Lymphoma of the colon: the spectrum of radiologic changes

Diffuse large B-cell lymphoma of the colon with synchronous liver metastasis: a rare case report mimicking metastatic colorectal adenocarcinoma

BACKGROUND

Primary colorectal lymphoma represents a rare minority among the colonic neoplasms. Early diagnosis is often difficult because of unspecific symptoms, with subsequent delays in diagnosis and management. We describe a rare case of colonic lymphoma presenting with synchronous liver metastasis.

CASE PRESENTATION

A 70-year-old male with a 6-mo history of vague abdominal pain, constipation and melena was referred to our hospital. Computed tomography scan of abdomen revealed the presence of a mass along the proximal ascending colon. Colonoscopy biopsy showed external compression of the cecum with two ulcerations of mucosa, but it was not consistent for a definitive diagnosis. Because the difficulties in the preoperative pathological diagnosis, the high risk of bowel obstruction and the correlated hemorrhagic risk, the patient underwent a right hemicolectomy associated with locoregional lymphadenectomy and liver resection.The surgically resected right colon and liver tumors were all immunohistochemically diagnosed as diffuse large B-cell lymphomas (DLBCL). The patient refused any other antineoplastic treatment; he is alive and free of disease at 3 years after initial diagnosis.

CONCLUSIONS

Primary colonic lymphomas represent a rare minority among the colonic neoplasms. Their correct pre-operative identification is crucial for the design of treatment. This case highlights the difficulty in diagnosing of primary colonic lymphoma. To our knowledge, this is the first report of a colonic lymphoma presenting with a colonic mass and a synchronous liver metastasis.

Primary colon lymphoma in Korea: a KASID (Korean Association for the Study of Intestinal Diseases) Study

Although almost all primary colorectal lymphomas are of B-cell lineage in Western countries, primary colorectal T-cell lymphomas are not uncommon in the East. The aim of this study was to review the clinical characteristics and treatment outcomes of primary colorectal lymphomas, with special emphasis on the differences between T-cell and B-cell lymphomas. Ninety-five cases of primary colorectal lymphomas that satisfied Dawson's criteria were identified from the clinical databases of 13 university hospitals in Korea. The mean age at the time of presentation was 51.1 years and the male:female ratio was 64:31. The clinical information, including endoscopic and histological characteristics, was retrospectively analyzed. Of the primary colorectal lymphomas, 78 cases (82.1%) were of B-lineage and 17 cases (17.9%) were of T-cell lineage. Patients with T-cell lymphomas presented at a younger age than patients with B-cell lymphomas (42.8 vs 52.9 years, respectively; P = 0.016). The most common presenting symptom was abdominal pain (87.1%) for B-cell lymphomas, whereas hematochezia or night fever was more common for T-cell lymphomas (52.9% and 35.3%, respectively). The most common endoscopic type was fungating mass (54.0%) for B-cell lymphomas and ulcerative/ulcero-infiltrative lesions (80.0%) for T-cell lymphomas. Intussusception was more common in B-cell lymphomas than in T-cell lymphomas (30.8% vs 5.9%, respectively; P = 0.035), but perforation was more common in T-cell lymphomas than in B-cell lymphomas (23.5% vs 3.8%, respectively; P = 0.005). The prognosis was significantly worse for T-cell lymphomas than for B-cell lymphomas (P = 0.002). Primary colorectal T-cell lymphomas are characterized by multifocal ulcerative lesions in relatively young patients, a high rate of hematochezia, fever, or perforation, and a poor prognosis even for cases of localized disease.

Clinicopathologic features of ileocolonic malignant lymphoma: analysis according to colonoscopic classification

BACKGROUND

The aims of this study were to classify primary ileocolonic lymphomas according to colonoscopic findings and to determine the clinicopathologic relationship according to classes.

METHODS

Thirty-two patients (22 men, 10 women; age range 29 to 75 years) with primary malignant lymphoma of the terminal ileum and/or colorectum were studied. The clinicopathologic features were evaluated according to colonoscopic findings.

RESULTS

Thirty-six lesions in 32 patients were endoscopically classified as follows: fungating (14, 39%), ulcerofungating (11, 31%), infiltrative (5, 14%), ulceroinfiltrative (4, 11%), and ulcerative (2, 6%). Location of the lesions was as follows: terminal ileum, 15 (42%); colorectum, 14 (39%); both regions, 7 (19%). The most common histopathologic types were diffuse large cell (22, 69%) and large cell immunoblastic (5, 16%). There was no relationship between the endoscopic findings and histologic types. In 9 patients (28%), the clinical manifestation was intussusception, and all were found endoscopically to have the fungating type lesion.

CONCLUSIONS

Primary ileocolonic lymphomas can be classified endoscopically into fungating, ulcerative, infiltrative, ulcerofungating, and ulceroinfiltrative types. Among these, fungating and ulcerofungating are the most frequent. Intussusception is a common clinical finding in ileocolonic lymphomas, occurring mainly in patients with the fungating type of lesion.

A case of primary non-Hodgkin's lymphoma of the transverse colon presenting as inflammatory bowel disease

Primary colonic lymphoma (PCL) is uncommon. We report such a case in a 76-year-old man who presented with diarrhoea and a barium enema that suggested a diagnosis of inflammatory bowel disease (IBD). However, subsequent endoscopy confirmed the diagnosis of PCL. PCL is a rare entity and can be misdiagnosed as IBD because of the symptoms and radiological findings. The correct diagnosis is important, since the management of these two conditions is entirely different.

