Primary malignant lymphoma of the colon and rectum. A histopathological and immunohistochemical analysis of 45 cases with clinicopathological correlations

Mantle zone lymphoma in a gastric glomus tumor

A 61-year-old man had an ileocolectomy for resection of an obstructing lesion of the terminal ileum, which proved to be a mantle zone variant of intermediate lymphocytic lymphoma. At laparotomy, an intramural nodule in the gastric antrum was observed; on resection, this was found to be a typical gastric glomus tumor, focally infiltrated by lymphoma. This combined tumor has not been described previously, to the knowledge of the authors, and could be misdiagnosed easily, although both components should be considered in the differential diagnosis of small cell gastric neoplasms and can be identified readily by immunohistochemical studies.

Primary colorectal lymphoma in Taiwan

BACKGROUND

Sixteen patients with primary lymphoma of the colon and rectum were studied.

METHODS

The median age of these patients was 34 years, and 13 were men. These patients often experienced abdominal pain, diarrhea, a palpable abdominal mass, weight loss, bloody stools, and tumor of the cecum. Intermediate or high-grade lymphomas occurred in 14 patients, and 5 patients had T-cell lesions. The diagnoses were established by using laparotomy in 14 patients and colonoscopic biopsy in 2 patients. Fourteen patients had surgical resections followed by chemotherapy: cyclophosphamide, doxorubicin, vincristine, and prednisolone in 10; cyclophosphamide, vincristine, and prednisolone (COP) in 2; and cyclophosphamide, vincristine, methotrexate, and prednisolone in 1 patient. Two patients underwent biopsy alone followed by chemotherapy with COP in one and chemotherapy with prednisolone in the other.

RESULTS

The median follow-up time was 38 months (range, 2-82 months). Eight patients are alive with no evidence of disease (range, 10-82+ months). Six patients died of disease from 2 to 44 months after diagnosis. One patient who had no evidence of lymphoma died of esophageal carcinoma at 61 months. The median survival time was 59 months.

CONCLUSIONS

The authors' experience with colorectal lymphoma in Taiwan is different from that reported from Japan and other countries. The patients of this study were significantly younger and many had T-cell lesions. Despite the frequently poor histologic types, surgical resection and adjuvant chemotherapy can result in long-term, disease-free survival in many patients with primary colorectal lymphoma.

Gastrointestinal malignant lymphomas of the mucosa-associated lymphoid tissue: factors relevant to prognosis

Three hundred seven cases (244 gastric, 63 intestinal) of primary gastrointestinal non-Hodgkin's lymphoma (NHL) in stages EI and EII, according to a modified Ann Arbor system, were examined retrospectively. The histological classification for mucosa-associated lymphoid tissue-derived lymphomas was applied. Gastric NHLs (male-female ratio, 0.97; mean age, 64.5 years) were stage EI in 51% and stage EII in 49% of cases. Histological grade of malignancy was low in 41% and high in 59% of cases; all NHLs were B-cell type. Tumors were radically resected in 87%, and overall 2-, 5-, and 10-year survival rates were 61%, 55%, and 46%, respectively. Early lymphomas (substage EI1) had best prognosis (5- and 10-year survival rates, 90% and 70%, respectively). Intestinal NHLs (male-female ratio, 1.1; mean age, 54.4 years) were stage EI in 30% and stage EII in 70% of cases. Histology was low grade in 21% and high grade in 79%, and all but 11 cases were B-cell type. In 58% of cases, radical tumor resection resulted in overall 2- and 5-year survival rates of 44% and 24%, respectively. Major prognosticators for survival in gastric location were low-grade histology, low depth of infiltration, and low stage and radical resectability of lymphoma; all factors were strictly intercorrelated. In intestinal site, radical tumor resectability was highly significant for survival. Cumulative proportion of relapses after 5 years was higher in intestinal than in gastric sites (44% vs. 22%). In conclusion, primary gastrointestinal tract NHLs may represent an entity with respect to characteristic histological features, focal tumor growth, and potential cure by radical resection. Because of late relapses, clinical follow-up is needed.

