 18.8262%;\" valign=\"top\" width=\"24.422442244224424%\"\u003e\n \u003cp\u003e62-106\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30.7165%;\" valign=\"top\" width=\"39.93399339933993%\"\u003e\n \u003cp\u003eALT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27.2485%;\" valign=\"top\" width=\"35.478547854785475%\"\u003e\n \u003cp\u003e13 U/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 18.8262%;\" valign=\"top\" width=\"24.422442244224424%\"\u003e\n \u003cp\u003e0-41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30.7165%;\" valign=\"top\" width=\"39.93399339933993%\"\u003e\n \u003cp\u003eRetic #\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.4865%;\" valign=\"top\" width=\"35.478547854785475%\"\u003e\n \u003cp\u003e144.8 x10^3/uL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.6639%;\" valign=\"top\" width=\"24.58745874587459%\"\u003e\n \u003cp\u003e50.0-100.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30.7165%;\" valign=\"top\" width=\"39.93399339933993%\"\u003e\n \u003cp\u003eRetic %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 35.4865%;\" valign=\"top\" width=\"35.478547854785475%\"\u003e\n \u003cp\u003e6.2 %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.6639%;\" valign=\"top\" width=\"24.58745874587459%\"\u003e\n \u003cp\u003e0.5-2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eInterventional radiology team was contacted for embolization. There was no contrast extravasation during CT angio by interventional radiology, so no embolization done. CT abdomen with contrast showed features of gastric carcinoma with cervical peri gastric and possibly left paraaortic metastatic lymph nodes and suspected transverse mesocolon peritoneal nodules. During hospitalization, the patient developed multiple episodes of symptomatic anemia and melena.\u003c/p\u003e\n\u003cp\u003eHe was treated conservatively by blood transfusion and started on Traneximic acid for 3 days. Biopsy revealed Mantel cell lymphoma. Therefore, the patient underwent urgent hemostatic Radiotherapy.\u003c/p\u003e\n\u003ch2\u003eHistopathology\u003c/h2\u003e\n\u003cp\u003eSections from the gastric biopsy (Fig.\u0026nbsp;2) show expansion of the lamina propria with sheets of small monotonous lymphocytes with small nuclei and perinuclear clearing artifact.\u003c/p\u003e\n\u003cp\u003eNo large cells or lymphoepithelial lesions identified. There are adjacent areas of ulceration and intestinal metaplasia (not shown).\u003c/p\u003e\n\u003cp\u003eBy immunohistochemical stains, the neoplastic cells are of B-cell nature which stained positive with CD20 (Fig. 3), and co-express CD5 (Fig. 4), cyclin-D1 (Fig. 5) and SOX-11 (not shown). They are also positive for BCL2. The proliferation marker Ki-67 is positive in 20% of cells (not shown). The neoplastic cells are negative for CD10 and CD23 (not shown). The non-neoplastic T cells are highlighted with CD3 (not shown). The morphologic and immuno-phenotypical features are consistent with mantle cell lymphoma.\u003c/p\u003e"},{"header":"Discussion","content":" \u003cp\u003eAt the time of diagnosis, the majority of MCL patients are in an advanced stage of the disease (70 percent). While lymphadenopathy is the primary symptom in around 75% of patients, extranodal disease is the primary clinical manifestation in the remaining 25%\u003csup\u003e5\u003c/sup\u003e. The lymph nodes, spleen (45 to 60 percent), Waldeyer's ring, bone marrow (\u0026gt;\u0026thinsp;60 percent), blood (13 to 77 percent), and extranodal sites like the gastrointestinal tract, breast, pleura, and orbit are all common sites of involvement\u003csup\u003e56\u003c/sup\u003e. The explanation for mantle cell lymphoma's affinity for the gastrointestinal tract is unknown\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePatients with mantle cell lymphoma that has spread to the gastrointestinal tract may be asymptomatic, or experience a variety of symptoms, including abdominal pain, obstruction, diarrhea, melena, and hematochezia. The ileocecal region is the most common site of gastrointestinal tract involvement, but any area from the stomach to the rectum could be affected. In a study published by Romaguera et al., up to 26% of patients had gastrointestinal symptoms at the time of diagnosis \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEndoscopy can reveal MCL involvement in the gastrointestinal tract that is not visible on radiological imaging. During the staging process and during the follow-up period for MCL patients, endoscopic examinations are recommended\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Moreover, chemotherapy for primary gastrointestinal mantle lymphomas might result in potentially fatal gastrointestinal bleeding. Much attention should be paid to the prevention and treatment of PGIL gastrointestinal bleeding while receiving chemotherapy\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e "},{"header":"Conclusions","content":" \u003cp\u003eMCL should be kept in mind when assessing massive upper GI bleeding, as an unusual cause of bleeding gastric ulcer. Also, predict the advancement of bleeding or onset of new bleeding after initiation of chemotherapy in patients with MCL.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003ei. Funding:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eii. Conflicts of interest/Competing interests:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe authors report no conflict of interest.