Primary gastrointestinal non-Hodgkin's lymphomas. A retrospective clinicopathologic study of 150 cases

Multifocal colorectal non-Hodgkin's lymphoma in a patient with ulcerative colitis: A case report

A case of multifocal non-Hodgkin's (Diffuse large B cell type) lymphoma of colon in a patient with ulcerative colitis is described. The patient was a 69-year old male treated with azathioprine and methotrexate for ulcerative colitis for 2 years. He was admitted with loose stools and hematochezia. Colonoscopy revealed two deep ulcers in ascending colon and a large ulcer in rectum. Biopsy from both the sites revealed atypical large lymphoid cells, which were CD20 positive. A whole body PET-CT scan showed disease localized to colon with bone marrow examination showing no evidence of lymphoma. The patient was given chemotherapy cycles and recovered well.

Appendiceal Orifice Inflammation in Ulcerative Colitis Mimicking Mucosa-Associated Lymphoid Tissue Lymphoma in the Cecum

A 55-year-old Japanese woman, who had been diagnosed with ulcerative colitis at 18 years of age, underwent screening endoscopy examinations. Esophagogastroduodenoscopy revealed an extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) of the stomach. Colonoscopy showed a slightly elevated reddish lesion with dilated microvessels but no erosions or ulcers. Although MALT lymphoma in the cecum was endoscopically suspected, flow cytometry and pathological analyses led to the diagnosis of appendiceal orifice inflammation in ulcerative colitis. This case highlights the diversity of the endoscopic appearance of appendiceal orifice inflammation in ulcerative colitis.

Primary Rectal Non-Hodgkin's Lymphoma Treated with Urgent Radiotherapy and Chemotherapy: A Case Report and Literature Review

Rectal malignancy is usually symptomatic due to its location, and most of the time presents with pain and bleeding due to its growth and ulceration. It is difficult to identify the primary as carcinoma or lymphoma based on symptoms only, as both have a similar presentation. As it presents the rarest form of histology, non-Hodgkin's lymphoma in the rectum is still difficult to diagnose initially, and its treatment is debatable. We describe the case of a 49-year-old male from Bangladesh with the same presentation. His treatment was delayed for more than a month as immunohistochemistry and staging delayed the final diagnosis. The disease was diagnosed as stage IE with the help of a positron emission tomography (PET)-CT scan, and due to the local progression the patient had a massive rectal bleeding that needed an urgent intervention. Radiotherapy was applied to stop the bleeding. Hypofraction followed by a conventional fraction of external beam radiotherapy (EBRT) with a total of 40 Gy was applied. Post-EBRT digital rectal examination showed no residual except scaring, and a PET scan was also negative for residual disease. Due to uncertainties and lack of any precious guideline, 6 cycles of adjuvant chemotherapy with the R-CHOP schedule were also completed. Without surgery, the combination of EBRT and chemotherapy helped to preserve the organ, and the patient has been disease free for more than 2.5 years since his treatment.

Using the primary site as a prognostic tool for nodal mantle cell lymphoma: a SEER-based study

Background: Nodal mantle cell lymphoma (NMCL) has a worse survival than extra-nodal mantle cell lymphoma. Materials & methods: A cohort study was conducted to evaluate the primary site role as a mortality predictor using data from 1983 to 2011 from the Surveillance, Epidemiology, and End Results (SEER) database. Results: Most patients had NMCL in multiple regions (71.9%). There was a significantly increased incidence of NMCL cases over years with 83.2% of them occurred between 1998 and 2011. The mean survival was 52.9 months with overall survival/cancer-specific survival rate of 29.2/42.9%, respectively. Lymph nodes of intrathoracic and multiple regions had a worse overall survival while the head, face and neck, intra-abdominal, pelvic, inguinal region and leg as well as multiple regions had worse cancer-specific survival. Conclusion: NMCL primary site can serve as a prognostic factor. We encourage adding it to MCL International Prognostic Index.

Colorectal Lymphoma: A Review

Non-Hodgkin lymphoma (NHL) that primarily involves the colon is rare and should be distinguished from the more common systemic nodal lymphoma. It has unique clinical expectations and management consideration. Different histologic subtypes of NHL involve the colon, which varies in the clinical behavior and likelihood of obtaining durable remissions with treatment. This article will review the current understanding of the different histologic subtypes of primary colorectal lymphoma and propose management algorithms.

Gastrointestinal follicular lymphoma: Current knowledge and future challenges

The gastrointestinal (GI) tract is the most commonly involved site of extranodal follicular lymphoma (FL). GI-FL shows very indolent clinical behavior and localized at GI tract without any progression or transformation compared to nodal FL. The most frequently involved site of the GI tract was the duodenum followed by the jejunum and ileum, and only 15% of FL arising in the second part of the duodenum were localized there without scattered very small daughter lesions in other GI tract examined by double-balloon endoscopy. The typical macroscopic appearance of GI-FL was multiple white nodules. Microscopically, neoplastic cells were small- to medium-sized lymphoid cells and formed neoplastic follicles. Most of the cases (>95%) were histologically Grade 1 to 2 (low grade). Several pathological and molecular characteristics were seen in GI-FL (especially duodenal FL) compared with nodal FL: immunoglobulin heavy chain deviation to VH4 and VH5; memory B-cell immunophenotype; and molecular features shared by mucosa-associated lymphoid tissue lymphoma. Considering the pathological and molecular uniqueness of this disease, GI-FL should be separately managed from nodal FL.

