Primary gastrointestinal tract mantle cell lymphoma as multiple lymphomatous polyposis

Colonic lymphomatous polyposis mantle cell lymphoma: a case report and review of literature

INTRODUCTION

Mantle cell lymphoma is a rare lymphoma of the gastrointestinal tract that may present as multiple lymphomatous polyposis. We report a case of lymphomatous polyposis with a review of the literature.

CASE REPORT

A 56-year-old man of Black ethnicity and Ivorian nationality with no relevant past medical history, consulted for a sudden onset symptoms of gastrointestinal obstruction, which evolved over 2 days. Macroscopic examination revealed the presence of multiple polyploid formations of the colonic mucosa. Histology showed diffuse lymphomatous proliferation of submucosa consisting off small lymphoid cells with a hyperchromatic crenelated nucleus, suggesting lymphomatous polyposis. Immunohistochemical examination showed expression by the tumor cells of antibodies to CD20, CD5, Bcl2, and cyclin D1. They did not express antibodies to CD10 and CD23. The Ki67 proliferation index was 25%. We have thus retained the diagnosis of mantle cell lymphomatous polyposis.

CONCLUSION

Multiple lymphomatous polyposis is a rare entity characterized by the presence of numerous gastrointestinal polyploid lesions sometimes involving several segments of the gastrointestinal tract. Typical lymphoma presenting as lymphomatous polyposis is mantle cell lymphoma; although, other tumors may have this aspect.

Synchronous rectal adenocarcinoma and intestinal mantle cell lymphoma: A case report

BACKGROUND

Mantle cell lymphoma (MCL) of the gastrointestinal tract is a rare malignancy, accounting for about 0.2% of malignant colorectal tumors. MCL synchronous with rectal adenocarcinoma is extremely rare. We know of only a few cases reported in the literature. We describe the case of a patient with synchronous rectal adenocarcinoma and intestinal MCL.

CASE SUMMARY

A 63-year-old man was admitted to our hospital due to abdominal pain and hematochezia over the past month. The patient was diagnosed with middle rectal cancer cT2N0M0 and underwent surgery. However, we found a large tumor in the small intestine during surgery. The patient underwent total mesorectal excision for rectal cancer and resectioning of the ileal segment containing the large mass. Pathology and immunohistochemistry revealed the presence of both rectal adenocarcinoma and pathognomonic MCL stage IIE presenting as multiple lymphomatous polyposis. The patient subsequently underwent RDHAP/RCHOP chemotherapy and was maintained with rituximab. A Positron Emission Tomography and Computed Tomography (PET/CT) scan showed that the disease responded well to treatment without tumor-increased metabolism in the gastrointestinal tract.

CONCLUSION

Synchronous rectal adenocarcinoma and intestinal MCL presenting as multiple lymphomatous polyposis are extremely rare. MCL is often discovered fortuitously when rectal cancer is diagnosed. The coexistence of these tumors poses treatment challenges.

Small bowel lymphoma: clinical update and challenges for the gastroenterologist

PURPOSE OF REVIEW

The diagnosis of small bowel lymphoma (SBL) can be challenging, as they are very rare and also have a varied presentation. In this review, we aim to provide a broad overview of the types of SBL and also about the various modalities used for their diagnosis. We also discuss the overview of treatment strategies for a gastroenterologist.

RECENT FINDINGS

Small bowel capsule endoscopy (SBCE) and devise-assisted enteroscopy (DAE) has revolutionized the way we investigate the small bowel. DAE also makes it possible to obtain histological samples for further characterization of SBL. This has led to a significant improvement in diagnosis and management of the disease in conjunction with cross-sectional imagining.

SUMMARY

The diagnosis and management of small bowel lymphoma remains challenging despite the development of newer techniques such as SBCE and DAE. The current available diagnostic modalities have limitations; in the absence of a gold standard, the current investigative modalities compliment each other in reaching the final diagnosis.

B Cell Lymphomas of the GI Tract

PURPOSE OF THE REVIEW

Primary GI lymphomas of B cell origin are a diverse group of lymphomas. In this article, we provide an overview of the diagnosis, pathologic and molecular features, and management of these varied lymphomas.

