Pathology of intestinal lymphomas

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.

Clinical prognostic analysis of 116 patients with primary intestinal non-Hodgkin lymphoma

The gastrointestinal tract is the most common extranodal invasion site of non-Hodgkin lymphoma (NHL). Primary gastrointestinal NHL is often discussed together in most survival analyses. Primary intestinal NHL is significantly different from primary gastric NHL with regard to clinical features, pathological subtype, treatment, and prognosis. In this article, we analyzed clinical and pathological characteristics of primary intestinal NHL, and we also explored prognostic factors for primary intestinal NHL. A retrospective analysis was carried out on clinical data from 116 cases of confirmed primary intestinal NHL. The Kaplan-Meier method was used for the survival analysis. A Cox model was used for a multivariate analysis. In 116 patients with primary intestinal NHL, 79 patients were men (68.1%) and 37 patients were women (31.9%). In the cases used in this study, 68 were B-cell NHL and 48 were T-cell NHL. The age, incidence of intestinal obstruction, B symptom and performance status (PS) were closely related with pathological subtype. One-year and two-year survival rates were 76.7 and 58.3%, respectively. The log-rank univariate analysis showed male patients, PS score greater than or equal to two, hypoproteinemia, intestinal perforation, T-cell type, late stage (III/IV), no radical surgery, and no chemotherapy had relatively poor prognoses. Cox multivariate analysis shown that gender (95.0% CI 0.218-0.721), pathological subtype (95.0% CI 1.484-4.179), and radical surgery (95.0% CI 0.110-0.394) were independent prognostic risk factor for primary intestinal NHL. Male patients, T-cell intestinal lymphoma, and no radical surgery had rapid clinical processes and poor prognoses.

Primary gastrointestinal tract mantle cell lymphoma as multiple lymphomatous polyposis

Primary gastrointestinal involvement of mantle cell lymphoma (MCL) is rare with a frequency reported between 4 and 9% of all gastrointestinal B-cell non-Hodgkin lymphomas. It was first described and so-called as multiple lymphomatous polyposis (MLP). Its clinical presentation is usually characteristic, with multiple lymphomatous polyps involving several digestive tract segments and a marked tendency towards extra-intestinal spread. The constant and typical phenotypic features of the small cleaved tumour cells, characterised as CD20+, CD5+ CD23- with a t(11;14) (q13;q32) and cyclin D1 overexpression on immunochemistry, allow MLP to be considered as the gastrointestinal counterpart of peripheral nodal MCL. They both share a very poor outcome. Response to intensive chemotherapy regimens usually results in regression of macroscopic and sometimes microscopic lesions but remissions are short and median survival from 3 to 4 years. Prognosis has been significantly improved since in younger patients, intensive front-line immunochemotherapy with autologous stem cell transplantation has been proposed. Earlier diagnosis with further studies integrating novel agents are still required to determine the optimal treatment with less toxicity.

Therapy of mantle cell lymphoma: current standards and future strategies

Mantle cell lymphoma is characterized clinically by an aggressive clinical course and is relatively resistant to conventional chemotherapies. When in its advanced stages, currently available immunochemotherapy regimens remain noncurative despite high initial response rates. In contrast, consolidating high-dose therapy with autologous stem cell retransfusion significantly extends progression-free survival of young patients. Currently, allogenic bone marrow transplantation represents the only therapy with the potential for a curative approach, although associated with a high rate of complications. New concepts of therapy are urgently warranted, including new molecular approaches, such as bortezomib, thalidomide, lenalidomide, and temsirolimus.

Imaging features of primary extranodal lymphomas

Lymphomas are generally considered tumours of lymph nodes, but up to 40% arise extranodally. This group shows distinctive pathological, radiological, and clinical features. Different subtypes of extranodal lymphoma may show sufficiently specific radiological features to be of significant value in both establishing a diagnosis of lymphoma and ascertaining the exact subtype. Rapidly evolving lymphoma classifications and emergence of new entities have, however, hampered the accurate description of these features in the literature. In this review, we discuss the radiological appearances, using a variety of imaging methods, of the full spectrum of primary extranodal lymphomas, categorized according to the current World Health Organisation classification.

