What is the next step in managing a 77-year-old patient with a history of Diffuse Large B-Cell Lymphoma (DLBCL) of the abdomen, recently diagnosed with sclerosing mesenteritis?

Management of Sclerosing Mesenteritis in a 77-Year-Old Patient with History of DLBCL

For a 77-year-old patient with history of abdominal DLBCL recently diagnosed with sclerosing mesenteritis, the next step should be a comprehensive evaluation to rule out lymphoma recurrence, including FDG-PET/CT scan and consideration of tissue biopsy to distinguish between sclerosing mesenteritis and potential DLBCL relapse.

Initial Evaluation

Given the patient's history of DLBCL, it's critical to determine whether the sclerosing mesenteritis is:

• A benign idiopathic condition
• A paraneoplastic manifestation of recurrent lymphoma
• A misdiagnosis of actual lymphoma recurrence

Recommended Diagnostic Steps:

1. FDG-PET/CT scan - Gold standard for lymphoma evaluation 1, 2

   • Will help differentiate between inflammatory changes and metabolically active lymphoma
   • Can identify additional sites of disease if present

2. Laboratory studies

   • Complete blood count
   • Comprehensive metabolic panel including LDH (elevated in lymphoma)
   • Protein electrophoresis 1, 2

3. Tissue confirmation

   • CT- and ultrasound-guided needle biopsy with coaxial technique 3
   • Provides adequate tissue while being minimally invasive
   • Essential to rule out lymphoma recurrence, as imaging alone may be insufficient to distinguish between sclerosing mesenteritis and lymphoma

Rationale for Aggressive Evaluation

• Sclerosing mesenteritis can mimic or be associated with malignancies, particularly lymphoma 4
• The patient's history of DLBCL significantly increases the risk that this finding represents disease recurrence
• DLBCL has a >30% relapse rate according to ESMO guidelines 1
• Delayed diagnosis of recurrent lymphoma could significantly impact mortality and morbidity

Treatment Approach

If confirmed as isolated sclerosing mesenteritis:

• Asymptomatic patients require no treatment 5
• For symptomatic patients, consider:
  • First-line: Tamoxifen 10 mg twice daily plus prednisone 40 mg daily 5
  • Monitor for response with follow-up imaging

If lymphoma recurrence is identified:

• Treatment based on DLBCL relapse protocols 1:
  • For patients not suitable for high-dose therapy (likely in a 77-year-old):
    • Salvage regimens such as R-GEMOX (rituximab, gemcitabine, oxaliplatin) 1
    • Consider clinical trials with novel agents if available

Follow-up

• If sclerosing mesenteritis confirmed without lymphoma:

  • Clinical evaluation every 3 months for first year
  • Repeat imaging at 6 months to assess response to therapy

• If lymphoma recurrence confirmed:

  • Follow standard DLBCL relapse monitoring protocols
  • Response evaluation after 3-4 cycles of salvage therapy 1

Common Pitfalls to Avoid

1. Assuming sclerosing mesenteritis is benign without ruling out lymphoma recurrence
2. Delaying biopsy when the diagnosis is uncertain
3. Missing the association between sclerosing mesenteritis and underlying malignancy
4. Inadequate tissue sampling - ensure sufficient material for comprehensive pathological evaluation including immunohistochemistry

Remember that sclerosing mesenteritis can mimic several conditions including lymphoma, desmoid tumors, and carcinomatosis 6, 7, making tissue confirmation particularly important in this patient with history of DLBCL.