RECENT FINDINGS

The most common primary GI lymphomas are diffuse large B cell lymphoma (DLBCL) and marginal zone lymphomas (MZL), but follicular lymphomas (FL), mantle cell lymphomas (MCL), post-transplant lymphoproliferative disorders (PTLD), and Burkitt lymphoma of the GI tract also occur. Many features of these lymphomas are similar to their nodal counterparts, but certain clinical and biological aspects are unique. Diagnostic and treatment strategies for these lymphomas continue to evolve over time. There are ongoing discoveries about the unique pathophysiology, molecular characteristics, and complications of primary B cell GI lymphomas that are already leading to improvements in management of this histologically diverse set of lymphomas.

Giant mantle cell lymphoma in the soft tissue of the leg: rare presentation

BACKGROUND

Mantle cell lymphomas are aggressive, mature B-cell neoplasms characteristically showing overexpression of cyclin D1. Although lymphadenopathy is the most common presentation, involvement of extranodal sites including bone marrow, peripheral blood, liver, gastrointestinal system, and Waldeyer ring is also seen frequently. Soft tissue localization is extremely rare. It has blastoid and pleomorphic subtypes associated with aggressive course.

CASE DESCRIPTION

We describe a 74-year-old man who had been diagnosed 3 years previously with "mantle cell lymphoma-blastoid type" and presented 3 months ago with a giant mass in the right lower extremity that enlarged rapidly up to 15 cm in a few months.

CONCLUSION

We present this rare presentation, which was evaluated in favor of hemangioma before biopsy, together with the data in the literature to emphasize the need for differential diagnosis, especially in cases with a clinical history.

Clinical characteristics and outcomes of primary versus secondary gastrointestinal mantle cell lymphoma

Primary gastrointestinal (GI) mantle cell lymphoma (MCL) is rare and the optimal management is unknown. We reviewed 800 newly diagnosed MCL cases and found 22 primary (2.8%) and 79 (9.9%) secondary GI MCL cases. Age, sex, and performance status were similar between primary and secondary cases. Secondary cases had more elevations in lactate dehydrogenase (28% vs 0%, P = 0.03) and a trend for a higher MCL international prognostic index (P = 0.07). Observation or local therapy was more common for primary GI MCL (29% vs 8%, P < 0.01), and autologous stem-cell transplant was more common for secondary GI MCL (35% vs 14%, P < 0.05). The median follow-up was 85 months. Primary and secondary GI MCL had similar 5-year progression-free survival (PFS) (30% vs 28%, P = 0.59) and overall survival (OS) (65% vs 66%, P = 0.83). The extent of GI involvement in primary GI MCL affected treatment selection but not outcome, with a 5-year PFS of 43% vs 14% vs 31% (P = 0.48) and OS of 57% vs 71% vs 69% (P = 0.54) in cases with single lesion vs multiple lesions in 1 organ vs multiple lesions in ≥2 organs. Less aggressive frontline treatment for primary GI MCL is reasonable. It is unknown whether more aggressive treatment can result in improved outcomes.

Primary GI MCL is rare. These patients tend to be treated less aggressively in the frontline setting yet have similar outcomes as those with secondary GI MCL.

Less aggressive frontline treatment for primary GI MCL is reasonable given decent outcome, although it is unknown whether more aggressive treatment can result in improved outcomes.

Recent advances upper gastrointestinal lymphomas: molecular updates and diagnostic implications

Approximately one-third of extranodal non-Hodgkin lymphomas involve the gastrointestinal (GI) tract, with the vast majority being diagnosed in the stomach, duodenum, or proximal small intestine. A few entities, especially diffuse large B-cell lymphoma and extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue, represent the majority of cases. In addition, there are diseases specific to or characteristic of the GI tract, and any type of systemic lymphoma can present in or disseminate to these organs. The recent advances in the genetic and molecular characterisation of lymphoid neoplasms have translated into notable changes in the classification of primary GI T-cell neoplasms and the recommended diagnostic approach to aggressive B-cell tumours. In many instances, diagnoses rely on morphology and immunophenotype, but there is an increasing need to incorporate molecular genetic markers. Moreover, it is also important to take into consideration the endoscopic and clinical presentations. This review gives an update on the most recent developments in the pathology and molecular pathology of upper GI lymphoproliferative diseases.

