A case of late recurrence of Burkitt's Lymphoma presenting with abdominal masses and haematemesis.

In August, 2005, a 10 year old boy was admitted to a district hospital with marked haematemesis and a huge abdominal mass. Initially, he was treated for ruptured oesophageal varices, but in vain. Then he was transferred to Mzuzu Central Hospital. The history revealed a previous clinical diagnosis of Burkitt’s lymphoma (BL) in 2002, without pathological confirmation, when he had bilateral jaw masses and an epigastric mass. He had received four doses of cyclophosphamide (CPM) chemotherapy, 40mg/kg/dose fortnightly and responded partially with shrinkage of abdominal mass. One dose of intravenous combined chemotherapy of CPM, vincristine (1.5mg/sq.m/dose) and methotrexate (20mg/sq.m/dose) (COM) was then administered before he was lost to follow up. Examination showed pale conjunctivae and a palpable rounded epigastric mass, with low grade fever. Abdominal ultrasound demonstrated a mass 4.2 × 5.0 cm behind the stomach and just above the pancreatic tail. Emergency endoscopy revealed active bleeding from the posterior wall of the upper stomach, without evidence of oesophageal varices. A thick blood film was positive for Plasmodium falciparum with ++s. Abnormally high lactate dehydrogenase (LDH) of 1036 U/L (reference value: 120-330 U/L) was also noted. His haemoglobin decreased from 9.6 to 4.6 g/dl. Several blood transfusions, intravenous cimetidine, vitamin K, tranexamic acid and quinine were given and his condition stabilized gradually. Follow up endoscopy a week later showed a healing ulcer with convergent folds on the posterior wall of the stomach. Presuming recurrent BL, we gave him intravenous CPM, 40 mg/kg/dose at 14 day intervals, but abdominal ultrasound after four doses showed no tumour regression. Since the tumour was not accessible to fine needle aspiration (FNA), an exploratory laparotomy was done in September 2005 and two tumours were found. One, of 10 cm greatest diameter, occupied the lesser sac and the other of 7 cm was located retroperitoneally on the left, below the transverse mesocolon. The margin of the stomach was smooth without any infiltration by the tumour. The retroperitoneal tumor was partially resected and submitted for pathological examination. Because of the poor response to initial treatment, we changed to six doses of COM and two doses of CNS prophylaxis with intrathecal hydrocortisone (25mg/dose) and methotrexate (12.5mg/ dose). Follow up abdominal ultrasound after six courses of COM chemotherapy showed the abdominal tumor had shrunk in size but not resolved completely. He responded well and was symptom free though some residual tumour remained on ultrasound, and was discharged. His weight increased from 20 to 24kg and LDH levels became normal at 310 U/L. Currently, he is being followed up regularly at our outpatient clinic.