Abdominal Lymphoma - the Place for Surgery

Gastrointestinal lymphoma (GIL) is rare but may be cured by surgery and chemotherapy. Because symptoms frequently mimic common abdominal conditions, presentation is often to a surgeon. Fiftyfive patients with GIL were treated between 1975 and 1984: all underwent operations before the correct diagnosis was made, 22 (40%) as emergencies. Misdiagnosis in 23 (42%) led to a delay in correct treatment of ≥ 6 months from the start of symptoms: in 17 (31%) the delay was ≥ one year. Endoscopy and radiology were inaccurate and suggested peptic ulceration, Crohn's disease or irritable bowel syndrome. The site of disease was usually stomach and duodenum (26, 47%) or ileum and jejunum (29, 53%). The extent of surgical resection was associated with survival at ≥3 years - in 16 (29%) who underwent ‘complete resection’ 14 survived, but only one of 28 survived when the operation was limited to diagnostic biopsy (P < 0.0001). Most deaths occurred within one year of operation, commonlyfrom perforation or haematemesis from residual mural disease during chemotherapy. In 5 of 11 patients who had biopsy only, CT scans suggested localized disease, and ‘complete resection’ was achieved at a second laparotomy. Complete resection should be attempted wherever possible before chemotherapy. The place for surgeons with experience is clearly central to the management of this disease.

Cardiovascular mortality trends in non-Hodgkin's lymphoma: a population-based cohort study

BACKGROUND

Non-Hodgkin's lymphoma (NHL) survivors are at a higher risk of cardiovascular diseases (CVDs).

METHODS

A population-based study was conducted to investigate the cardiovascular mortality trends to identify NHL survivors at the highest risk.

RESULTS

The CVDs mortality was the second most common cause of death (13.07%) after NHL. There were more patients ≥ 60 years old in the cardiovascular group (87.2%), P < 0.001. Patients who died from CVDs had the best survival while patients who died from NHL had a significantly lower mean survival. The overall survival rate was 92.4%. Consistently, older age, unmarried, male patients, not recently diagnosed with NHL and not receiving radiation and/or surgery were associated with a worse survival across all models. The black race and stage IV only had a worse cardiovascular specific survival (CVSS).

CONCLUSIONS

Although the CVSS improved over time, the mortality from the CVDs is still the second most common cause of death after NHL. Older age, not married, black, male patients, not recently diagnosed with NHL, with an advanced stage and not receiving radiation and/or surgery were associated with a worse survival. Risk factor modification along with CVDs screening should be intensified in NHL patients with these mortality predictors.

Clinical characteristics, treatment, and outcome of primary rectal lymphoma: a single center experience of 16 patients

BACKGROUND

The rectum is a relatively uncommon site for lymphoma compared with other gastrointestinal sites; no consensus regarding management of primary rectal lymphoma (PRL) has been formed due to its limited frequency. We aimed to investigate clinical characteristics and treatment outcomes in patients with PRL in a single center patient cohort.

METHODS

We retrospectively analyzed the results of 16 consecutive patients with PRL, identified and treated at the Asan Medical Center, Seoul, Korea between January 1993 and December 2014.

RESULTS

These 16 patients with PRL constituted 0.8% of all non-Hodgkin's lymphoma patients (N=1,984). B-cell lymphomas (N=14) made up the majority of the series, and half of these were extranodal marginal zone lymphomas (ENMZL, N=7). Ten patients received systemic chemotherapy with (N=3) or without rituximab (N=7), and 4 of these received additional local therapy. The others received radiotherapy (N=3) or endoscopic mucosal resection (N=3). Twelve patients (75%) achieved complete response (CR) after first-line treatment. Event-free survival (EFS) and overall survival (OS) in stages IE and IIE were significantly longer compared with stages IVE (P=0.001 and P=0.001, respectively). All patients with ENMZL (N=7) achieved CR during or after initial treatment.

CONCLUSION

PRL is very rare and seems to present mostly as B-cell type. Stage is the most important prognostic factor, with significantly better survival associated with localized diseases. ENMZL may be one of the most common types of PRL with favorable treatment outcomes.

Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma of the Colon: A Case Report and a Literature Review

Patient: Female, 56

Final Diagnosis: Colonic MALT lymphoma

Symptoms: Epigastric pain

Medication: —

Clinical Procedure: Colonoscopy and biopsy

Specialty: Gastroenterology and Hepatology

Gastrointestinal lymphoma in Western Algeria: pattern of distribution and histological subtypes (retrospective study)

BACKGROUND

Primary gastrointestinal (GI) lymphomas (GIL) are uncommon diseases that can involve the whole GI tract. Considerable variation exists in the literature with respect to incidence of the various histological subtypes and sites of involvement. This study was undertaken to establish the anatomic distribution, histological subtypes and sites of GI lymphomas of patients from Western Algeria.

METHODS

The case records of 58 consecutive patients with GIL diagnosed at the Pathologies Departments of Algerian west region (the Military Hospital of Oran city and the Central University Hospital of Sidi Bel Abbes city) from January 2006 to December 2013 were retrospectively evaluated for epidemiology and histopathology report. All lymphomas were reclassified according to the WHO 2008 classification.

RESULTS

A total of 58 patients (39 male, 19 female) with mean age of 61 years and a range of 20-89 years were included in this study. Stomach was the most common site involved (70.7%). The commonest histological subtype was mucosa-associated lymphoid tissue (MALT) B cell lymphoma (46.6%), followed by diffuse large B-cell lymphomas (DLBCL) (43.1%).The frequency of Helicobacter pylori (HP) positivity differ between gastric and intestinal location P=0.003 and correlates with the histological type P=0.01.

CONCLUSIONS

This retrospective study of patients with GI lymphoma from Western Algeria illustrates the pattern of distribution of various common and rare histological subtypes. More studies are necessary to find a potential cause, risk factor or genetic mutation that can explain these specific characteristics of GIL.