Hematologic malignancies of the gastrointestinal luminal tract

Hematologic malignancies include several lymphoproliferative and myeloproliferative disorders, many of which are frequently encountered in current health care settings. These malignancies frequently affect the gastrointestinal (GI) tract, either by secondary extranodal or extramedullary extension to the GI tract, or as a primary process arising in the GI tract. In fact, the GI tract may represent the most common extranodal site of involvement in many of them, such as lymphoma. Furthermore, in the current era of improved cancer treatment and advanced transplant procedures with increased survival, it has been quite common to encounter GI involvement by these malignancies through the disease course. Post-transplant lymphoproliferative disorder following kidney transplantation, for example, very commonly involves the GI tract. Other conditions that can involve the GI tract include multiple myeloma, plasmacytoma, myeloid sarcoma, mastocytosis, and Castleman disease. Imaging diagnosis of these malignancies can be challenging, since they are much less common than primary GI cancers and both share many common imaging features as well. However, certain imaging features, particularly in combination with a matching clinical scenario, play a pivotal role in diagnosing these conditions and directing further evaluation. In this article, we review common and rare hematologic malignancies of the GI tract and discuss their pathophysiologic, clinical, and imaging features.

Mantle cell lymphoma with gastrointestinal involvement and the role of endoscopic examinations

Background

Studies on gastrointestinal (GI) tract involvement in mantle cell lymphoma (MCL) are lacking. We investigated the clinical characteristics and prognosis of MCL with GI tract involvement.

Methods

We retrospectively analyzed 64 patients diagnosed with MCL from January 2009 to April 2017. At the time of MCL diagnosis, patients who were identified to have GI involvement by endoscopic or radiologic examination were assigned to the GI-MCL group. The other patients were assigned to the non GI-MCL group.

Results

The GI-MCL group included 28 patients (43.8%). The most common endoscopic finding of MCL was lymphomatous polyposis (20/28, 71.4%). The GI-MCL group had higher stage and International Prognostic Index status (P = 0.012 and P = 0.003, respectively). Among the total 51 GI lesions in the GI-MCL group, 31.4% (16/51) were detected only by endoscopic examinations and were not detected on CT or PET-CT. The cumulative incidence of recurrence was higher in the GI-MCL group compared with the non GI-MCL group but the difference was not statistically significant (P = 0.082). Stage (HR 1.994, 95% CI 1.007–3.948) and auto PBSCT (HR 0.133, 95% CI 0.041–0.437) were identified as independent predictive factors for recurrence. Recurrences at GI tract were identified in 59.1% (13/22) and 11.1% (2/18) of the GI-MCL and non GI-MCL group, respectively. Among 15 GI tract recurrences, five recurrences were detected only with endoscopic examinations.

Conclusions

Endoscopy can reveal the GI involvement of MCL that is not visualized by radiological imaging. Endoscopic examinations are recommended during staging workup and the follow-up period of MCL patients.

ALK-positive anaplastic large cell lymphoma presenting multiple lymphomatous polyposis: A case report and literature review

BACKGROUND

Anaplastic large cell lymphoma (ALCL) is a type of T-cell lymphoma that can be divided into two categories: anaplastic lymphoma kinase-positive (ALK+) and ALK-negative. Gastrointestinal ALK+ ALCL is rare. Multiple lymphomatous polyposis (MLP) is thought to be a representative form of gastrointestinal lesion in mantle cell lymphoma, and T-cell lymphomas seldom show this feature. Here, we report the first known case of ALK+ ALCL with gastroduodenal involvement to present with MLP.

CASE SUMMARY

The patient was a 43-year-old man who was complained of a mass in the left inguinal area and was performed open biopsy. ALK+ ALCL was diagnosed pathologically. Computed tomography scan demonstrated multiple lymph node lesions in the abdomen - pelvis/inguinal region, and scattered nodular lesions in both lung fields. He did not complain of gastrointestinal symptoms. While, esophagogastroduodenoscopy identified MLP lesions from the antrum of the stomach to the descending portion of the duodenum and mild thickened folds on the corpus of the stomach, and biopsy showed invasion of ALK+ ALCL. We treated this patient with six cycles of CHOEP (Cyclophosphamide, Doxorubicin, Vincristine, Etoposide, and Prednisone) chemotherapy. At the conclusion of treatment, there was complete remission. Numerous white scars were found on the stomach, endoscopically consistent with a remission image of lymphoma. The endoscopic features of this case were thought to be similar to those of MCL.