Rectal lymphoma after colectomy for ulcerative colitis

Primary colonic lymphoma is an increasingly recognised complication of ulcerative colitis. We report the first known case of rectal lymphoma occurring after colectomy and ileorectal anastomosis in ulcerative colitis.

The assessment of proliferating cell nuclear antigen (PCNA) immunostaining in primary gastrointestinal lymphomas and its relationship to histological grade, S+G2+M phase fraction (flow cytometric analysis) and prognosis

PCNA is a nuclear protein that is synthesized in late G1 and S phases of the cell cycle and is, therefore, correlated with the cell proliferative state. A new monoclonal antibody (PC10) to genetically engineered PCNA has been shown to label proliferating cells in formalin-fixed paraffin-embedded normal human tissues. Previous studies in lymphomas, using various markers of cell proliferation, have shown a strong correlation between indices of cell proliferation and histological grade. These studies have shown that within each histological subtype there is often a wide range of proliferative indices and that these may be of some prognostic significance. Thirty-one gastrointestinal lymphomas were studied. Our results show that there is a good correlation between PC10 index and histological grade of tumour (0.01 P greater than P greater than 0.001) and also a significant relationship between PC10 index and S+G2+M phase fraction as measured by flow cytometric analysis (r2 = 0.62; P less than 0.01). Twenty-three cases were available for survival analysis. In these cases a high PC10 score correlated with poor survival (P = 0.04). Based on this series, it appears that there is a significant relationship between PC10 index and histological grade, and between PC10 index and S+G2+M phase as measured by flow cytometric analysis. In addition, our results suggest that a high PC10 index is an adverse prognostic factor in primary gastrointestinal lymphoma.

Pathology and clinical features of gastro-intestinal lymphoma in Saudi Arabia

The histopathology and clinical presentation of 19 cases of primary gastrointestinal lymphoma is described. Our patients are similar to others in the Middle East but have a lower incidence of diarrhoea and malabsorption. All revealed a widespread chronic inflammatory background. Four patients with primary gastric lymphoma had endoscopic biopsies from the duodenum; these biopsies were completely free from tumour but showed a moderate to severe diffuse lymphoplasmacytic infiltrate. Electron microscopy shows that tumour cells penetrate basement membranes and invade the epithelium which becomes thin and attenuated. Substances which inhibit lymphocyte tropism might be useful in preventing intestinal ulceration. The MALT concept has been found useful in classification of the tumours. Two patients with unusual mesenteric node histology are described and it is thought that the appearances may indicate a substantial capacity for differentiation in the group of tumours.

14;18 translocation in primary intestinal lymphoma: detection by polymerase chain reaction in routinely processed tissue

Chromosomal translocations involving the heavy chain immunoglobulin locus on chromosome 14 and a region on chromosome 18 encoding the bcl-2 gene [t(14;18)] are a characteristic and prevalent chromosomal abnormality in nodal malignant lymphoma, particularly follicular lymphoma. Using the polymerase chain reaction on routinely processed tissue, t(14;18) has been demonstrated in 22% of primary intestinal lymphomas, i.e. in two of nine cases of malignant lymphomatous polyposis, in four of 19 cases of polymorphic B-cell lymphoma and in one of four high-grade unclassified tumours. The findings in this study contradict those of other studies which have shown no such translocation in primary gastric and small intestinal lymphoma. The presence of t(14;18) indicates heterogeneity of molecular abnormalities within histopathologically homogeneous tumours and suggests that caution should be employed in using molecular cytogenetic data to support theories of tumour histogenesis. The low prevalence of this translocation in intestinal lymphoma makes the use of such a methodology as a primary diagnostic aid doubtful, although the technique may help to distinguish primary and secondary lymphoma and could also be used to demonstrate secondary spread.

The World Health Organization's histologic classification of gastrointestinal tumors. A commentary on the second edition

The World Health Organization's (WHO) histologic classification of gastrointestinal tumors has been revised. Although the general basis of classification and the overall outline remain similar to the first edition, advances in the last decade justified changes in classifying certain entities; among them were malignant lymphomas, endocrine tumors, and dysplasias. Several newly recognized entities have also been added.