Early, Isolated Duodenal Mucosa-Associated Lymphoid Tissue Lymphoma Presenting without Symptoms or Grossly Apparent Endoscopic Lesions and Diagnosed by Random Duodenal Biopsies

Clinical data regarding mucosa-associated lymphoid tissue lymphoma (MALToma) solely involving the duodenum are sparse because of the relative rarity of the disease. A comprehensive literature review revealed only 17 cases reported until 2004, and only a moderate number of cases have been reported since. MALToma can be asymptomatic in its very early stages but frequently produces localized or nonspecific symptoms, including early satiety, abdominal pain, vomiting, and involuntary weight loss in later stages. While gastric MALToma is strongly associated with gastric Helicobactor pylori infection, duodenal MALToma is often unassociated with H. pylori infection. A 74-year-old female presented with only dysphagia (without symptoms referable to a duodenal lesion), without systemic 'B' symptoms, and with no evident duodenal lesions at esophagogastroduodenoscopy; however, she was diagnosed with duodenal MALToma by pathologic examination of random duodenal biopsies performed to exclude celiac disease. An important clinical feature of this case is that duodenal MALToma was diagnosed by pathologic analysis of duodenal biopsies despite (1) no endoscopically apparent duodenal lesions; (2) duodenal involvement without gastric involvement; (3) lack of symptoms attributable to duodenal MALToma, and (4) absence of evident H. pylori infection. This work shows that early duodenal MALToma can be difficult to diagnose because of absent symptoms, absence of gastric involvement, absence of endoscopic abnormalities, and absence of H. pylori infection; it may require random duodenal biopsies for diagnosis.

Primary Gastric Burkitt's Lymphoma

The primary gastrointestinal non-Hodgkin’s lymphoma, although rare, is among the most common extra-nodal lymphomas, considering that gastric lymphomas are more common than intestinal lymphomas. Burkitt’s lymphoma (BL) is an aggressive form of B-cell lymphoma that is typically endemic in Africa, while non-endemic cases are found in the rest of the world. Primary gastric BL is extremely rare and only around 50 cases have been reported worldwide. Here we present the case of a young HIV-negative male, who was referred to our department with a stage IV gastric BL. He was planned for palliative chemotherapy, but after the first cycle of chemotherapy he succumbed to the progression of the disease.

Refractory peptic ulceration following radiation therapy in primary gastric lymphoma: A report of two cases

The optimal prognosis for primary gastric lymphoma (PGL) is observed in those patients exhibiting PGL with minimal infiltration and who are eligible for radical resection. The initial treatment strategy for high-grade PGL (stages I/II) is chemotherapy followed by radiotherapy, however, subsequent to chemotherapy and/or radiotherapy for PGL, there is a risk of gastric bleeding and perforation. The present study reports two cases of PGL with refractory peptic ulcers that were negative for Helicobacter pylori following radiotherapy. Although the two patients received regular treatment for their ulcers and symptoms, the position and size of the ulcers remained unchanged for a number of years.

Primary intestinal B-cell lymphoma: a prospective multicentre clinical study of 91 cases

BACKGROUND & AIMS

Clinical presentation, diagnosis and prognosis of different primary intestinal lymphomas have not been well described and compared so far. Our aim was to prospectively analyse a series of consecutive patients presenting different types of B-cell primary intestinal lymphomas.

METHODS

Adult patients with primary intestinal lymphoma, collected between 1991 and 2000 within the multicenter national study in France were evaluated and followed up prospectively. Clinical features and treatment outcomes were analyzed and compared among different groups of lymphomas.

RESULTS

Among 91 cases of B-cell primary intestinal lymphomas identified, 38 (41%) were diffuse large B cell lymphomas, 34 (37%) mantle cell lymphomas, 12 (13%) follicular lymphomas, 5 (5%) marginal zone MALT-lymphomas, and 2 (3%) Burkitt's lymphomas. A differential diagnosis could be made on the basis of tumour cell morphology and phenotype assessed by immunohistochemistry. Clinical presentation of the different types of lymphomas varied with respect to age, symptoms, circumstances of diagnosis, and stage. Overall survival was the poorest for mantle cell lymphomas while diffuse large B cell lymphomas could be cured if in complete remission after first line treatment.

CONCLUSIONS

This study underlines the existence, within the B-cell primary intestinal lymphomas, of several distinct entities with different clinico-pathological features and prognosis, whose identification is important for choosing appropriate therapeutic strategy.

[A case of primary sigmoid colon mucosa-associated lymphoid tissue lymphoma]

The gastrointestinal (GI) tract is the most frequently involved site of mucosa-associated lymphoid tissue (MALT) lymphoma. Stomach is the most common site of involvement among the GI tract. However, MALT lymphoma of the large intestine is rare. A diagnosis is established by pathological examination of the surgical or endoscopic specimens. A 72-year-old man with low abdominal pain was diagnosed as a sigmoid MALT lymphoma, which was noted as an obstructing mass in a colonoscopic examination. A left hemicolectomy was performed, and the patient has had no recurrence postoperatively without any chemotherapy.

Burkitt's Lymphoma of the Stomach: a Case Report with Molecular Cytogenetic Analysis

In 1974, a 28-year-old man presented with a 12 cm sized ulcerated tumor involving the middle third of the stomach, which was originally diagnosed as "lymphosarcoma". Clinical recurrence of the lymphoma resulted in rapidly progressing disease and the patient died 4 months after initial diagnosis. Retrospective work-up of the 29-year-old tumor blocks revealed the typical histologic appearance and phenotype (CD20, CD10, BCL-6 positive) of Burkitt's lymphoma (BL) with a proliferation rate of 95%. By fluorescence in situ hybridization (FISH). the tumor cells were shown to harbor an IGH-MYC fusion indicating the presence of the hallmark Burkitt-translocation t(8;14)(q24;q32). Considering the typical clinical features of BL requiring appropriate treatment regimes the case presented here highlights the importance of modern histopathologic and molecular cytogenetic techniques for the proper classification of such rare lymphomas presenting at atypical sites.

