DIAGNOSIS OF POST-TRANSPLANT B-CELL LYMPHOMA FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY

Objectives: There is a well-established connection between the immunosuppressed state following solid organ transplantation and neoplastic and lymphoproliferative disease processes. While these post-transplant pathologies usually present with a wide range of symptomatology leading to their workup and eventual diagnosis, less commonly they can be discovered incidentally during unrelated procedures or radiographic studies.

Methods: We report the case of kidney transplant recipient incidentally diagnosed with B-cell lymphoma following laparoscopic cholecystectomy as an example of the heightened suspicion for potential malignancies that is warranted in immunosuppressed patients.

Results: A 70 year-old male with history of deceased-donor kidney transplant for end stage renal disease presented to our surgical clinic at the referral of his transplant nephrologist after being found to have elevated transaminases on routine laboratory studies. Ultrasonography of the biliary system was performed and identified no obvious etiology, though it did note the presence of cholelithiasis. Though he was not experiencing typical biliary symptomatology, he was offered cholecystectomy out of concern for an atypical presentation of symptomatic cholelithiasis.

At the time of surgery the patient initially appeared to have a grossly unremarkable gallbladder, though after some further inspection he was noted to have an abnormally enlarged lymph node just adjacent to the cystic artery. After obtaining a critical view of safety, the gallbladder was resected in standard fashion, but given the nodes prominence and abnormal appearance, it was included in the resection of the specimen. There were no other intra-peritoneal abnormalities identified other than hepatic steatosis. Pathologic evaluation of the surgical specimen revealed an atypical lymphoid proliferation within the above-described lymph node, consistent with a diagnosis of B-cell lymphoma. He was subsequently referred to medical oncology for further staging and treatment. Of note, positron emission tomography did not reveal any additional areas of hypermetabolic activity.

Conclusion: When evaluating immunosuppressed patients (such as those who are recipients of solid organ transplants) for seemingly unrelated surgical disease processes, it is vital for the general surgeon to remain aware of the heightened potential for undiagnosed malignancy in these patients. This vigilance is only more vital when presenting symptoms seem atypical or a diagnosis is not readily apparent. We offer this case both as an example of the importance of this awareness, as well as of the potential utility of inclusion of lymphoid tissue in resection specimens.