Mantle cell lymphoma in a tubular adenoma: unusual presentation with synchronous colonic carcinoma

An 80-year-old man underwent sigmoidectomy for adenocarcinoma. Six months later, after a near-syncope incident, pancytopenia was detected in the absence of occult blood in the stools. A bone marrow biopsy showed malignant lymphoma, suggestive of mantle cell lymphoma (MCL). Colonoscopy at this time revealed 3 colonic tubular adenomas. Reassessment of the histology of the colonic polyps and appropriate immunohistochemical stains showed that the lamina propria of one of the tubular adenomas was infiltrated by MCL. Reexamination of the sections taken at the time of the original sigmoidectomy showed MCL in 2 of the regional lymph nodes removed at that time, but no evidence of lymphoma in the colon was found. To our knowledge, this is the fifth reported case of synchronous occurrence of intestinal MCL and colonic carcinoma and the first report of MCL presenting in a tubular adenoma of the colon.

Coexpression of CD43 by Benign B Cells in the Terminal Ileum

Expression of CD43 by B cells is often used as a diagnostic criterion in favor of a B-cell lymphoproliferative disorder, including small lymphocytic lymphoma/chronic lymphocytic leukemia, mantle cell lymphoma, Burkitt lymphoma, precursor B-lymphoblastic lymphoma, and a subset of marginal zone B-cell lymphomas. Benign B cells generally do not coexpress CD43. The authors analyzed 20 biopsies of the terminal ileum for nonneoplastic disease for expression of CD43 and compared them with other sites and with CD20, CD138, and CD3 reactivity. The majority of cases (85%) showed strong coexpression of CD43 by benign perifollicular B cells. The presence of CD43 coexpression in B-cell populations of the terminal ileum, including those of Peyer's patches, should not be used as a diagnostic parameter to differentiate extranodal marginal zone B-cell lymphoma of MALT type from reactive processes.

T‐Cell Lymphoma of the Rectum in a Patient with AIDS and Hepatitis C: A Case Report and Discussion

Primary T-cell non-Hodgkin's lymphoma (NHL) occurring in the context of acquired immune deficiency syndrome (AIDS) is uncommon. Here, we report and discuss such a case presenting in the rectum, and review relevant literature. Although typical in some respects, the case is, in other ways, somewhat unusual for an AIDS-related NHL (ARL); ARL tends to be B cell and advanced stage and our case was T cell and stage IE. In addition, the patient suffered from concomitant cirrhosis related to hepatitis C. Chemotherapeutic options for ARL were limited early in the AIDS epidemic due to poor tolerability. Although this has largely been mitigated by the advent of highly active antiretroviral therapy, our patient eventually suffered complications of chemotherapy, apparently related more to his liver disease than to either his lymphoma or AIDS, that ultimately brought about his demise.

Severe gastritis secondary to Epstein-Barr viral infection. Unusual presentation of infectious mononucleosis and associated diffuse lymphoid hyperplasia in gastric mucosa

Infectious mononucleosis is usually a self-limited clinical syndrome caused by primary Epstein-Barr virus infection. It is occasionally compounded by severe complications involving many different organ systems. Predominant gastrointestinal involvement is rarely documented. We present an unusual case of acute Epstein-Barr virus infection-associated gastritis with diffuse atypical lymphoid hyperplasia in gastric mucosa. The clinical, radiographic, histopathologic, immunohistochemical, and in situ hybridization features needed for accurate diagnosis and differentiation from gastric malignancies are discussed.

Synchronous adenocarcinoma and mantle cell lymphoma of the colon

Synchronous occurrence of malignant lymphoma and carcinoma, both located in the intestinal tract, is unusual. We report a unique case of an adenocarcinoma of the cecum and a simultaneous mantle cell lymphoma of the colon, terminal ileum, and regional lymph nodes in an 85-year-old man. Grossly, the adenocarcinoma was identified as a cecal mass. Lymphomatous involvement of the gastrointestinal tract was evident only on microscopic examination. The terminal ileum and colon showed microscopic disseminated multiple mucosal nodules, with involvement of the regional lymph nodes. There was no involvement of distant organs, suggesting that the mantle cell lymphoma was early in its evolution without formation of polyps or a mass lesion. To our knowledge, this is the fourth reported case with this association and the second case that showed early involvement of the gastrointestinal tract with mantle cell lymphoma without polyp formation.