Immunoproliferative small intestinal disease: a study of 13 cases with alpha heavy-chain disease

The pathology of 13 cases of immunoproliferative small intestinal disease (IPSID) associated with alpha-heavy-chain disease--one an apparent non-secretor and another with localized infiltration--is described. Four cases exhibited immunohistological light-chain monotypia. In one of these, evolution of a light-chain negative cell population was observed over a 7-year period. In the intestine, centrocyte-like cells produced lympho-epithelial lesions in 11 cases and enlarged lymphoid follicles in three. In lymph nodes, perifollicular infiltration was observed in 11 cases and abnormal follicles in six. Of three patients with high-grade lymphoma at presentation, one died untreated at 2 months, and two are alive at 34 and 91 months. Of 10 patients with low-grade disease at presentation, two died--one at 76 months, the other after transforming to high-grade lymphoma at 73 months. Eight patients with low-grade disease are alive, an average of 67 months after presentation. Four of five conservatively treated low-grade cases (including three in remission) showed evidence of monoclonality at presentation (light-chain monotypia in two and gene rearrangement in two), while two of the five exhibited DNA aneuploidy. It is concluded that IPSID with alpha-heavy-chain disease is neoplastic in all its stages and is a variant of mucosa-associated lymphoma. The role of centrocyte-like cells and the response to conservative therapy are discussed.

Malignant lymphomatous polyposis: diagnosis and response to chemotherapy

Malignant lymphomatous polyposis is a low-grade lymphoma with aggressive features. It may mimic polyposis coli on a barium enema and colonoscopic examination. An histological diagnosis may be made from a tissue biopsy taken via the colonoscope. We discuss the methods of diagnosis, the clinical behaviour and response to chemotherapy.

Cecocolic intussusception in multiple lymphomatous polyposis of the gastrointestinal tract. Report of a case

A rare case of recurrent cecocolic intussusception in an adult patient with multiple lymphomatous polyposis of the gastrointestinal tract is presented. Clinical features, especially the difficulty in distinguishing this entity from adenomatous polyposis on colonoscopy, and histopathology are discussed. It is important that surgeons and colonoscopists be aware of this rare form of diffuse gastrointestinal lymphoma because of therapeutic implications.

Primary rectal lymphoma and malignant lymphomatous polyposis. Two cases illustrating current methods in diagnosis and management

Two cases of colorectal lymphoma are presented. Preoperative histologic diagnosis is difficult and examination of the fresh specimen using immunocytochemical and gene rearrangement techniques are necessary to establish the precise nature of the lesion. Surgical excision is the mainstay of treatment for localized lymphoma of the colorectum and chemotherapy for malignant lymphomatous polyposis.

Prognostic significance of activation and differentiation antigen expression in B-cell non-Hodgkin's lymphoma

Immunophenotyping shows heterogeneity of expression of activation and differentiation antigens in B-cell non-Hodgkin's lymphoma (NHL). To investigate whether antigen expression correlates with clinical behaviour we have studied the clinical presentation and follow-up of a series of 111 B-cell lymphomas previously phenotyped for a panel of antigens including CD groups 5, 9, 10, 21, 23, 25, 30, 38, 4F2 antigen, and transferrin receptor. CD antigens 5, 10, and 23 were expressed significantly more often by low grade lymphomas whereas CD38, 4F2 antigen, and transferrin receptor were more often expressed by high grade lymphomas. There was a significant correlation with survival and age, stage at presentation, histological grade, and expression of 4F2 antigen and transferrin receptor but not with the other antigens studied. 4F2 antigen and transferrin receptor may identify a poor prognostic group of cases in low grade lymphoma but we conclude that phenotyping B-cell NHL for many of the antigens expressed at various stages of B-cell differentiation and activation does not provide clinically useful information in addition to that obtained from standard histological classifications.