Primary non-Hodgkin lymphomas in the small and large intestine: clinicopathological characteristics and management of 40 patients

To investigate the clinicopathological characteristics and optimal treatment modalities of primary non-Hodgkin lymphoma (NHL) in the small and large intestine. Forty patients with primary NHL in the small and large intestine were studied retrospectively. All cases were reclassified according to the World Health Organization (WHO) classification of lymphoma in 2001. Fourteen patients had primary disease in the small intestine, which were all of B-cell origin with diffuse large B-cell lymphoma (DLBCL) diagnosed in 5 of 14 (35.7%) patients and mucosa-associated lymphoid tissue (MALT) lymphoma in 8 of 14 (57.1%) patients. Ileum was the most commonly involved site (8 of 14 patients, 57.1%), followed by jejunum (2 of 14 patients, 14.3%) and duodenum (1 of 14 patients, 7.1%). Twenty-five patients had primary colorectal lymphoma, with B-cell origin accounting for 92.0% and T-cell origin for 8.0% of these patients. The ileocaecal region has the highest involved rate (13 of 25 patients, 52.0%), followed by colon (7 of 25 patients, 28.0%) and rectum (3 of 25 patients, 12.0%). Compared with surgery alone, post-operation chemotherapy or chemoradiotherapy can significantly improve DLBCL patients' event-free survival (EFS). However, no post-operation treatment modality can improve OS or EFS for patients with MALT lymphoma. B-cell lymphoma is the most common pathological type of intestinal lymphomas. Chemotherapy-containing treatment modality is an effective way to improve intestinal lymphoma patients' EFS, especially for those with DLBCL subtype.

Histiocytic and t-cell rich b-cell lymphoma (TCRBCL) of the stomach

Although stomach is a frequent site of extranodal lymphomas, histiocyte-rich TCRBCL has not yet been described there. Even histology of repeated gastrobiopsies of this uncommon, diffuse, large B-cell lymphoma may be inconclusive and partial gastrectomy cannot be avoided. It is only immunohistology (CD20, CD43, CD68) of the paraffin blocks from the resection specimen that can lead to the final diagnosis of intermediate grade malignant lymphoma.

Spontaneous intestinal perforation due to non-Hodgkin's lymphoma: evaluation of eight cases

Primary intestinal lymphoma with spontaneous perforation and after systemic chemotherapy is rare. The present study summarizes retrospectively the outcome of eight free intestinal perforated patients diagnosed with intestinal non-Hodgkin's lymphoma. Two patients had a history of systemic chemotherapy before perforation. The most common symptoms of the patients were abdominal pain, nausea, vomiting, weight loss, and fever. Sites of perforation were ileum in four, jejunum in two, cecum in one, and sigmoid colon in one patient. Synchronous lymphoma was present in three patients. The perforation was closed by primary closure in three patients. Resection/anastomosis was performed in four patients and sigmoid colostomy was performed in one patient. Three patients were lost due to leakage or septicemia. Intestinal lymphoma might be kept in mind as a cause in free intestinal perforations. Because of the high mortality rate early diagnosis and treatment are important to improve the prognosis of bowel perforation in patients with non-Hodgkin's lymphoma.

Therapy of gastric mucosa-associated lymphoid tissue lymphoma

Mucosa-associated lymphoid tissue (MALT) lymphoma is a relatively common lymphoma and comprises approximately 7% of all newly diagnosed non-Hodgkin's lymphoma. It is mainly located in the stomach and has become a focus of interest due to its unique pathophysiological link with Helicobacter pylori (HP) and the consecutive response to HP eradication therapy. In view of this, HP eradication has become standard treatment for patients with localised disease, and recent data have suggested that HP-negative patients might benefit from antibiotic treatment. In case of non-response, however, the standard approach in such patients is unclear. Both radiation and chemotherapy have shown promising results, and at present there is only one randomised study, which nevertheless suggests chemotherapy as management of choice. The objective of this review is, therefore, to summarise and evaluate the data available for treatment of gastric MALT lymphoma and to highlight potential focus for further research.

Primary duodenal mucosa-associated lymphoid tissue (MALT) lymphoma--a rare presentation of gastric outlet obstruction

Malignant lymphoma of mucosa-associated lymphoid tissue (MALT) can arise in a variety of anatomical sites. The majority of these tumors arise in the stomach, with fewer than 30% arising in the small intestine. Primary duodenal MALT lymphoma is a very rare neoplasm. There are very few cases of duodenal MALT lymphoma reported in the literature. This is the third published case presenting clinically as a gastric outlet obstruction. The patient was successfully treated with a combination of chemotherapy and rituximab.

Prospective clinical study of surgical resection followed by CHOP in localized intestinal diffuse large B cell lymphoma

This study aimed to assess the efficacy of surgical treatment followed by post-surgical CHOP chemotherapy and to analyze the impact of T and N stage on survival in localized intestinal diffuse large B cell lymphoma (DLBL) patients. A prospective non-randomized study was conducted and 40 patients received primary surgical resection with lymph node dissection and post-operative CHOP chemotherapy. After a median follow-up duration of 33.3 months (range, 5.1-75.9 months), an estimated 5-year overall survival rate was 88.9% and a 5-year disease-free survival rate was 83.1%. Primary surgical resection followed by post-operative CHOP chemotherapy showed high efficacy in intestinal DLBL patients.

Primary colorectal lymphomas

OBJECTIVE

The incidence of primary colorectal lymphomas is rare, comprising 10-20% of gastrointestinal lymphomas and only 0.2-0.6% of large bowel malignancies. There is a male predominance, with a maximal reported incidence in the 50- to 70-year age group. Patients often present delayed with nonspecific symptoms and consequently have advanced disease at the time of diagnosis. Inflammatory bowel disease and immunosuppression have been reported as risk factors, although a direct causal link has yet to be established. Treatment often involves a multimodality approach, combining surgery and chemotherapy, with the use of radiotherapy in selected cases. We present our experience in the management of primary colorectal lymphomas over a 10-year period (1989-1999).

PATIENTS AND METHODS

We reviewed all cases of primary colorectal lymphoma seen at our institution from 1989 to 1999. Patients were included based on standard diagnostic criteria for primary intestinal lymphoma established by Dawson in 1961. The following clinical information was obtained: age, sex, presentation, site of tumour, operation performed, histology, length of stay, intraoperative complications, adjuvant therapy and duration of follow-up. The type of lymphoma was classified according to the WHO classification system. For staging, a modification of the Ann Arbor system for gastrointestinal lymphoma, proposed by Musshoff, was used.

