Is there an association between mesenteric panniculitis and lymphoma? A case control analysis

Sclerosing mesenteritis following immune checkpoint inhibitor therapy

PURPOSE

Sclerosing mesenteritis (SM), a fibroinflammatory process of the mesentery, can rarely occur after immune checkpoint inhibitor (ICI) therapy; however, its clinical significance and optimal management are unclear. We aimed to assess the characteristics and disease course of patients who developed SM following ICI therapy at a single tertiary cancer center.

METHODS

We retrospectively identified 12 eligible adult cancer patients between 05/2011 and 05/2022. Patients' clinical data were evaluated and summarized.

RESULTS

The median patient age was 71.5 years. The most common cancer types were gastrointestinal, hematologic, and skin. Eight patients (67%) received anti-PD-1/L1 monotherapy, 2 (17%) received anti-CTLA-4 monotherapy, and 2 (17%) received combination therapy. SM occurred after a median duration of 8.6 months from the first ICI dose. Most patients (75%) were asymptomatic on diagnosis. Three patients (25%) reported abdominal pain, nausea, and fever and received inpatient care and corticosteroid treatment with symptom resolution. No patients experienced SM recurrence after the completion of corticosteroids. Seven patients (58%) experienced resolution of SM on imaging. Seven patients (58%) resumed ICI therapy after the diagnosis of SM.

CONCLUSIONS

SM represents an immune-related adverse event that may occur after initiation of ICI therapy. The clinical significance and optimal management of SM following ICI therapy remains uncertain. While most cases were asymptomatic and did not require active management or ICI termination, medical intervention was needed in select symptomatic cases. Further large-scale studies are needed to clarify the association of SM with ICI therapy.

Sclerosing Mesenteritis: A Rare Cause of Abdominal Pain

Sclerosing mesenteritis (SM) is a rare inflammatory fibrotic disease of the small intestine mesenteric fat often discovered incidentally on a CT scan. Clinical manifestations depend on the mass effect on the viscera and vessels. The most common symptoms are abdominal pain, bloating, and nausea. SM occurs predominantly in Caucasian men, during the fifth to seventh decades of life. We present a 69-year-old woman with SM whose symptoms were thought to be from irritable bowel syndrome.

A 69-year-old female with a history of fibromyalgia presented with recurrent bouts of abdominal pain across her mid-abdomen lasting 30 minutes to an hour associated with nausea, alternating constipation and diarrhea with occasional mucus, and bloating. She used bismuth subsalicylate and ondansetron with temporary relief. Upper endoscopy and colonoscopy were unrevealing. Initially, she was felt to have irritable bowel. Later she presented with nausea and right upper quadrant pain and underwent cholecystectomy. When her pain recurred, the patient had a CT abdomen and pelvis which showed multiple sub-centimeter mesenteric lymph nodes with surrounding haziness and stranding in the root of the mesentery consistent with SM. The patient had a pannus biopsy showing fat necrosis that confirmed the diagnosis. She continued to have waxing and waning symptoms over several years and in the interim was diagnosed with melanoma limited to the skin. The patient had a particularly severe episode of abdominal pain prompting a repeat CT scan with a subsequent biopsy of an enlarged left para-aortic lymph node that revealed lymphoma.

Our patient’s diagnosis of SM was delayed as her symptoms were mistaken for irritable bowel syndrome. Worsening symptoms should alert clinicians to an alternate diagnosis such as SM. There are characteristic radiographic findings on CT scans and biopsy of the lesions. SM’s association with neoplastic diseases such as lymphoma, melanoma, colorectal, and prostate cancer is controversial, however, practitioners should be aware of this possibility and consider biopsy for any suspicious lesions.

Follicular Lymphoma Treated with First-Line Immunochemotherapy: A Review of PET/CT in Patients Who Did Not Achieve a Complete Metabolic Response in the GALLIUM Study

Complete metabolic response (CMR) on PET/CT was the sole independent predictor of overall survival in the PET substudy of the phase III GALLIUM trial (NCT01332968) in first-line treatment of high-tumor-burden follicular lymphoma. The aim of this analysis was to further investigate the outcome of patients not achieving CMR. Methods: Two international experts rereviewed PET/CT scans from patients failing to achieve CMR assessed by the Independent Review Committee masked otherwise to committee results. Metabolic response category and Deauville score were assigned. Progression-free survival (PFS) was investigator-assessed with contrast-enhanced CT. Kaplan-Meier methodology was used to estimate landmark PFS and time to next treatment from end of induction by Deauville score. Patients who experienced CT-based progressive disease at the end of induction were excluded. Results: Fifty-four patients were reviewed. Six had CMR, 37 had a partial metabolic response, 2 had no metabolic response, and 9 had progressive metabolic disease. Patients were reassigned to CMR because ¹⁸F-FDG uptake was considered inflammatory (n = 2), was considered incidental neoplasia (n = 2), or was visually close to liver uptake but quantitatively lower (n = 2). There was a trend for shorter PFS and time to next treatment for patients with a Deauville score of 5 than a score of 4. High-grade mesenteric uptake at the end of induction was common, occurring in 20 patients with non-CMR, 14 of whom achieved CMR at all other sites. Only 3 of 14 (21%) patients with mesenteric uptake as the only site of disease experienced progression or death within 24 mo, whereas 4 of 6 patients (67%) with mesenteric and additional sites of ¹⁸F-FDG-avid disease experienced progression or death within 24 mo. All patients with early progression had measurable disease on contrast-enhanced CT at ¹⁸F-FDG-avid sites at the end of induction. Conclusion: After induction immunochemotherapy, CMR was assigned after reassessment in some patients, in whom increased ¹⁸F-FDG uptake was considered due to inflammation or incidental neoplasia rather than to lymphoma. Quantitative assessment to confirm the visual impression of residual uptake in lesions is suggested. Isolated mesenteric ¹⁸F-FDG uptake is likely a common false-positive finding at the end of induction and does not warrant changes in clinical management or disease surveillance unless there is measurable disease on contrast-enhanced CT or clinical suspicion of active disease.