Radiologic imaging modalities in the diagnosis and management of colorectal cancer

Colorectal carcinoma poses a serious public health threat. Detection in its early stages in the best predictor for long-term survival, which is the impetus for population-based screening programs. We believe that full-colon imaging by either DCBE or colonoscopy is necessary for colon cancer screening because flexible sigmoidoscopy, even if perfect, only detects 50% to 60% of colon cancers, a rate far worse than even the worst rate reported for single-contrast barium enema. Screening for colon cancer with flexible sigmoidoscopy is equivalent to performing a "left" mammogram for the detection of breast cancer. The role of CT colonography is still to be determined. When confronted with a symptomatic patient, barium enema is applied in conjunction with CT to detect primary colorectal carcinoma, to differentiate it from other benign and malignant processes involving the colon, and to assess for disease extent before surgery in selected high-risk patient populations. Pelvic MRI may be useful in the preoperative assessment of patients with rectal carcinoma as a means for assisting surgical planning. CT, MRI, and barium enema are used in postoperative follow-up for detecting local recurrence and distant spread. In response to known difficulty in discriminating between normal postoperative changes and tumor recurrence and in determining the nature of certain liver lesions, FDG-PET has been approved for the detection and localization of recurrent colorectal cancer in patients with rising CEA levels and indeterminate findings on standard imaging studies. Given its current promise of offering high sensitivity, specificity, and accuracy, the indications for PET may well expand in the future, but its final role in still to be determined.

CT appearance of acute abdomen as initial presentation in lymphoma of the large and small bowel

Computed tomography (CT) is playing an increasingly greater role as the initial diagnostic imaging modality for acute abdomen. Abdominal pain is the most common presenting complaint for intestinal lymphoma, and acute abdomen is a not infrequent admitting complaint. We present the CT findings of five patients with intestinal lymphoma whose initial complaint was acute abdomen. Of these five patients, four had an identifiable mass that was located in the right lower quadrant, with the fifth patient having no identifiable mass on CT. The average mass size was 7.8 cm. Three of the patients showed involvement of the colon only, and two showed involvement of the small bowel only, with acute abdomen in only one of the patients with small-bowel involvement being due to direct extension from mesenteric lymph nodes. Pneumoperitoneum and free intraperitoneal fluid were seen in two patients. It is important, therefore, that the radiologist be aware that one of the causes of acute abdomen with primary bowel involvement is lymphoma, which can simulate appendicitis or diverticulitis in its presentation clinically and by physical examination.

CT of primary colonic lymphoma

The article presents the computed tomography (CT) findings in 15 patients with histopathologically proven primary lymphoma of the colorectum. CT is invaluable for the characterization of primary colonic lymphomas and for definition of tumor invasion and spread. The lymphomas in our series were categorized according to their CT appearance as either discrete bulky masses (n = 6), focal mural infiltration (n = 5), or diffuse colonic invasion (n = 5). Primary colonic lymphomas that were manifested as mass lesions had a greater depth of mural invasion (x = 4.3 cm) than did infiltrative lesions (x = 2.7 cm, P < .05), and tended to present at an earlier stage. In the setting of solitary mass lesions in the colon that are not associated with adenopathy, CT findings can help to distinguish primary lymphoma from adenocarcinoma. Cecal tumors that grow into the terminal ileum, tumors which are fairly well demarcated from the surrounding pericolonic fat and show no evidence of invasion or obstruction of neighboring viscera, and tumors which perforate in the absence of desmoplastic reaction should suggest lymphoma. A clinical history of human immunodeficiency virus infection should also prompt consideration of colonic lymphoma.

Primary lymphoma of the colon and rectum: CT and barium enema correlation

This paper presents the computed tomographic (CT) and barium enema (BE) findings in seven patients with proven primary lymphoma of the colon and rectum. CT and BE examination are complimentary studies in the evaluation of primary lymphoma of the colorectum, and certain relevant findings may be missed when radiographic evaluation does not include both modalities. Both CT and barium studies are very accurate in detecting bulky endoexoenteric tumor masses, although CT may suggest features which can differentiate primary lymphoma from adenocarcinoma. The renal utility of obtaining both a CT and BE examination may lie more in diagnosing complications, such as fistula formation and in the evaluation of subtle infiltrative lesions. While CT is necessary for staging purposes, BE examination may be invaluable for detecting subtle mucosal filling defects which could be missed on CT.

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.

The radiology of lymphoma

The development of new imaging techniques over recent years has improved the accuracy with which the extent of the disease can be demonstrated in patients with lymphoma. These methods either complement or replace existing conventional radiological methods such as plain films, bariums, intravenous urograms or lymphography. CT in particular, and to a lesser extent ultrasound and radionuclides, now plays an important part in helping the clinician to manage patients with lymphoma. It is impractical and unnecessary to use all available imaging studies. More than ever, close co-operation between the clinician and radiologist is essential to derive the maximum amount of information from the studies and to use the techniques effectively and appropriately. This chapter has reviewed the advantages and limitations of each imaging method, stressing the role of each in staging the lymphomas and in monitoring response to treatment. The common radiological appearances of the effects of lymphoma on each organ system have been described. The possible contribution that other techniques may make in the future has been discussed.