RESULTS

During the 10-year period from 1989 to 1999, 14 cases of primary colorectal lymphomas were identified. This comprised 0.44% of all colorectal malignancies (14 of 3199 cases) seen in our department during this period. There were 13 men and one woman. Their mean age at presentation was 61 years. The common presentations included a combination of abdominal pain (71.4%), anorexia and loss of weight (42.9%) and an abdominal mass (28.6%). The two most common sites of involvement were the caecum (57.1%) and the rectum/sigmoid colon (21.4%). The lesions manifested in a variety of ways, ranging from solitary fungating masses to multiple colonic polyps. All but one patient underwent attempted curative surgical resection. All cases were non-Hodgkin's B-cell lymphomas, with a majority being diffuse large B-cell lymphomas (57.1%). The diagnoses were established through laparotomy in all cases. All cases presented with evidence of spread to regional lymph nodes or beyond. Eleven patients (78.6%) received postoperative chemotherapy, with a regimen that included cyclophosphamide, vincristine, doxorubicin and prednisone. The remaining three were too ill or refused. There were no mortalities within 30 days of surgery. The patients were followed up for a median of 20 months (range 2-84) and more than half are alive and continue to be on follow-up with no evidence of recurrence.

CONCLUSION

Primary colorectal lymphoma is a rare condition. It predominantly affects males between the sixth and seventh decade of life and most commonly occurs in the caecum. It often presents with abdominal pain and loss of weight and due to the nonspecific nature of these symptoms, patients frequently present late with advanced loco-regional disease. The histology is usually B cell and of intermediate grade. Therapy usually involves resection of the affected colon and regional lymphovascular structures, followed by adjuvant chemotherapy, with a reported 5-year survival of 27-55%.

A single-center study of treatment outcomes and survival in patients with primary gastric lymphomas between 1990 and 2003

Primary gastric lymphomas are the most common extranodal non-Hodgkin's lymphomas and are divided into indolent (low grade) and aggressive (high grade) types. They are mainly the disease of middle age, with a male predominance reported by most of the studies. For several years, surgery played a central role in diagnosis, staging, and treatment of this entity, yet recently there has been a move away from a surgical approach to conservative treatment. To determine the role of surgery as the initial treatment modality, we performed this retrospective single-center research on 245 patients with primary gastric lymphoma who were treated according to our protocol between 1990 and 2003. The patients' characteristics, distribution of histological types, treatment results, and disease-specific survival were followed. According to the histology, 59.2% had diffuse large B-cell lymphoma (DLCL), 26.1% MALT lymphoma, 9.8% mixed lymphoma (indolent and aggressive at the same time), while other types were infrequent. In total, 161 patients (65.7%) were treated with surgical resection as the initial treatment, which was then followed or not by additional therapy (chemotherapy, chemotherapy and radiotherapy, radiotherapy) depending on the histological type of lymphoma and the extent of residual disease after surgery. In 84 patients (34.3%), the treatment approach was conservative. The selection of treatment (chemotherapy, chemotherapy and radiotherapy, radiotherapy or Helicobacter pylori eradication only) was based on the histological type of lymphoma, considering also the patients' physical condition. The disease-specific survival in the group of patients who underwent surgery was statistically significantly better than in patients who were treated conservatively (p=0.049). At 5 years, it was 96.9% for the group treated with surgery and 89.8% in patients treated conservatively. However, the results were biased, as the patients who were treated conservatively were either in a worse performance status or presented with a more extensive disease. Similarly, in the DLCL type the disease-specific survival was better in the surgically treated group (97.2%) than in the conservatively treated patients (89.2%). The difference was barely significant (p=0.046) and again the results have to be considered with caution due to the selection of patients in a worse performance status or with a more extensive disease for conservative treatment. In the MALT lymphoma and mixed lymphoma types, there were no differences in the disease-specific survival between both treatment groups. Regarding the statement that for conservative treatment patients were selected who were unsuitable for the resection on account of concomitant diseases or due to the fact that the process was inoperable, we believe that the conservative approach gives comparable outcomes to the approach including initial surgery. The existing evidence thus no longer justifies surgery as the standard initial treatment and preference should be given to conservative treatment approaches.

Gastric Burkitt lymphoma is a distinct subtype that has superior outcomes to other types of Burkitt lymphoma/leukemia

Burkitt lymphoma/leukemia (BL) is a highly aggressive non-Hodgkin's lymphoma (NHL) often presenting in extranodal sites or as an acute leukemia. Because of the shared molecular and genetic features, the World Health Organization classification of lymphoid diseases recognizes the lymphomatous and leukemic phases of BL as a single entity: a mature B cell neoplasm, subtype Burkitt lymphoma/Burkitt cell leukemia. Because BL frequently appears in the stomach, we investigated the clinical presentation and outcome of gastric BL. We discovered 21 patients with gastric BL through a survey of our NHL registry, and retrospectively analyzed the distinct features of BL, including the St Jude/Murphy staging, other extranodal involvement, morphology and immunophenotype, response to treatment, and clinical outcome. The patients' median age was 48 years (range, 7-75), and the male-to-female ratio was 2.5. Stage 1 was found in five patients, stage 2 in five patients, and stage 4 in 11 patients. The stomach body and antrum were most frequently involved. All 21 patients were treated with systemic intensive chemotherapy, producing a 71% (15/21) rate of complete response (CR) to chemotherapy. Both the 2-year disease-free and overall survival rates were 55%. All ten patients in BL stages 1 and 2 showed outstanding outcomes, and nine of the ten patients exhibited CR and long-term survival. These data show that a high proportion of patients with gastric BL have a localized disease that is limited to stage 1 and 2, and that these localized BLs have outstanding outcomes. These findings suggest that these BLs could represent a distinct subtype that might have a different biology, which needs to be defined.