Clinicopathological features of primary intestinal lymphoma in Taiwan: a study of 21 resected cases

In Taiwan, primary intestinal lymphomas (PIL) have rarely been reported and characterized. Using WHO classification, we retrospectively studied the clinicopathological features of PIL cases surgically resected in Taiwan. There were 21 cases, 14 males and seven females, with a median age of 66. The most common symptom at presentation was abdominal pain (n = 14; 66.7%). Six (28.6%) cases showed perforation and two (9.5%) intussusception. Two patients had multicentric tumors. The most common location was ileum (n = 11, 52.4%). Twenty cases (95.2%) were of B-cell lineage, and one (4.8%) was of T-cell lineage. These cases were classified as diffuse large B-cell lymphoma (DLBL) (n = 18; 85.7%), Burkitt lymphoma (n = 2; 9.5%), and enteropathy-type T-cell lymphoma (EATL) (n = 1; 4.8%). One case was lost to follow-up. The 1- and 2-yr survival rates of the remaining 20 patients were 44.4% and 26.7%, respectively. In conclusion, we describe the clinicopathological findings of a rare case of appendiceal DLBL and another one of ileal EATL, that have never been reported in Taiwan previously. We found that in Taiwan PIL occurred in the elderly, with a male predominance, showing a relatively aggressive clinical course, and a pattern similar to that seen in western countries, except for the absence of multiple lymphomatous polyposis.

Primary intestinal diffuse large B-cell non-Hodgkin's lymphoma: clinical features, management, and prognosis of 66 patients

BACKGROUND

In Saudi Arabia, primary gastrointestinal non-Hodgkin's lymphoma (NHL) is common. Recently we have reported one of the largest series of primary gastric (PG) diffuse large B-cell lymphoma (DLCL). This has prompted the analysis of another series of patients with primary intestinal DLCL to depict the clinical features and the outcome of that disease and to compare those with that for PG involvement.

PATIENTS AND METHODS

The data of 66 adult patients with primary intestinal NHL having DLCL histology were retrospectively reviewed.

RESULTS

Patients had a median age of 45 years. Of 64 treated patients, 16% and 84%, received single and multiple modality treatment, respectively. Seventy-six percent, ten percent, and fourteen percent attained complete remission (CR), partial remission (PR), and no response/progressive disease, respectively. Multivariate analysis failed to identify any variable that predict the likelihood of attaining CR. Over a median follow-up of 81 months for all 66 patients, 32 (48%) were alive and disease-free, 5 (8%) were alive with evidence of disease, and the remaining 29 (44%) were dead. The median overall survival (OS) was 101 months and it was 58% (+/- 6%) and 48% (+/- 7%) at 5- and 10-year, respectively. Of the 54 patients who achieved CR or PR, the median event-free survival (EFS) was not reached, but the predicted 5- and 10-year EFS was 61% (+/- 7%) and 52% (+/- 7%), respectively. Only low serum albumin (<30 g/l) was associated with adverse OS and EFS in a univariate analysis, however, multivariate analysis was not possible. Our analysis showed that compared with single-modality management, multi-modality strategy attained significantly higher CR, and advantageous EFS, but without a significant superior effect on OS. In comparison with patients with PG DLCL, those with primary intestinal disease demonstrated more adverse prognostic features, but had an equivalent survival.

CONCLUSIONS

This series characterized the clinico-pathologic features and outcome of patients with primary intestinal DLCL. While surgical resection in primary intestinal NHL seems beneficial, only prospective randomized studies can ascertain its precise role. Compared with patients with PG NHL, patients with primary intestinal disease had more prevalence of adverse prognostic features.