CONCLUSION

The macroscopic/endoscopic features of gastrointestinal ALK+ ALCL may be more similar to those of B-cell lymphomas rather than T-cell lymphomas.

Recurrent Mantle Cell Lymphoma Presenting as Gastrointestinal Bleeding

Mantle cell lymphoma is a rare and aggressive subtype of B-cell non-Hodgkin lymphomas. Mantle cell lymphoma frequently involves extranodal sites, and gastrointestinal tract is involved microscopically and macroscopically in more than 80$ of cases. We present two cases of recurrent mantle cell lymphoma presenting with lower and upper gastrointestinal bleeding, respectively. A 58-year-old woman with a history of recurrent mantle cell lymphoma treated with chemotherapy and stem cell transplantation presented with left-sided abdominal pain and hematochezia. Colonoscopy showed a mass-like lesion in the ascending colon, polyps in the ascending colon, and splenic flexure. A 68-year-old man with a history of mantle cell lymphoma treated with chemotherapy presented with epigastric pain and melena. Esophagogastroduodenoscopy showed a large polypoidal ulcerated mass with oozing in the duodenal bulb. Biopsies in both patients were suggestive of mantle cell lymphoma. Patients with mantle cell lymphoma could be asymptomatic or may present with abdominal pain, obstruction, diarrhea, or gastrointestinal bleeding. In patients presenting with gastrointestinal symptoms, endoscopy must be pursued and biopsies must be taken for any suspicious lesions as well as normal mucosa to exclude mantle cell lymphoma as an etiology for the lesion or symptoms. Even though there are no standard guidelines for endoscopic screening of gastrointestinal tract in asymptomatic patients, one should be aware of involvement of gastrointestinal tract in the early course of disease or recurrent disease. Although mantle cell lymphoma is initially responsive to chemotherapy, it eventually becomes refractory with a median survival of 3–5 years.

Gastrointestinal lymphomas: French Intergroup clinical practice recommendations for diagnosis, treatment and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, SFH)

INTRODUCTION

This document is a summary of the French Intergroup guidelines on the management of gastro-intestinal lymphomas, available on the web-site of the French Society of Gastroenterology, SNFGE (www.tncd.org), updated in September 2017.

METHODS

This collaborative work was realised under the auspices of several French medical societies and involved clinicians with specific expertise in the field of gastrointestinal lymphomas, including gastroenterologists, haematologists, pathologists, and radiation oncologist, representing the major French or European clinical trial groups. It summarises their consensus on the management of gastrointestinal lymphomas, based on the recent literature data, previous published guidelines and the expert opinions.

RESULTS

The clinical management, and especially the therapeutic strategies of the gastro-intestinal lymphomas are specific to their histological subtypes and to their locations in the digestive tract, with the particularity of gastric MALT lymphomas which are the most frequent and usually related to gastritis induced by Helicobacter pylori.

CONCLUSION

Lymphomas are much less common than epithelial tumours of gastro-intestinal digestive tract. Their different histological subtypes determine their management and prognosis. Each individual case should be discussed within the expert multidisciplinary team.

Smoldering mantle cell lymphoma

Background

Mantle cell lymphoma (MCL) is an aggressive disease, with poor prognosis and a limited survival. However, some patients with indolent MCL can survive beyond 7~10 years. These patients remain largely asymptomatic and can be in observation for a long time without any treatment. The process of “wait and watch” leaves these patients with the potential risk of evolution to classic, aggressive MCL. On the other hand, early treatment for these patients may not impact overall survival but rather affects the quality of life. Therefore, it is essential to clearly identify this type of indolent MCL at the time of diagnosis.

