Gastrointestinal lymphomas: Morphology, immunophenotype and molecular features

Management approaches for primary hepatic lymphoma: 10 year institutional experience with comprehensive literature review

Purpose/objective

Primary hepatic lymphomas (PHL) are an extremely rare form of non-Hodgkin Lymphoma (NHL) for which there are no established treatment guidelines, with available literature largely comprised of small case reports. Therefore, we evaluate our institutional experience treating PHL within the context of existing literature to better understand treatment modalities, role of radiotherapy (RT), and outcomes.

Materials/methods

We conducted a single institutional retrospective study of all patients with PHL diagnosed from 2000-2021, defined as a biopsy-proven liver lesion in the absence of other lymphomatous solid organ involvement, except for concurrently diagnosed hepatosplenic lymphomas. Subgroup analysis was performed for diffuse large B-cell lymphoma (DLBCL) and indolent lymphomas, which included marginal zone lymphoma (MZL), Grade 1-2 follicular lymphoma (FL), and low-grade B-cell lymphoma (BCL), NOS. Univariable (UVA) and multivariable analysis (MVA) for overall survival (OS) were performed using the Cox proportional hazards model. A literature review was conducted using key words "liver", "lymphoma", and "treatment" to identify relevant literature.

Results

We identified 30 patients with PHL within the institutional cohort and 192 patients from comprehensive literature review. Subgroup analysis of DLBCL included 15 patients. On MVA for OS, only ECOG score (p=0.02) and Lugano stage (p=0.04) remained significant. Subgroup analysis of the indolent lymphoma group included 9 patients. On MVA for OS, only age remained significant. Systemic therapy was the most common treatment modality overall (20 patients; 67%) with surgery, radiation and observation utilized in 4 patients (13%) each. Seventeen (57%) of patients were alive at the time of data collection, with 8 (27%) deceased and 5 (17%) lost to follow-up.

Conclusion

PHL are an extremely rare subtype of NHL for which there is no clear treatment consensus. Primary hepatic DLBCL appears to be treated mostly with chemotherapy with good disease control. For indolent PHL, low-dose RT appears to have good overall disease control with minimal toxicity. Our RT data is limited by the short duration of follow-up for patients receiving RT compared to those who received chemotherapy, surgery or observation. However, our results are encouraging for the use of RT for appropriate patients with indolent PHL.

Rare primary gastric peripheral T-cell lymphoma not otherwise specified: A case report

BACKGROUND

Gastrointestinal lymphoma typically arises in the stomach, small bowel, or colorectum and is usually a B-cell lymphoma. However, primary T-cell lymphomas originating in the stomach are particularly rare. Gastric peripheral T-cell lymphoma-not otherwise specified (PTCL-NOS) is an extremely rare subtype.

CASE SUMMARY

We report a 63-year-old male presenting with epigastric pain. Esophagogastroduodenoscopy revealed a large ulcerative lesion in the gastric cardia. Biopsy and immunohistochemical profiling confirmed PTCL-NOS. Imaging indicated stage II disease involving the stomach and intra-abdominal lymph nodes. The patient is planned to undergo cyclophosphamide, doxorubicin, vincristine, and prednisone or cyclophosphamide, doxorubicin, vincristine, prednisone, and etoposide chemotherapy.

CONCLUSION

This case highlights the necessity of considering PTCL-NOS in differential diagnoses of gastric lesions. Comprehensive histopathological and immunohistochemical analysis is crucial for accurate diagnosis and guiding treatment.

Dysphagia in an 80-Year-Old Woman: A Rare Case of Metastatic Melanoma Presenting in the Small Bowel

This report discusses the case of an 80-year-old female presenting with non-specific gastrointestinal symptoms and who was ultimately diagnosed as having metastatic melanoma of the jejunum. Notably, on admission, the patient had failed to report a past medical history of melanoma on her back a few years prior, and this significantly impacted the diagnostic process. This case highlights the challenges in diagnosing metastatic melanoma. It adds to the literature by underscoring the rarity and diagnostic complexity of this condition, which in this particular case presented as a jejunal mass.