\u003c/p\u003e\n\u003ch2\u003eiii. Ethics approval:\u003c/h2\u003e\n\u003cp\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003ch2\u003eiv. Consent to participate:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eDue to the COVID-19 situation and its impact on direct patient contact, only verbal consent was obtained to publish this case.\u003c/p\u003e\n\u003ch2\u003ev. Consent for publication:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eDue to the COVID-19 situation and its impact on direct patient contact, only verbal consent was obtained to publish this case.\u003c/p\u003e\n\u003ch2\u003evi. Availability of data and material (data transparency):\u003c/h2\u003e\n\u003cp\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003ch2\u003evii. Code availability (software application or custom code):\u003c/h2\u003e\n\u003cp\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003ch2\u003eviii. Authors\u0026apos; contributions:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eK.A. wrote the initial draft of the manuscript and literature review, M.B.H. participated in literature review and editing the manuscript, F.A. Description of pathological findings, M.A.Y. Editing and revising.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eArmitage JO, Weisenburger DD. New approach to classifying non-Hodgkin\u0026rsquo;s lymphomas: clinical features of the major histologic subtypes. Non-Hodgkin\u0026rsquo;s Lymphoma Classification Project. Journal of clinical oncology: official journal of the American Society of Clinical Oncology. 1998;16(8):2780\u0026ndash;95. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1200/JCO.1998.16.8.2780\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsaacson PG, MacLennan KA, Subbuswamy SG. Multiple lymphomatous polyposis of the gastrointestinal tract. Histopathology. 1984;8(4):641\u0026ndash;56. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1365-2559.1984.tb02377.x\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuskon\u0026eacute;-Fourmestraux A, Delmer A, Lavergne A, et al. Multiple lymphomatous polyposis of the gastrointestinal tract: prospective clinicopathologic study of 31 cases. Groupe D\u0026rsquo;\u0026eacute;tude des Lymphomes Digestifs. Gastroenterology. 1997;112(1):7\u0026ndash;16. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s0016-5085(97)70212-9\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang T, Gui W, Shen Q. Primary gastrointestinal non-Hodgkin\u0026rsquo;s lymphoma: clinicopathological and prognostic analysis. \u003cem\u003eMedical oncology (Northwood, London, England)\u003c/em\u003e. 2010;27(3):661\u0026ndash;666. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12032-009-9265-1\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArgatoff LH, Connors JM, Klasa RJ, Horsman DE, Gascoyne RD. Mantle cell lymphoma: a clinicopathologic study of 80 cases. Blood. 1997;89(6):2067\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRomaguera JE, Medeiros LJ, Hagemeister FB, et al. Frequency of gastrointestinal involvement and its clinical significance in mantle cell lymphoma. Cancer. 2003;97(3):586\u0026ndash;91. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/cncr.11096\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee HH, Cho S-G, Lee IS, et al. Mantle cell lymphoma with gastrointestinal involvement and the role of endoscopic examinations. PLOS ONE. 2020;15(9):e0239740.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZheng W, Song Y, Lin N, Tu M, Liu W, Zhu J. Primary gastrointestinal mantle lymphoma with massive bleeding: a case report and literature review. Chinese journal of cancer research = Chung-kuo yen cheng yen chiu. 2013;25(2):250\u0026ndash;3. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3978/j.issn.1000-9604.2012.12.05\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mantle cell, lymphoma , GI bleeding, gastrointestinal tract","lastPublishedDoi":"10.21203/rs.3.rs-439768/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-439768/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAlthough it usually involves extra-nodal sites such as gastrointestinal tract in more than 80% of case, Mantle cell lymphoma is considered a rare cause of gastrointestinal bleeding, especially a severe and life-threatening bleeding.\u003c/p\u003e \u003cp\u003eWe are reporting a 60 year old man, known to have peptic ulcer disease, who presented with a severe upper GI bleeding and found to have large gastric ulcer, which diagnosed as primary gastric mantle cell lymphoma.\u003c/p\u003e","manuscriptTitle":"Mantle Cell Lymphoma Presenting with Severe Upper GI Bleeding.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-06-18 14:19:45","doi":"10.21203/rs.3.rs-439768/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"60a5f071-1053-4803-8be9-6d3ee02ea895","owner":[],"postedDate":"June 18th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":5112126,"name":"Clinical Pharmacology"},{"id":5112127,"name":"Scientific Communication"}],"tags":[],"updatedAt":"2022-01-04T21:29:55+00:00","versionOfRecord":[],"versionCreatedAt":"2021-06-18 14:19:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-439768","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-439768","identity":"rs-439768","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}