Results

Reported findings of indolent presentation of MCL include: lack of B symptoms, normal serum lactic dehydrogenase (LDH) and β2-microglobulin levels (β2M), low MCL-International Prognostic Index (MIPI) score, maximum tumor diameter less than 3 cm, spleen size < 20 cm, positron emission tomography/computerized tomography with the Standard Uptake Value max <6, Ki-67 less than 30%, with some particular immunophenotype, such as CD5 and CD38 negative, markedly increased CD23 positive lymphocytes proportions, high expression of CD200, kappa light chain restriction, without C-myc, TP53 and NOTCH1/2 mutations, non-blastoid/pleomorphic histology, and no tumor growth on reevaluation every 2~3 months (followed for at least 6 months). Imaging evaluation may only be performed in the presence of disease-related symptoms or organ involvement. Meanwhile, if novel nodal or extranodal lesion is found, biopsy is mandatory to exclude lymphoma.

Common clinopathological forms of indolent presentations include monoclonal B lymphocytosis with t (11; 14); “indolent leukemic” presentation of MCL with involvement of peripheral blood, bone marrow involvement, splenomegaly, and minimal lymphadenopathies and in situ lymphoma (often found in lymph nodes removed for other reasons, and in gastrointestinal biopsies).

Conclusions

Considering these distinct indolent clinical presentations with particular features in cytology and gene mutational status, we propose to include these MCL clinical presentations under the umbrella of “Smoldering Mantle Cell Lymphoma”.

Lymphocytic duodenitis or microscopic enteritis and gluten-related conditions: what needs to be explored?

Microscopic enteritis (ME) is characterized by abnormal infiltration of intraepithelial lymphocytes in intestinal mucosa. It was described as duodenal lymphocytosis or lymphocytic duodenitis until the dedicated Consensus Conference of 2015. ME represents a common feature of several gluten-mediated and non-gluten related diseases; therefore, it is an umbrella term embracing several conditions. The most frequent causes of ME are gluten-related disorders (celiac disease, non-celiac gluten sensitivity, wheat allergy), Helicobacter pylori infection and drug-related damages. Less frequently, ME may be secondary to inflammatory bowel disease, some autoimmune conditions, immunoglobulin deficiencies, blood malignancies, infections and irritable bowel syndrome. Therefore, the differential diagnosis of ME may be challenging. The diagnosis of ME needs to be driven by predominant symptoms and patient history. However, it is often difficult to achieve an immediate identification of the underlying condition, and a broad variety of diagnostic tests may be required. Ultimately, long-term surveillance is needed for a final diagnosis in many cases, since a hidden or quiescent condition may be disclosed after a period of latency. In any case, strict collaboration between the clinician and the pathologist is pivotal. The treatment of ME should be personalized, depending on the underlying disease. For gluten-related conditions (celiac disease, gluten sensitivity, wheat allergy, dermatitis herpetiformis), a gluten-free diet may be proposed. For other conditions, a targeted etiologic treatment is necessary. In conclusion, ME represents a novel entity that is attracting increasing interest. The growing epidemiologic trend confirms that it will become a common condition in clinical practice.

Asymptomatic Multiple Lymphomatous Polyposis Identified during Staging Bidirectional Endoscopy of Mantle Cell Lymphoma

Multiple lymphomatous polyposis (MLP) as an extranodal manifestation of mantle cell lymphoma (MCL) in the gastrointestinal tract is rare and not often reported in the literature. We describe the case of a 63-year-old female with asymptomatic MLP found during staging bidirectional endoscopy of MCL. The patient presented only with dyspnea, but was found on physical exam to have diffuse lymphadenopathy, and subsequent positron emission tomography (PET) CT showed extensive lymph node adenopathy consistent with lymphoma. Excisional lymph node biopsy revealed high-risk MCL. Prior to therapy, staging bidirectional endoscopy was performed, which revealed duodenal bulb polyps and diffuse polyposis in the colon. Biopsies showed atypical lymphoid infiltrate identical to the initial excisional lymph node biopsy. The patient underwent aggressive induction therapy, chemotherapy and bone marrow transplantation. Four months later, repeat colonoscopy and biopsies showed normal mucosa, and repeat PET CT showed no evidence of systemic disease. Eight months later, the patient began having symptoms consistent with cauda equina syndrome, and she was found to have leptomeningeal recurrence of MCL. In spite of other medical treatment, the patient's MCL progressed and she passed away 3 years after the initial presentation.