Recurrent Acute Upper Gastrointestinal Bleed Due to Diffuse B-cell Lymphoma of the Duodenum in a Renal Transplant Patient: A Case Report and Literature Review

A patient status post (s/p) renal transplantation in 2014 presented with an upper gastrointestinal bleed (UGIB). The source of the bleed was found to be a large mass in the duodenum with histopathology from biopsies obtained during esophagogastroduodenoscopy revealing diffuse large B-cell lymphoma (DLBCL) of the duodenum. His mycophenolate was stopped, and the tacrolimus dose was reduced due to active malignancy. He was discharged and completed one cycle of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) before presenting back to ED with hemorrhagic shock from a large upper GI bleed requiring admission to the medical intensive care unit. Post-transplant lymphoproliferative disorders such as DBLCL can present 10 years from the transplant date. These malignancies are at high risk for bleed, especially after treatment with chemotherapy is initiated.

Sonographic and computed tomographic features of intestinal mast cell tumors mimicking alimentary lymphoma in 2 dogs

Two shih tzu dogs were referred to our clinic because of hematochezia and vomiting. Abdominal ultrasonography revealed a focal, asymmetric, exophytic small intestinal mass with loss of wall layering and muscular layer thickening of the adjacent intestine. Computed tomography (CT) in both dogs revealed a focal, asymmetric, homogenously contrast-enhanced exophytic jejunal and duodenal mass with an intact mucosal layer and generalized lymphadenopathy. Metastasis and ulceration were not detected on CT. The initial imaging diagnosis was lymphoma in both dogs; however, histopathological examination revealed the presence of intestinal mast cell tumors (iMCTs). Despite its similarity to alimentary lymphoma, iMCT should be considered a possible diagnosis, based on imaging characteristics, to ensure that proper treatments are selected. This is the first veterinary report describing detailed ultrasonographic and CT characteristics of iMCTs. Key clinical message: This is the first veterinary case report demonstrating sonographic and computed tomographic features of canine iMCT, which can be misdiagnosed as alimentary lymphoma. This report provides another differential diagnosis to consider when determining the appropriate patient treatment direction and histopathological examination.

Deep learning model for predicting the survival of patients with primary gastrointestinal lymphoma based on the SEER database and a multicentre external validation cohort

PURPOSE

Due to the rarity of primary gastrointestinal lymphoma (PGIL), the prognostic factors and optimal management of PGIL have not been clearly defined. We aimed to establish prognostic models using a deep learning algorithm for survival prediction.

METHODS

We collected 11,168 PGIL patients from the Surveillance, Epidemiology, and End Results (SEER) database to form the training and test cohorts. At the same time, we collected 82 PGIL patients from three medical centres to form the external validation cohort. We constructed a Cox proportional hazards (CoxPH) model, random survival forest (RSF) model, and neural multitask logistic regression (DeepSurv) model to predict PGIL patients' overall survival (OS).

RESULTS

The 1-, 3-, 5-, and 10-year OS rates of PGIL patients in the SEER database were 77.1%, 69.4%, 63.7%, and 50.3%, respectively. The RSF model based on all variables showed that the top three most important variables for predicting OS were age, histological type, and chemotherapy. The independent risk factors for PGIL patient prognosis included sex, age, race, primary site, Ann Arbor stage, histological type, symptom, radiotherapy, and chemotherapy, according to the Lasso regression analysis. Using these factors, we built the CoxPH and DeepSurv models. The DeepSurv model's C-index values were 0.760 in the training cohort, 0.742 in the test cohort, and 0.707 in the external validation cohort, which demonstrated that the DeepSurv model performed better compared to the RSF model (0.728) and the CoxPH model (0.724). The DeepSurv model accurately predicted 1-, 3-, 5- and 10-year OS. Both calibration curves and decision curve analysis curves demonstrated the superior performance of the DeepSurv model. We developed the DeepSurv model as an online web calculator for survival prediction, which can be accessed at http://124.222.228.112:8501/ .