Clinicopathologic characteristics and therapeutic outcomes of primary gastrointestinal non-Hodgkin's lymphomas in central Anatolia, in Turkey

Primary gastrointestinal lymphoma is a common presentation of non-Hodgkin's lymphoma. The main controversy arises when many aspects of its classification and management are under discussion, particularly regarding roles for surgical resection. The aim of this study was to evaluate clinicopathologic characteristics and the therapeutic outcome of primary gastrointestinal non-Hodgkin's lymphoma. We carried out a retrospective analysis of 74 patients who were presented to our center with histopathological diagnosis of primary gastro-intestinal non-Hodgkin's lymphoma between 1990 and 2001. All patients have been staged according to Lugano Staging System. For histopathological classification, International Working Formulation was applied. The treatment choice concerning the surgical or non-surgical management was decided by the initially acting physician. Treatment modalities were compared using the parameters of age, sex, histopathological results, stage, and the site of disease. Of the 74 patients, 31 were female and 43 were male, with a median age of 49 years (range 15-80). The stomach was the most common primary site and was seen in 51 of 74 patients (68.9%). The intermediate and high grade lymphomas constituted 91.9% of the all cases. In a median follow-up of 29 months (range 2-128), 20 out of 74 patients died. There was a three year overall survival rate in 65.4% of all patients. The three year overall survival rate was better in stage I and II1 patients who were treated with surgery plus chemotherapy (+/-RT) than those treated with chemotherapy alone (93.7% vs. 55.6%, p < 0.05). The stage and presence of B symptoms affected the disease free survival and overall survival significantly, but the histopathologic grade only affected the overall survival. On the basis of these results, we suggest that surgical resection is necessary before chemotherapy in early stage (stage I and II1) patients with gastrointestinal non-Hodgkin's lymphomas because of the significant survival advantage it would bring to the patient.

Management of Less Common Tumors of the Colon, Rectum, and Anus

The majority of colorectal and anal malignancies are adenocarcinomas and squamous cell cancers, respectively. Despite the predominance of these neoplasms in these locations, rare histiotypes of the colon, rectum, and anus do occur. These histotypes include but are not limited to lymphoma, melanoma, diffuse cavernous hemangioma, and sarcomas, such as leiomyosarcoma or Kaposi's sarcoma. These tumors often present challenges to clinicians with respect to diagnosis, staging, management, and pathology because of their unfamiliarity. A Medline search using "colon," "rectum,""anus," "lymphoma," "melanoma," "diffuse cavernous hemangioma," "squamous cell carcinoma," "carcinoid," "sarcoma," "leiomyosarcoma," "Kaposi's sarcoma," "Paget's disease," "Bowen's disease," and "basal cell carcinoma" as key words was performed as well as a cross-referencing of the bibliography cited in each work. Rare tumors of the colon, rectum, and anus present diagnostic and management dilemmas for clinicians. Because of their infrequency and poor prognosis, the optimal management of these tumors is controversial. For some histotypes, such as squamous cell carcinoma and carcinoids of the rectum, treatment depends on location and size of the tumor. For uncommon anal lesions, such as Bowen's disease, Paget's disease, and basal cell carcinoma, wide local excision (WLE) with negative margins is the standard of care. For other lesions such as anorectal melanoma or leiomyosarcoma, abdominal perineal resection versus WLE is still being debated. Because the optimal treatment of these tumors is still unclear, we recommend a multidisciplinary approach including a surgeon, primary care physician, medical oncologist, radiation oncologist, and pathologist to offer the patient the best outcome.

Clinical and therapeutic considerations of rectal lymphoma: A case report and literature review

Primary rectal lymphoma is a rare presentation of gastrointestinal lymphomas. Its clinical presentation is indistinguishable from that of rectal carcinoma. Although surgical resection is often technically feasible, optimal therapy for colorectal lymphoma has not yet been identified. We report a case of primary rectal lymphoma (non-Hodgkin’s large cell lymphoma of type B) with high-grade features that disappeared completely after chemo-radiotherapy. This case underlines that primary treatment with systemic chemotherapy and involved-field radiotherapy can be successful for rectal lymphoma, with surgery reserved for complications and chemotherapy failures.

Non-Hodgkin's lymphoma of the stomach: treatment outcomes for 57 patients over a 20-year period

BACKGROUND

Gastric non-Hodgkin's lymphoma (NHL) is a rare subtype of malignancy, for which no consensus exists about treatment. In this study, the treatment outcomes of gastric NHL in 57 patients were retrospectively evaluated for a period of 20 years at a single institute.

METHODS

Clinical stages were classified according to the Ann Arbor staging system: 29 patients were stage 1, 17 stage II, two stage III, and nine stage IV. The 46 stage I/II patients received aggressive, multimodal therapy: 24 of these (group A) were treated with surgery-based management, which included surgery alone (n = 6), surgery + chemotherapy (CT; n = 14), surgery + radiotherapy (RT; n = 2), and surgery + CT + RT (n = 2); 22 patients (group B) did not receive surgery, but received CT alone (n = 11), CT + RT (n = 5), or, in patients with low-grade mucosa-associated lymphoid tissue (MALT) lymphoma, an oral anti-Helicobacter pylori regimen (n = 6). The 11 stage III/IV patients received CT and/or RT with regimens similar to those for stage I/III patients.

RESULTS

Except for 1 patient with an initial surgical diagnosis, 56 patients underwent gastric endoscopic examination, which proved that 42 had NHL. The rate of diagnostic accuracy by gastroscopy was 75%. After multimodal treatment (n = 46) and a median follow-up of 54 months (range, 1-210 months), the 5-year survival rate was 40.3%. The 5-year survival rates for stage 1, II and III/IV patients were 57.2%, 47% and 0%, respectively (p < 0.005). Of the 24 surgical patients (group A) who received sequential CT, with or without RT, 12 remained disease-free after a median follow-up of 98 months (range, 1-210 months); three patients died because of postoperative complications. Of the 22 non-surgical patients (group B) who received CT, alone or combined with RT, 14 remained disease-free after a median follow-up of 40 months (range, 4-189 months); 1 patient died because of massive gastric hemorrhage after CT. All stage III and IV patients died after a median survival of 4 months (range, 1-8 months).