A very unusual cause of dysphagia: mantle cell lymphoma

Dysphagia is an alarm symptom requiring a prompt investigation. Different benign and malignant diseases may present such a symptom. We describe a case of a 79-year-old patient who complained of fluctuating dysphagia episodes following solid food ingestion in the previous 5 months with mild weight loss. No other gastrointestinal symptoms were present. The patient was referred by the General Practitioner for a videofluoroscopic swallow examination which revealed nodularity of mucosa surface in the oropharynx, esophagus, fundus, and gastric body. Upper endoscopy confirmed the feature, also showing a normal mucosa of the antrum and duodenum. The histological examination revealed a mantle cell lymphoma (MCL). A stage III, MCL involving the esophagus and proximal stomach was eventually diagnosed. Esophageal MCL localization is extremely rare, and this is the first report showing a clinical onset with dysphagia.

From the radiologic pathology archives: gastrointestinal lymphoma: radiologic and pathologic findings

Gastrointestinal (GI) lymphoma encompasses a heterogeneous group of neoplasms that have a common lymphoid origin but variable pathologic and imaging features. Extranodal marginal zone B-cell lymphoma (ENMZL) and diffuse large B-cell lymphoma (DLBCL) are the most common. ENMZL usually occurs in the stomach, where it is associated with chronic infection by Helicobacter pylori, and is typically a superficial spreading lesion that causes mucosal nodularity or ulceration and mild wall thickening. DLBCL may arise de novo or from transformation of ENMZL or other low-grade lymphomas. This form of lymphoma produces extensive wall thickening or a bulky mass, but obstruction is uncommon. Mantle cell lymphoma is the classic cause of lymphomatous polyposis, but multiple polyps or nodules can also be seen with ENMZL and follicular lymphoma. Burkitt lymphoma is usually characterized by an ileocecal mass or wall thickening in the terminal ileum in young children, often in the setting of widespread disease. Primary GI Hodgkin lymphoma, which is rare, may be manifested by a variety of findings, though stenosis is more common than with non-Hodgkin lymphoma. Enteropathy-associated T-cell lymphoma is frequently associated with celiac disease and is characterized by wall thickening, ulceration, and even perforation of the jejunum. Accurate radiologic diagnosis of GI lymphoma requires a multifactorial approach based on the clinical findings, site of involvement, imaging findings, and associated complications.

Rare gastrointestinal lymphomas: The endoscopic investigation

Gastrointestinal lymphomas represent up to 10% of gastrointestinal malignancies and about one third of non-Hodgkin lymphomas. The most prominent histologies are mucosa-associated lymphoid tissue lymphoma and diffuse large B-cell lymphoma. However, the gastrointestinal tract can be the site of rarer lymphoma subtypes as a primary or secondary localization. Due to their rarity and the multifaceted histology, an endoscopic classification has not been validated yet. This review aims to analyze the endoscopic presentation of rare gastrointestinal lymphomas from disease diagnosis to follow-up, according to the involved site and lymphoma subtype. Existing, new and emerging endoscopic technologies have been examined. In particular, we investigated the diagnostic, prognostic and follow-up endoscopic features of T-cell and natural killer lymphomas, lymphomatous polyposis and mantle cell lymphoma, follicular lymphoma, plasma cell related disease, gastrointestinal lymphomas in immunodeficiency and Hodgkin’s lymphoma of the gastrointestinal tract. Contrarily to more frequent gastrointestinal lymphomas, data about rare lymphomas are mostly extracted from case series and case reports. Due to the data paucity, a synergism between gastroenterologists and hematologists is required in order to better manage the disease. Indeed, clinical and prognostic features are different from nodal and extranodal or the bone marrow (in case of plasma cell disease) counterpart. Therefore, the approach should be based on the knowledge of the peculiar behavior and natural history of disease.

Primary gastrointestinal mantle cell lymphoma: a retrospective study

INTRODUCTION

Primary gastrointestinal tract mantle cell lymphoma is very rare. There is paucity of literature regarding natural history and outcome of this unusual entity.

AIMS AND OBJECTIVES

The aim of the present study was to analyze clinical profile, epidemiological parameters, and outcome of primary gastrointestinal mantle cell lymphoma patients treated at our institute.

MATERIALS AND METHODS

This was a retrospective observational study of consecutive patients diagnosed with primary gastrointestinal mantle cell lymphoma at our institute between 2001 and 2012.