CONCLUSIONS

This DeepSurv model with external validation is superior to previous studies in predicting short-term and long-term survival and can help us make better-individualized decisions for PGIL patients.

Clinical and endoscopic features of primary small bowel lymphoma: a single-center experience from mainland China

OBJECTIVE

The worldwide incidence of primary small intestinal lymphoma (PSIL) is increasing. However, little is known about the clinical and endoscopic characteristics of this disease. The aim of this study was to investigate the clinical and endoscopic data of patients with PSIL, with the goal of enhancing our understanding of the disease, improving diagnostic accuracy, and facilitating more accurate prognosis estimation.

METHODS

Ninety-four patients diagnosed with PSIL were retrospectively studied at Qilu Hospital of Shandong University between 2012 and 2021. The clinical data, enteroscopy findings, treatment modalities, and survival times were collected and analyzed.

RESULTS

Ninety-four patients (52 males) with PSIL were included in this study. The median age of onset was 58.5 years (range: 19-80 years). Diffuse large B-cell lymphoma (n=37) was the most common pathological type. Abdominal pain (n=59) was the most frequent clinical presentation. The ileocecal region (n=32) was the most commonly affected site, and 11.7% of patients had multiple lesions. At the time of diagnosis, the majority of patients (n=68) were in stages I-II. A new endoscopic classification of PSIL was developed, including hypertrophic type, exophytic type, follicular/polypoid type, ulcerative type, and diffusion type. Surgery did not show a significant increase in overall survival; chemotherapy was the most commonly administered treatment. T-cell lymphoma, stages III-IV, "B" symptoms, and ulcerative type were associated with poor prognosis.

CONCLUSION

This study provides a comprehensive analysis of the clinical and endoscopic features of PSIL in 94 patients. This highlights the importance of considering clinical and endoscopic characteristics for accurate diagnosis and prognosis estimation during small bowel enteroscopy. Early detection and treatment of PSIL is associated with a favorable prognosis. Our findings also suggest that certain risk factors, such as pathological type, "B" symptoms, and endoscopic type, may affect the survival of PSIL patients. These results underscore the need for careful consideration of these factors in the diagnosis and treatment of PSIL.

Review of lymphoma in the duodenum: An update of diagnosis and management

The presentation, subtype, and macroscopic images of lymphoma vary depending on the site of the tumor within the gastrointestinal tract. We searched PubMed for publications between January 1, 2012 and October 10, 2022, and retrieved 130 articles relating to duodenal lymphoma. A further 22 articles were added based on the manual screening of relevant articles, yielding 152 articles for full-text review. The most predominant primary duodenal lymphoma was follicular lymphoma. In this review, we provide an update of the diagnosis and man-agement of representative lymphoma subtypes occurring in the duodenum: Follicular lymphoma, diffuse large B-cell lymphoma, extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue, mantle cell lymphoma, and T-cell lymphomas.

Unusual Instance of Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma Confined to a Colonic Polyp

Extranodal marginal zone lymphoma (EMZL) of mucosa-associated lymphoid tissue (MALT) commonly affects the gastrointestinal (GI) tract but rarely occurs within the colon. Colonic EMZL is a rare diagnosis accounting for 2.5% of EMZL and less than 0.5% of colon cancers. We present a unique case of asymptomatic colonic EMZL diagnosed on a routine surveillance colonoscopy. The lymphoma was confined to a single colonic polyp presenting endoscopically as a sessile polypoid lesion at the recto-sigmoid junction. The patient was successfully treated with polypectomy with no recurrence of the disease.

Unusual Instance of Primary Diffuse Large B-cell Lymphoma of the Colon

Diffuse large B-cell lymphoma (DLBCL) commonly affects the gastrointestinal (GI) tract, although primary DLBCL rarely occurs in the colon. Primary colorectal lymphoma is a surprisingly rare diagnosis, accounting for a minute percentage of GI lymphomas and colorectal malignancies. We present an interesting case of an immunocompromised young adult female who was diagnosed with DLBCL confined to a cecum polyp after she underwent a colonoscopy for a GI bleed. The lymphoma presented endoscopically as a semi-sessile polyp in the cecum that was successfully removed. The patient was treated with appropriate therapy of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP).