CT features associated with underlying malignancy in patients with diagnosed mesenteric panniculitis: Mesenteric panniculitis: CT features associated with underlying malignancy

PURPOSE

The purpose of this study was to identify abdominal computed tomography (CT) features associated with underlying malignancy in patients with mesenteric panniculitis (MP).

MATERIALS AND METHODS

This single-institution retrospective longitudinal cohort study included patients with MP and a minimum 1-year abdominopelvic CT follow-up or 2-year clinical follow-up after initial abdominopelvic CT examination. Two radiologists, blinded to patients' medical records, conjointly reviewed CT-based features of MP. Electronic medical records were reviewed for newly diagnosed malignancies with the following specific details: type (lymphoproliferative disease or solid malignancy), location (possible mesenteric drainage or distant), stage, time to diagnosis. An expert panel of three radiologists and one hemato-oncologist, who were blinded to the initial CT-based MP features, assessed the probability of association between MP and malignancy based on the malignancy characteristics.

RESULTS

From 2006 to 2016, 444 patients with MP were included. There were 272 men and 172 women, with a median age of 64 years (age range: 25-89); the median overall follow-up was 36 months (IQR: 22, 60; range: 12-170). A total of 34 (8%) patients had a diagnosis of a new malignancy; 5 (1%) were considered possibly related to the MP, all being low-grade B-cell non-Hodgkin lymphomas. CT features associated with the presence of an underlying malignancy were the presence of an MP soft-tissue nodule with a short axis >10 mm (P < 0.0001) or lymphadenopathy in another abdominopelvic region (P < 0.0001). Associating these two features resulted in high diagnostic performance (sensitivity 100%; [95% CI: 57-100]; specificity 99% [95% CI: 98-100]). All related malignancies were identified.

CONCLUSION

Further workup to rule out an underlying malignancy is only necessary in the presence of an MP soft-tissue nodule >10 mm or associated abdominopelvic lymphadenopathy.

Colchicine as an Alternative First-Line Treatment of Sclerosing Mesenteritis: A Retrospective Study

BACKGROUND

Sclerosing mesenteritis is a rare condition characterized by chronic inflammation and fibrotic changes of the mesentery.

AIMS

To determine the long-term management and outcomes of patients with sclerosing mesenteritis.

METHODS

Patients with biopsy-proven sclerosing mesenteritis at the Mayo Clinic between January 2006 and December 2016 were identified. Clinical data were collected retrospectively.

RESULTS

One hundred and three patients were identified, median age 68.0 years (range 35.0-85.3). Most patients were symptomatic (87.4%) at presentation. Patients received no treatment (52.4%), medical therapy (42.7%) or surgery (4.9%) on initial diagnosis. The most common initial regimens were prednisone plus tamoxifen (41.9%), prednisone alone (23.3%), and prednisone plus colchicine (11.6%) with 55.6%, 57.2%, and 60% of patients improving, respectively, p = 0.85 for a difference in response rates. At least half of the patients responded to prednisone plus tamoxifen, prednisone plus colchicine, or prednisone alone at 6.0, 7.2, and 8.4 months, respectively. At a median follow-up of 45.6 months (95% CI 24.1-69.7), 65.4% of patients were receiving medical therapy. Of those receiving tamoxifen-based, steroid-based, or steroid-sparing regimens, 100%, 87.5%, and 77.8% had improved by their last follow-up appointment respectively, p = 0.15.

CONCLUSION

Prednisone plus colchicine has a similar efficacy to prednisone plus tamoxifen for the initial and long-term treatment of sclerosing mesenteritis. The majority of patients were initiated on medical therapy over the long term with most reporting symptomatic improvement within a year. Death from SM was rare.

Mesenteric panniculitis does not confer an increased risk for cancers: A systematic review and meta-analysis

BACKGROUND

Mesenteric panniculitis (MP) is a non-specific, localized inflammation at the mesentery of small intestines which often gets detected on computed tomography. An association with malignant neoplasms remains unclear. We performed a systematic review and meta-analysis to examine the association of malignancy with MP.