RESULTS

A total of seven patients, all males with a median age of 67.7 years, were diagnosed with primary gastrointestinal mantle cell lymphoma. Sites involved were the stomach, colon, and rectum. Blastoid and diffuse variants were observed in three patients each, and one patient had nodular pattern. Five patients received cyclophosphamide, adriamycin, vincristine, and prednisolone (CHOP) chemotherapy. Only one patient achieved complete remission and remained disease free for 21 months before being lost to follow up. The remaining four patients had inadequate response to CHOP chemotherapy with a median survival of 6 months. Cyclophosphamide, vincristine, prednisolone (CVP) was given to one patient in view of poor performance status. He had progressive disease and died after first cycle of chemotherapy. One patient is currently undergoing treatment and receiving rituximab with chemotherapy.

CONCLUSIONS

Primary gastrointestinal mantle cell lymphoma is highly aggressive with the Mantle Cell Lymphoma International Prognostic Index (MIPI) scores in high-risk group; survival is poor compared to nodal mantle cell lymphoma involving the gastrointestinal tract; patients respond poorly to CHOP chemotherapy. As majority of patients are elderly and not eligible for transplant, the use of rituximab in remission induction and maintenance should be considered to improve outcome of these patients.

Endoscopic features of gastro-intestinal lymphomas: From diagnosis to follow-up

Many progresses have been done in the management of gastrointestinal (GI) lymphomas during last decades, especially after the discovery of Helicobacter pylori-dependent lymphoma development. The stepwise implementation of new endoscopic techniques, by means of echoendoscopy or double-balloon enteroscopy, enabled us to more precisely describe the endoscopic features of GI lymphomas with substantial contribution in patient management and in tailoring the treatment strategy with organ preserving approaches. In this review, we describe the recent progresses in GI lymphoma management from disease diagnosis to follow-up with a specific focus on the endoscopic presentation according to the involved site and the lymphoma subtype. Additionally, new or emerging endoscopic technologies that have an impact on the management of gastrointestinal lymphomas are reported. We here discuss the two most common subtypes of GI lymphomas: the mucosa-associated lymphoid tissue and the diffuse large B cell lymphoma. A general outline on the state-of-the-art of the disease and on the role of endoscopy in both diagnosis and follow-up will be performed.

Mantle cell lymphoma: a rare cause of a solitary duodenal mass

Mantle cell lymphoma is a very aggressive lymphoma with a very poor prognosis. It commonly involves the gastrointestinal tract but rarely presents as primary gastrointestinal lymphoma. The most notable cases of primary gastrointestinal mantle cell lymphomas have been described as multiple lymphomatous polyposis and have a very poor prognosis. We report a case of primary gastrointestinal mantle cell lymphoma that was discovered by endoscopic biopsy of a single duodenal polyp in a 70-year-old woman who was previously treated for Helicobacter pylori gastritis. She presented with a 6-month history of indigestion, heartburn and abdominal bloating. A subsequent workup revealed one extranodal site of involvement, lymphatic involvement below the diaphragm and a normal bone marrow biopsy. We followed a wait-and-watch approach including serial CT scans and blood tests. Two years later, her symptoms have not progressed and her disease has remained stable.

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.

High-grade GI lymphoma presenting with diarrhoea

A 63-year-old male carpenter presented with diarrhoea after returning from a holiday in Egypt with no other abdominal features. Physical examination showed generalised lymphadenopathy and splenomegaly. Blood tests including inflammatory markers were within normal limits. Microbiological stool sample analysis was unremarkable. Endoscopies of the large bowel showed patchy inflammation from the rectum to the hepatic flexure with multiple tiny polyps. Histology revealed a lymphocytic infiltrate suggestive of multiple lymphomatous polyposis. Some time later, he presented with small bowel obstruction requiring emergency laparotomy and ileostomy. After recovery from surgery he started definite treatment with chemotherapy resulting in complete remission.