Effect of Clinical, Endoscopic, Radiological Findings, and Complications on Survival in Patients with Primary Gastrointestinal Lymphoma

BACKGROUND

The purpose of this study was to evaluate the clinical, endoscopic, and radiological characteristics, complications, survival outcomes, and prognostic factors of patients with primary gastrointestinal lymphoma.

METHODS

This study retrospectively analyzed the demographic, laboratory, endoscopic, and radiological characteristics and treatment outcomes of 43 patients with newly diagnosed primary gastrointestinal lymphoma.

RESULTS

The median age was 62 years (range: 26-83). The primary lesion location was the gastric in 33 (77%) patients and the intestinal in 10 (23%) patients. The most common lesions were the corpus (33%) and corpus+antrum (24%) in primary gastric lymphoma and the ileum (60%) in primary intestinal lymphoma. The most common endoscopic findings were diffuse infiltrative lesion (23%) and massforming (33%), while the most common computed tomography finding was wall thickening (53%). Wall thickening and mass-forming at computed tomography were greater in primary intestinal lymphoma than in primary gastric lymphoma (P = .034). Complications were observed in 9 (21%) patients and 13 (31%) patients who underwent surgery. Complication and surgery rates were higher in primary intestinal lymphoma than in primary gastric lymphoma (P = .003 and P = .014, respectively). Five-year overall survival and 5-year eventfree survival rates were 75% and 72%, respectively. Univariate analysis showed that intestinal involvement, advanced clinical stage, a high International Prognostic Index score, mass-forming and wall thickening at computed tomography, extranodal involvement, and complication were found to adversely affect survival. Multivariate analysis revealed that intestinal involvement and a high International Prognostic Index score were independent prognostic factors for overall survival and event-free survival.

CONCLUSION

Patients with primary gastrointestinal lymphoma with intestinal involvement and high International Prognostic Index score should be followed closely.

Multifocal Colonic Ulcerations: An Unusual Presentation of Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma

INTRODUCTION

Mucosa-associated lymphoid tissue (MALT) lymphoma is relatively uncommon and accounts for only 5% of all non-Hodgkin lymphomas. The most common site of extranodal involvement is the gastrointestinal (GI) tract, with most cases affecting the stomach (up to 75% of all GI MALT lymphomas). Colonic disease occurs in only 2.5% of cases, most commonly manifesting as a single polypoid lesion on endoscopic evaluation.

CASE PRESENTATION

We present the case of a 61-year-old woman whose colonoscopy (after a positive fecal occult blood test as part of colorectal cancer screening) revealed superficially ulcerated pseudo-polypoid lesions in the ascending proximal colon and hepatic flexure; microscopical and immunohistochemical analysis of the tissue sample was compatible with MALT lymphoma. Staging computed tomography showed concomitant nodular pulmonary lesions, the largest being located in the superior left lobe and 34 mm in size. Due to the disseminated state of the disease, systemic treatment with bendamustine and rituximab was initiated. Up to the time of submitting this paper, the patient was still asymptomatic and under chemotherapy treatment.

CONCLUSION

With this case report, we aim to demonstrate the diversity of presentation of MALT lymphoma as well as its less typical locations; gastroenterologists should have an awareness of these and a low suspicion threshold.

Progress in elucidating the relationship between Helicobacter pylori infection and intestinal diseases