METHODS

MEDLINE, EMBASE, Web of Science, and Cochrane databases were searched for articles published from inception to 2020 that evaluated the association of malignant neoplasms with MP in comparison with control groups. Using random-effects method, a summary odds ratio (OR) estimate with 95% confidence intervals for malignant neoplasms in MP was estimated.

RESULTS

Four case-control studies reporting data on 415 MP patients against 1132 matched-controls met inclusion criteria and were analyzed. The pooled OR for finding a malignant neoplasm in patients with MP was 0.907 (95% CI: 0.688-1.196; P = .489). The heterogeneity was mild and non-significant. Also, there was no heightened risk of any specific type of malignancy with MP. Three more case-series with unmatched-control groups (MP: 282, unmatched-controls: 17,691) were included in a separate analysis where the pooled OR of finding a malignant neoplasm was 2.963 (95% CI: 1.434-6.121; P = .003). There was substantial heterogeneity in this group.

CONCLUSION

This meta-analysis of matched controlled studies proves absence of any significant association of malignant neoplasms with MP. Our study also demonstrates that the putative association of malignancy with MP is mainly driven by uncontrolled studies or case-series.

Mesenteric panniculitis mimicking early recurrence at end-of-treatment evaluation in malignant lymphoma: Differentiation by active surveillance with F-18 FDG PET/CT imaging

Mesenteric panniculitis is a relatively rare fibro-inflammatory condition of the mesentery. In acute phase, it demonstrates avid uptake on Fluorine-18 FDG PET/CT (PET/CT). Thorough assessment is needed to differentiate from viable or recurrent disease in patients with malignant lymphoma because it mimics active lymphomatous disease on PET/CT. In this article, 3 illustrative cases of malignant lymphoma are presented. PET/CT demonstrated new FDG-avid mesenteric lesions at the end-of-treatment evaluation while the original disease showed significant response. Early recurrence was initially suspected, but together with clinical course and findings, active surveillance was opted. Sequential follow-up PET/CTs showed various patterns of metabolic activity over time; it can persist for months or more, or metabolic activity can fluctuate over time. Eventually benignity was confirmed in these cases. These cases underscore the importance of interpretation with clinical context and awareness of chronological metabolic changes of mesenteric panniculitis to determine proper management.

Clinical and radiological features of mesenteric panniculitis: a critical overview

The mesenteric panniculitis is a rare form of inflammation that mainly involves the mesenteric adipose tissue. The etiology remains unknown and the disease has been associated with various conditions such as cancer, abdominal trauma, previous surgery, autoimmune diseases and obesity. Mesenteric panniculitis can be divided into two main groups: the mesenteric panniculitis with only the inflammation and degeneration of the mesenteric fat, and the retractile panniculitis, mainly fibrotic, with retraction of the surrounding structures. From a radiological point of view, there are two main signs: the fat ring sign, which is the presence of normal fat around vessels and lymph nodes, and the pseudocapsula around the lesion. In this paper, we present the imaging and clinical features of mesenteric panniculits with particular reference to the differential diagnosis and the possible etiological associations. (www.actabiomedica.it)

The Complex Relationship between Mesenteric Panniculitis and Malignancy - A Holistic Approach is Still Needed to Understand the Diagnostic Uncertainties

Mesenteric panniculitis is an idiopathic, localized inflammation involving the adipose tissue of the small bowel mesentery. The association of mesenteric panniculitis with malignancy, predominantly lymphomas, has been widely reported in the medical literature. In this review article, we will discuss the clinical guidelines in the diagnosis and management of mesenteric panniculitis and the clinical association between mesenteric panniculitis and malignancies.

Sclerosing Mesenteritis

Sclerosing mesenteritis is a rare non-neoplastic disorder characterized by fat necrosis, chronic inflammation, and fibrosis typically of the small bowel mesentery. Our understanding of this disorder is limited by its rarity as well as inconsistent terminology used across the literature. While prior abdominal surgery or trauma, autoimmunity, infection, ischemia, and malignancy have been suggested to be involved in the pathogenesis of the disorder, it remains poorly understood. The clinical course of sclerosing mesenteritis is generally benign with a large proportion of patients diagnosed incidentally on imaging obtained for other indications. In a subset of patients, symptoms may arise from a mass effect on the bowel, lymphatics, or vasculature resulting in bowel obstruction, chylous ascites, or mesenteric ischemia. Symptomatic patients should be treated with a combination of corticosteroid and tamoxifen as first-line therapy based on retrospective case series and experience in other fibrosing disorders. Surgical intervention may be required in those with persistent obstruction despite conservative treatment, though complete resection of the mass is often not feasible given intimate involvement with the mesenteric vasculature. A careful use of terminology and communication between the radiologist, pathologist, and clinicians in the care of these patients will be essential to future efforts at understanding this disease.