CONCLUSION

Clinical stage is the most important factor predicting the long-term survival of patients with gastric NHL. Surgery may still be necessary in cases of failed gastroscopic diagnosis. In early-stage gastric NHL, non-surgical treatment seems able to achieve the aims of improved long-term survival and, in some instances, cure.

Primary Duodenal Low-Grade Mucosa-Associated Lymphoid Tissue Lymphoma Presenting with Outlet Obstruction

Low-grade lymphoma arising in mucosa-associated lymphoid tissue (MALT) of the duodenum represents a very rare neoplasm. We report an unusual presentation of primary duodenal MALT lymphoma in a 78-year-old man. The patient initially presented with a suspected pulmonary embolus and was anticoagulated, which precipitated a major gastrointestinal hemorrhage. A large atypical ulcer with narrowing of the duodenum beyond the bulb was seen on endoscopy. Biopsies revealed atypical lymphoid cells. Abdominal CT scan revealed a mass in either the duodenum or head of the pancreas. An endoscopic retrograde cholangiopancreatography (ERCP) was performed, which revealed a normal pancreatic duct with a large calculus in the common bile duct, which was extracted after sphincterotomy. Elective surgery was planned for suspected lymphoma of the duodenum. The patient developed severe nausea, vomiting, and fullness after meals. The patient underwent pancreaticoduodectomy for a neoplastic mass causing duodenal obstruction. Pathological examination of the resected specimen revealed a low-grade B-cell lymphoma (MALToma) arising in the duodenum and invading the pancreas. Flow cytometry confirmed the phenotype typical of MALT lymphoma. Celiac, peripancreatic, pelvic, and cervical nodes were also involved with tumor. Bone marrow was also positive for metastasis. The patient was postoperatively treated with chemotherapy for stage IV disease.

Unfavourable prognosis of patients with trisomy 18q21 detected by fluorescence in situ hybridisation in t(11;18) negative, surgically resected, gastrointestinal B cell lymphomas

BACKGROUND

The most frequent cytogenetic alteration in gastrointestinal (GI) B cell lymphoma (BCL) is t(11;18)(q21;q21). GI B cell non-Hodgkin lymphomas lacking this translocation vary in their biology and clinical outcome. The t(11;18) negative subgroup shows increased numerical changes of chromosome 18, although its clinical relevance remains unknown.

METHODS

Thirty surgically resected primary GI BCLs were examined-11 low grade marginal zone mucosa associated lymphoid tissue (MALT) lymphomas, four marginal zone lymphomas with diffuse large BCL (DLBCL), and 15 de novo DLBCLs. Chromosome 18 aberrations were examined using interphase fluorescence in situ hybridisation. Trisomy 18 was studied applying a centromere 18 probe and a dual colour probe for the MALT1 gene at 18q21.

RESULTS

Using the MALT1 probe, only one marginal zone MALT lymphoma had a break apart pattern, indicating t(11;18) or variants. In the GI BCLs lacking MALT1 breaks, trisomy 18q21 was seen in seven patients (four with complete trisomy 18 and three with partial trisomy of 18q21). Trisomy 18q21 was found in two of 10 low grade MALT lymphomas and five of 19 GI BCLs with large cell component. Six of 17 patients with trisomy 18q21 presented with >/= stage II and one of 12 with stage I disease. Trisomy 18q21 was associated with significantly shorter disease specific survival in the whole group and GI BCLs with large cell component, but not in the low grade group.

CONCLUSIONS

Trisomy 18q21, including MALT1, may be associated with advanced tumour stage and may be a predictor of poor outcome in surgically resected primary GI BCLs.

Primary gastrointestinal non-Hodgkin's lymphoma: treatment outcome

Primary gastrointestinal lymphoma is the most common extranodal presentation of non-Hodgkin's lymphoma. In this retrospective study, all cases of primary gastrointestinal lymphoma registered at Kuwait Cancer Control Center between January 1992 and December 2001 were reviewed. Patients were diagnosed through an endoscopic biopsy or exploratory laparotomy. Staging procedures included computed axial tomography scan, bone marrow biopsy, barium and follow-through study, as well as routine chemistry (including lactate dehydrogenase) and hemography. There were 46 patients (30 men and 16 women); ages ranged from 16 to 82 years (median age, 43.6 years). The most common site of involvement was the stomach (70%), and the most common histology was large B cell. At least 50% of cases underwent primary radical surgery, and the majority of patients received subsequent chemotherapy and/or local radiation therapy. Chemotherapy consisted of the CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) regimen for large B-cell histology and CVP (cyclophosphamide/vincristine/prednisone) or oral alkylating agents for low-grade histology. Of this cohort, only 12 cases (26%) have had local or distant relapse. Disease-free survival rates for low-grade and high-grade non-Hodgkin's lymphoma were 64% and 81%, respectively. Primary gastrointestinal lymphoma is a potentially curable malignancy.

Feline gastrointestinal lymphoma

Gastrointestinal lymphoma is a common cause of anorexia and weight loss in older cats, with or without vomiting or diarrhea. Most cats are feline leukemia virus-negative and feline immunodeficiency virus-negative. Low-grade gastrointestinal lymphoma may be more common than previously thought, and these cats respond better to chemotherapy agents than cats with high-grade lymphoma. The most significant prognostic indicator is initial response to chemotherapy, with cats that survive the initial induction period generally achieving long-term remission. Thus far, investigations into molecular markers and immunophenotyping have failed to identify useful prognostic indicators.

Clinicopathological analysis of 143 primary malignant lymphomas in the small and large intestines based on the new WHO classification

AIM

To study the clinicopathological and immunohistochemical features of 143 cases of primary small and large intestinal non-Hodgkin's lymphoma (NHL) in Japanese patients who presented between 1981 and 2000.