Helicobacter pylori (H. pylori) infection causes changes to the intestinal flora, such as small intestinal bacterial overgrowth, and increases gastric acid secretion-stimulating gastrointestinal hormones, mainly gastrin, due to a decrease in gastric acid caused by atrophic gastritis. In addition, the cellular components of H. pylori travel through the intestinal tract, so the bacterial infection affects the immune system. Therefore, the effects of H. pylori infection are observed not only in the stomach and the proximal duodenum but also in the small and large intestines. In particular, meta-analyses reported that H. pylori-infected individuals had an increased risk of colorectal adenoma and colorectal cancer. Moreover, a recent study reported that the risk of developing colorectal cancer was increased in subjects carrying H. pylori vacuolating cytotoxin A antibody. In addition, it has been reported that H. pylori infection exacerbates the symptoms of Fabry’s disease and familial Mediterranean fever attack and is involved in irritable bowel syndrome and small intestinal ulcers. On the other hand, some studies have reported that the frequency of ulcerative colitis, Crohn’s disease, and celiac disease is low in H. pylori-infected individuals. Thus, H. pylori infection is considered to have various effects on the small and large intestines. However, few studies have reported on these issues, and the details of their effects have not been well elucidated. Therefore, additional studies are needed.

Primary Intestinal Lymphoma: Clinicopathological Characteristics of 55 Patients

Introduction

Gastrointestinal (GI) tract is the most common site of extranodal lymphoma accounting for 30–40% of the cases. In Western countries, stomach is the most common site of GI lymphoma, whereas in the Middle East and Mediterranean countries, small intestine is commonly involved. Studies about primary intestinal lymphoma (PIL) are heterogeneous in anatomical distribution, presentation, and histological subtypes. The present study was aimed at studying the anatomical distribution, histological subtypes, and clinical characteristics at tertiary care centers.

Materials and methods

The present study was retrospective, conducted between 2006 and 2020. Patient's data were collected from institutional medical records. PIL was diagnosed by Lewin's criteria. After histological diagnosis, PIL was classified as per the World Health Organization (WHO) criteria and staging was done according to the Ann Arbor classification as modified by Musshoff.

Results

A total of 941 lymphoma cases were diagnosed during the study period between 2006 and 2020 consisting of 238 Hodgkin's lymphoma and 703 non-Hodgkin's lymphoma (NHL) cases. PIL constituted 5.8% of all lymphoma cases (55 out of 941) and 50.9% (55 of 108) of all primary GI lymphoma. Median age at diagnosis was 44 years and comprised predominantly males (85.45%). Diffuse large B-cell lymphoma (DLBCL) and mucosa-associated lymphoid tissue (MALT) lymphoma were the most common histological subtype (78%) seen. Two patients with primary Hodgkin's lymphoma involving the intestine were seen. T-cell lymphoma was seen in three (5.4%) patients. Ileocecal region was the most common site involved (27%). The common presenting complaints were intestinal obstruction (40%) requiring surgical resection and abdominal pain (32%). Majority of the patients presented in the early stages (I and II).

Conclusion

Our study demonstrates the pattern of distribution and various histological subtypes of PIL including the rare variants like primary intestinal Hodgkin's lymphoma. Relatively more number of patients presented with intestinal obstruction requiring surgery in comparison with other studies.

How to cite this article

Malipatel R, Patil M, Rout P, et al. Primary Intestinal Lymphoma: Clinicopathological Characteristics of 55 Patients. Euroasian J Hepato-Gastroenterol 2021;11(2):71–75.

Primary gastric non-Hodgkin lymphomas: Recent advances regarding disease pathogenesis and treatment

Primary gastric lymphomas (PGLs) are distinct lymphoproliferative neoplasms described as heterogeneous entities clinically and molecularly. Their main histological types are diffuse large B-cell lymphoma (DLBCL) or mucosa-associated lymphoma tissue. PGL has been one of the main fields of clinical research of our group in recent years. Although gastric DLBCLs are frequent, sufficient data to guide optimal care are scarce. Until today, a multidisciplinary approach has been applied, including chemotherapy, surgery, radiotherapy or a combination of these treatments. In this minireview article, we provide an overview of the clinical manifestations, diagnosis and staging of these diseases, along with their molecular pathogenesis and the most important related clinical published series. We then discuss the scientific gaps, perils and pitfalls that exist regarding the aforementioned studies, in parallel with the unmet need for future research and comment on the proper methodology for such retrospective studies. Aiming to fill this gap, we retrospectively evaluated the trends in clinical presentation, management and outcome among 165 patients with DLBCL PGL who were seen in our institutions in 1980-2014. The study cohort was divided into two subgroups, comparing the main 2 therapeutic options [cyclophosphamide doxorubicin vincristine prednisone (CHOP) vs rituximab-CHOP (R-CHOP)]. A better outcome with immunochemotherapy (R-CHOP) was observed. In the next 2 mo, we will present the update of our study with the same basic conclusion.

