Rectal lymphoma in ulcerative colitis treated with azathioprine

Primary hepatic Epstein-Barr virus-positive diffuse large B-cell lymphoma associated with azathioprine immunosuppression: a case report

BACKGROUND

Hepatic masses are relatively common findings, and the diagnostic approach often begins by identifying patient and mass characteristics that are risk factors for malignancy. Chronic immunosuppression is a known risk factor for various malignancies, and azathioprine in particular has been reported in association with solid and hematologic malignancies, including diffuse large B-cell lymphoma.

CASE PRESENTATION

A 46-year-old white woman presented to clinic with several weeks of gastrointestinal symptoms and was found to have a hepatic mass on imaging. Her history was notable for neuromyelitis optica spectrum disorder on chronic immunosuppression with azathioprine. It was initially thought to be an inflammatory adenoma. On 6-month follow-up imaging, the mass had grown rapidly in size and was surgically resected. Further workup determined the mass to be an iatrogenic immunodeficiency-associated Epstein-Barr virus-positive diffuse large B-cell lymphoma confined to the liver. Azathioprine was discontinued and the patient underwent treatment with rituximab with no evidence of recurrence 2 years after the initiation of treatment.

CONCLUSIONS

This case report describes the first time hepatic Epstein-Barr virus-positive diffuse large B-cell lymphoma has been reported with azathioprine, which highlights the unique sequelae of chronic immunosuppression, including atypical hematologic malignancies, and the importance of considering chronic immunosuppression in the diagnostic evaluation of a hepatic mass.

A case of iatrogenic immunodeficiency-associated colonic lymphoma complicating ulcerative colitis

Background

Ulcerative colitis (UC) is one of the major types of inflammatory bowel diseases and is associated with a significantly increased risk of not only lymphoproliferative disorders but also lymphomas, of which most cases are related to the long-term usage of immunosuppressants. Here, we demonstrate a very rare case of other iatrogenic immunodeficiency-associated colonic diffuse large B-cell lymphoma (Oii-DLBCL) complicating UC and rectal perforation. In addition, we reviewed the clinicopathological features of previous cases of DLBCL related to UC.

Case presentation

A 68-year-old man was diagnosed with left-sided UC 26 months prior. Although he was followed by immunosuppressive therapy with azathioprine and infliximab, an emergency total proctocolectomy was performed due to rectal perforation. The resected specimen exhibited irregular wall thickening and elevated multinodular lesions extending from the mid-transverse colon to the rectum, measuring up to 52 cm in length. Histologically, the lesion was diagnosed as Oii-DLBCL and crypt abscess surrounded by mixed inflammatory cell was remained.

Conclusion

Oii-DLBCL complicating UC with rectal perforation is extremely rare. Macro- and microscopic findings are important for early diagnosis of the lesion.

Primary rectal diffuse large B-cell lymphoma associated with ulcerative colitis: a case report

We need to be aware of primary intestinal lymphoproliferative disease (PILD) associated with ulcerative colitis (UC). We should carefully monitor UC patients, particularly patients who meet the following conditions; a previous Epstein-Barr virus infection, treatment duration ≧4 years, male, and age ≧50 years.

Hodgkin's lymphoma rectosigmoid in a patient with ulcerative colitis on long-term azathioprine therapy

Hodgkin's lymphoma complicating chronic ulcerative colitis is extremely rare. We report a case of extranodal Hodgkin's lymphoma involving rectosigmoid in a patient of chronic ulcerative colitis on long-term azathioprine. A 67-year-old man presented with extensive ulcerative colitis, on follow-up since September 2005. He received long-term steroids, mesalamine and azathioprine. Serial surveillance colonoscopic examinations and colonic biopsies were performed. Surveillance colonoscopy performed 8 years after the onset of disease showed multiple deep ulcers and nodular masses involving the rectum and sigmoid colon. Histological examination of rectosigmoid biopsies showed classic Hodgkin's disease. Azathioprine was withdrawn. He received mechlorethamine, vincristine, procarbazine and prednisone (MOPP) chemotherapy protocol and was planned for total colectomy in follow-up. We believe patients with ulcerative colitis on long-term azathioprine should be on vigil for development of lymphomas by protocol surveillance colonoscopic examinations and biopsies. The risk of lymphoma in such patients is small and outweighs the benefits of long-term azathioprine therapy.

Concomitant adenocarcinoma and colonic non-Hodgkin's lymphoma in a patient with ulcerative colitis: a case report and molecular analysis

Ulcerative colitis (UC) complicated by colonic lymphoma is rare, although UC is often accompanied by adenocarcinoma of the colon. A concurrent existence of adenocarcinoma and lymphoma in a patient with UC is extremely rare, and has not yet been analyzed at the molecular level. We report a 64-year-old female patient with concomitant adenocarcinoma and diffuse large B-cell lymphoma (DLBCL) in the colon of UC. The genetic changes in these two neoplasms were analyzed. The colon adenocarcinomas had a mutation in MSH6 gene, DNA methylation in CDKN2A gene, and increased microsatellite instability (MSI), although these genetic changes were not recognized in either DLBCL or non-neoplastic UC mucosa. The DLBCL was diagnosed as primary colonic lymphoma, and confirmed Epstein-Barr virus (EBV) infection. The adenocarcinomas and the non-neoplastic UC mucosa were EBV-negative. Our case presented here clearly shows that the development of adenocarcinoma and lymphoma in the colon with UC was caused by individual mechanisms.

GI-lymphomas in immunosuppressed patients (organ transplantation; HIV)

Gastrointestinal lymphoma plays a major role complicating different diseases presenting with immunosuppression, both primary and acquired immunodeficiency (incl. HIV, transplantation, immunosuppression following chemotherapy, or inflammatory bowel disease). Lymphoma in diseases with immunosuppression are clinically and pathologically heterogeneous, but share some features such as frequent involvement of extranodal sites, diffuse aggressive histology, B-cell lineage derivation, viral association with EBV and clinically aggressive courses. While gastrointestinal lymphoma in congenital immunodeficiency disorders seems to be a rare event inspite of higher prevalences, in post-transplant lymphoproliferative disorders (PTLD) the gastrointestinal tract is one of the most important organs of lymphoma. In HIV-associated non-Hodgkin's lymphoma, gastrointestinal lesions as the most frequent extranodal localisation occur in 30-50% of lymphoma patients, are late events of HIV infection with severe immunosuppression and are mainly diagnosed with advanced disease stages Ann Arbour III or IV. They are characterised by unusual, often multifocal localisation in the gastrontestinal tract, high rates of life-threatening complications (bleeding, perforation or obstruction) and high-grade B-cell histology. With the introduction of highly active antiretroviral therapy (HAART) in the therapeutic concept in AIDS, a decrease of AIDS-related GI lymphoma was noted with improved survival rates and prognosis of lymphoma. Therapy strategies including chemotherapy, immunotherapy and HAART will show promising results in response and survival rates.