METHODS AND RESULTS

The new World Health Organization (WHO) classification was used to classify NHL. The patients included 109 males and 34 females, with an average age of 54.1 years. Tumour sites were as follows: ileocaecal (n = 51, 35.7%), ileum (n = 29, 20.3%), rectum (n = 13, 9.1%), and duodenum (n = 11, 7.7%). Macroscopically, 124 cases (86.7%) were classified as tumorous type, 12 (8.4%) as diffuse infiltration type (erosion, superficial ulceration), five (3.5%) as polyposis type, and only two cases (1.4%) as ulceration type. Immunohistochemically, 122 lesions (85.3%) were of B-cell phenotype and 21 lesions (14.7%) were of T-cell phenotype. According to the WHO classification, of the B-cell lymphomas, 84 cases (68.9%) were large cell, 16 (13.1%) were Burkitt, 10 (8.2%) were marginal zone B-cell lymphomas of mucosa-associated lymphoid tissue (MALT), and seven (5.7%) were mantle cell tumours. Among the T-cell lymphomas, 15 (71.4%) were of unspecified type, two (9.5%) were natural killer type, two were anaplastic large-cell lymphomas, one was lymphoblastic, and one was an adult T-cell leukaemia lymphoma. The survival rate for T-cell lymphomas was poorer than for B-cell lymphomas. Among the B-cell lymphomas, mantle cell lymphoma tended to have a poorer prognosis, whereas MALT lymphomas had a better prognosis than other B-cell tumour types.

CONCLUSIONS

Our retrospective study of patients with primary malignant lymphomas in the small and large intestines has illustrated the clinical features and outcomes of patients with this disease.

Mucosa-associated lymhpoid tissue (MALT) lymphoma of the jejunum and Helicobacter pylori--chance association?

Helicobacter pylori have been causally linked to primary gastric B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) type. Antibiotic therapy to eradicate H. pylori has been shown to induce remission of such lymphoma. We report a case of primary B-cell MALT lymphoma of the jejunum associated with H. pylori. The literature of intestinal MALT lymphoma is reviewed.

Primary gastrointestinal lymphoma in Japan: a clinicopathologic analysis of 455 patients with special reference to its time trends

BACKGROUND

An optimal treatment modality for patients with primary gastrointestinal lymphoma has not yet been established. This study aimed to elucidate the clinicopathologic features of this disease and the influence of therapeutic modalities on the prognosis in Japanese patients

METHODS

The clinicopathologic features of 455 patients with primary gastrointestinal lymphoma were investigated retrospectively regarding treatment modalities and time trends.

RESULTS

This study comprised 342 patients (75%) with gastric lymphoma, 96 patients (22%) with intestinal lymphoma, and 17 patients (4%) with both gastric and intestinal lymphoma. Two hundred thirty-one (51%) patients were classified as having low-grade B-cell lymphoma including 200 marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) type, 185 (41%) patients were classified as having high-grade B-cell lymphoma including 76 diffuse large cell lymphoma plus MALT lymphoma, and 39 (9%) patients were classified as having T-cell lymphoma. The frequency of nonsurgical treatment, including Helicobacter pylori eradication, chemotherapy, and radiation, increased during the latest decade. Patients who received nonsurgical treatment showed a better overall survival than those treated by surgery, but event-free survival did not differ between two groups. Cox multivariate analysis revealed that early stage, younger age, gastric localization, B-cell phenotype, and absence of B symptoms were independent prognostic factors for better overall and event-free survivals. Mucosa-associated lymphoid tissue-derived lymphoma was also an independent prognostic factor for event-free survival, but not for overall survival.

CONCLUSIONS

Nonsurgical treatment may be an optimal therapeutic modality for patients with primary gastrointestinal lymphoma.

CT findings in peripheral T-cell lymphoma involving the gastrointestinal tract

PURPOSE

To evaluate whether computed tomography (CT) accurately depicted gastrointestinal tract involvement in peripheral T-cell lymphoma (PTCL).

MATERIALS AND METHODS

CT scans were retrospectively reviewed in 14 patients with pathologically proved PTCLs of the gastrointestinal tract for the following considerations: sites, patterns of involvement (ie, morphologic features, bowel wall thickness or mass size, and contrast enhancement pattern), and ancillary findings at other sites (ie, lymphadenopathy, bowel perforation, and involvement of other organs).

RESULTS

PTCL involved the stomach in three patients, the small intestine in eight, both the stomach and the small intestine in one, and the sigmoid colon in two; multifocal involvement was seen in three (21%) patients. CT failed to demonstrate the bowel lesions in three of 14 patients. At CT, 11 patients had gastric or bowel wall thickening (n = 10) and a polypoid mass (n = 1). In 10 patients, the gastric or bowel wall thickening was mild (<1 cm) in six, moderate (1-2 cm) in three, and severe (>2 cm) in one. Lymphadenopathy was noted in nine (64%) patients, with the nonbulky type in eight and the bulky type in one. Bowel perforation occurred in four (29%) patients. Other organs were involved in eight (57%) patients.

CONCLUSION

CT can depict PTCL involving the gastrointestinal tract if it is not confined to the mucosa. There is a tendency toward preferential jejunal or duodenal involvement, as well as bowel perforation.

High-grade B-cell lymphoma arising in mucosa-associated lymphoid tissue of the duodenum

Duodenal mucosa-associated lymphoid tissue lymphoma is a rare neoplasm. We report a case of a 70-year-old man with non-Hodgkin's lymphoma located in the descending duodenum that was not associated with Helicobacter pylori infection of the stomach. A surgical resection due to obstruction of the bowel lumen above the ligament of Treitz was performed. No invasion into the adjacent structure was confirmed at surgery. The pathological examination showed an infiltration of the duodenal mucosa and submucosa with B lymphocytes. Monoclonal proliferation of the lymphoid tissue was demonstrated by polymerase chain reaction. The histological appearance and the demonstration of monoclonality fulfilled the criteria for malignant high-grade B-cell lymphoma arising from mucosa-associated lymphoid tissue.