Gastrointestinal B-cell lymphomas: From understanding B-cell physiology to classification and molecular pathology

The gut is the most common extranodal site where lymphomas arise. Although all histological lymphoma types may develop in the gut, small and large B-cell lymphomas predominate. The sometimes unexpected finding of a lymphoid lesion in an endoscopic biopsy of the gut may challenge both the clinician (who is not always familiar with lymphoma pathogenesis) and the pathologist (who will often be hampered in his/her diagnostic skill by the limited amount of available tissue). Moreover, the past 2 decades have spawned an avalanche of new data that encompasses both the function of the reactive B-cell as well as the pathogenic pathways that lead to its neoplastic counterpart, the B-cell lymphoma. Therefore, this review aims to offer clinicians an overview of B-cell lymphomas in the gut, and their pertinent molecular features that have led to new insights regarding lymphomagenesis. It addresses the question as how to incorporate all presently available information on normal and neoplastic B-cell differentiation, and how this knowledge can be applied in daily clinical practice (e.g., diagnostic tools, prognostic biomarkers or therapeutic targets) to optimalise the managment of this heterogeneous group of neoplasms.

Lymphoproliferative disorders of the gastrointestinal tract: a review and pragmatic guide to diagnosis

CONTEXT

The gastrointestinal tract is the most common site of extranodal lymphomas. Although all histologic categories of malignant lymphoma develop in the gastrointestinal tract, large B-cell lymphomas predominate, followed by extranodal marginal zone lymphomas of mucosa-associated lymphoid tissue (MALT) type; the latter is especially prevalent in stomach. The acceptance of extranodal marginal zone lymphoma of MALT type as a clinicopathologic entity has reduced the number of cases that formerly were interpreted as florid lymphoid hyperplasia ("pseudolymphoma"). Nonetheless, the distinction of lymphoid hyperplasia from a lymphoma of MALT type in small biopsy specimens remains problematic.

OBJECTIVE

To assess the relevant morphologic, immunologic, molecular, and genetic properties of gastrointestinal lymphomas and to present a feasible tactic for diagnosis, expressly for small biopsy specimens.

DATA SOURCES

Case-derived material and literature review using PubMed (National Library of Medicine).

CONCLUSIONS

Most gastrointestinal lymphomas are readily amenable to an unqualified diagnosis, primarily those cases consisting of monomorphic large cells whether of B- or T-cell lineage, including cases associated with enteropathy. Diagnosis for infiltrates dominated by small lymphocytes remains taxing, as the differential diagnosis embraces not only MALT lymphoma and lymphoid hyperplasia but also mantle cell lymphoma, follicular lymphoma, and chronic lymphocytic leukemia/small lymphocytic lymphoma. Adherence to strict morphologic criteria is the standard for diagnosis, but these criteria should be augmented by immunologic studies together with judicious use of molecular techniques to determine clonality. In establishing a diagnosis of gastric marginal zone lymphoma of MALT type, determination of t(11;18)(q21;q21) status may be required since this translocation has clinical ramifications.

Clinicopathological features and treatment of primary small intestinal lymphoma: recent advances

Primary small intestinal lymphoma (PSIL) is an extra-nodal lymphoma whose clinical and histological presentations are usually heterogeneous depending on the site of the lesion. Proper staging criteria are important for clinicopathological diagnosis. Although there is no consensus regarding the role of surgery and chemotherapy in the treatment of PSIL, surgery followed by chemotherapy and radiotherapy is still the main treatment. This review summarizes the clinicopathological features, diagnosis, therapy and prognosis of PSIL.

A rare case of mantle cell lymphoma as lymphomatous polyposis with widespread involvement of the digestive tract

Lymphomatous polyposis of the gastrointestinal tract is rare. It refers to a heterogeneous group of small B-cell lymphomas including mantle cell lymphoma, follicular lymphoma and MALT lymphoma. It is characterized by the presence of multiple lymphomatous polyps along one or more segments of the digestive tract. Clinical symptoms are non-specific. We herein report the case of a 74-year old man initially admitted for an upper and lower gastrointestinal endoscopy to explore a positive Hemoccult test. The endoscopy revealed multiple polyps all along the gastrointestinal tract. Histopathological study showed a diffuse lymphomatous proliferation of small B-cells whose immunohistochemical features were compatible with a mantle cell lymphoma. Tumoral B-cells showed a positivity of cyclin D1 markers but negativity for CD5. Immunochemotherapy with R-CHOP (rituximab, cyclophosphamide, adriamycine, vincristine and prednisone) was initiated. Based on this case study, the pitfalls of gastrointestinal tract lymphomatous polyposis diagnosis, prognosis and treatment options are discussed.