Morphologic and immunophenotypic characterization of primary brain lymphomas using paraffin-embedded tissue

Primary lymphomas of the brain constitute about 1% of all primary intracranial neoplasms, but recent studies suggest an increasing incidence. Most cases are associated with an immunosuppressed state. We reviewed 29 cases of primary brain lymphoma from the Yorkshire Health Authority Region between 1970 and 1988 and found a striking increase in incidence over this period. No overt evidence of immunosuppression was found in any case. All were non-Hodgkin's in type and were classified morphologically using Kiel criteria and immunophenotypically using a panel of antibodies. Cryo-preserved tissue was available in five cases for parallel immunophenotyping. The majority of tumours were high-grade lymphomas together with three of lymphoplasmacytoid type. Thirteen tumours showed a striking pleomorphic morphology with plasmacytoid features. A reactive, predominantly perivascular monomorphic T-cell population was seen in all tumours. Most tumours were of B-cell lineage. No cases of Hodgkin's disease, T-cell or histiocytic lymphoma were present. Light chain restriction was present in only 46% of cases. The results of tumour immunophenotyping on cryostat sections were comparable with those from paraffin blocks. Our study emphasizes the value of a panel of antibodies reactive in paraffin-embedded tissue, allowing simultaneous evaluation of morphology and immunophenotype, and suitable for small biopsies received from stereotactic procedures.

High-grade non-Hodgkin's lymphoma complicating polypoid nodular lymphoid hyperplasia and multiple lymphomatous polyposis of the intestine

Three patients with multiple lymphoid polyps of the small intestine--two with nodular lymphoid hyperplasia and one with multiple lymphomatous polyposis--developed high-grade B-cell lymphomas. A literature search has revealed only 10 previous cases of nodular lymphoid hyperplasia complicated by lymphoma and none of an association between multiple lymphomatous polyposis and high-grade lymphoma.

Primary malignant lymphoma of the large intestine complicating chronic inflammatory bowel disease

Ten cases of malignant lymphoma of the colon and rectum complicating chronic inflammatory bowel disease are presented. Seven patients had chronic ulcerative colitis with a history varying from 6 to 20 years. There was extensive colitis in six of these patients and left-sided colitis in one. All seven lymphomas showed the pathological and immunohistological features of primary B-cell tumours of the gastrointestinal tract with a predominance of high-grade tumours. Three patients had Crohn's disease of the large intestine complicated by malignant lymphoma of the sigmoid colon or rectum. The history of Crohn's disease varied from 30 months to 20 years and in each case there was fissuring and fistulae. There was extensive anal involvement in two cases. Histologically the three lymphomas were heterogeneous: one was of 'granulomatous' T-cell type and the other two were markedly polymorphic and of equivocal phenotype. They were also characterized by numerous multinucleate tumour giant cells. Primary colorectal malignant lymphoma should be regarded as a rare, but significant, complication of ulcerative colitis. Immunosuppression may be an additional factor in the genesis of intestinal lymphoma in Crohn's disease. The prognosis appears to be dependent on factors already known to be of prognostic significance in primary gut lymphomas: a predominance of high-grade tumours suggests that the outlook is generally worse than that for idiopathic primary large intestinal lymphoma.

Lymphoma phenotyping in formalin-fixed and paraffin wax-embedded tissues: II. Profiles of reactivity in the various tumour types

Recently, monoclonal antibodies capable of phenotyping malignant lymphomas in routinely fixed and processed tissue have become available. Some of these reagents identify lineage-restricted variants of the leucocyte common molecule, whereas others identify unique fixation-resistant epitopes on lymphoid cells, some of which are shared by non-lymphoid tissues. A new generation of antibodies recognizing 'classical' leucocyte antigens such as CD3 are also emerging. Refinements in antigen detection systems, especially for immunoglobulin recognition, combined with these new reagents promise to improve the accuracy of lymphoma diagnosis in routine histopathology. These new antibodies are reviewed, and their limitations, cross reactivities and profiles of staining in lymphoreticular disease are discussed. A strategy for their optimal use is proposed.