Primary Diffuse Large B-Cell Lymphoma of the Rectosigmoid Colon in a Patient With Ulcerative Colitis Who Never Received Immunosuppression

Primary rectal lymphoma is extremely rare, accounting for approximately 0.05% of all primary rectal neoplasms. We present a patient with long-standing ulcerative colitis, who was never treated with immunomodulators or biologic agents, diagnosed with primary diffuse large B-cell lymphoma of the rectosigmoid colon, and achieved remission after chemotherapy. As per current data, incidence of primary colorectal lymphoma has been associated with medications used for inflammatory bowel disease treatment, such as thiopurine, methotrexate, or tumor necrosis factor-α antagonist, and not with the inflammation itself. Given the rarity of this phenomenon, more data should be gathered before determining that no such association exists.

A Prognostic Model of Gastrointestinal Diffuse Large B Cell Lymphoma

Background

The digestive tract is the most common site of extranodal involvement in diffuse large B cell lymphoma (DLBCL) and its prognostic evaluation is different from that of ordinary DLBCL. Currently, for gastrointestinal lymphoma, in addition to the Ann Arbor staging system, the Lugano and the TNM staging systems are commonly used. However, there is no effective prognostic model to identify poor prognosis in patients with localized gastrointestinal diffuse large B cell lymphoma (GI-DLBCL).

Material/Methods

This study included 82 patients with GI-DLBCL that had a median follow-up of 75 months, and developed a model (HLAMA) with 5 variables: hemoglobin, age, lactate dehydrogenase (LDH), serum albumin, and the maximum intra-abdominal lesion diameter (MIALD). The specific indicators are: HGB <105 g/L (2 points); LDH ≥300 U/L; age ≥75 years, ALB <38 g/L, MIALD ≥4 cm (each scoring 1 point). We also developed a simplified model, which includes only 3 variables (HGB, LDH, and age).

Results

HLAMA model and the simplified model both demonstrated good ability to predict prognosis of patients with GI-DLBCL (P<0.001), performing better than the IPI score as it could distinguish low-risk groups in relatively elderly patients (60–75 years old).

Conclusions

This study established a prognostic model for diffuse large B cell lymphoma of the gastrointestinal tract. Both the HLAMA model and its simplified version are similar to the IPI score, but could be considered better as they can provide a simpler and more accurate prognostic assessment in patients with GI-DLBCL. For patients with localized GI-DLBCL, our model could distinguish high-risk patients.

Multicentric Study of Clinicopathological Features of Primary Gastrointestinal Lymphoma of Iran: from 2011 - 2016

Background: Gastrointestinal (GI) tract is the most common site for extranodal lymphoma. The primary GI lymphoma pattern in Iran is different from western countries and has been changed during the past 40 years. Objectives: This study was done to determine the clinical and pathological characteristics of primary GI lymphoma in Tehran, Hamedan, and Mashhad regions in Iran. Methods: In this cross-sectional comparative-descriptive study, 200 patients with primary GI lymphoma in Tehran, Hamadan, and Mashhad regions from 2011 to 2016 were enrolled in a consecutive manner, where the clinical and pathological characteristics of cases were determined. Results: Among 200 patients, 141 (70.5%) subjects were male and 59 (29.5%) subjects were female. The mean age at diagnosis was 54.3 ± 19.3 years. Also, 84%, 8.5%, and 7.5% of the patients’ specimens were from Tehran, Hamedan, and Mashhad, respectively. The stomach was the principal involved location in approximately half of the cases. Diffuse large B-cell lymphoma (DLBCL), was the main subtype that was observed in 64% of the cases. Treatment in 72% of cases was a combination of surgery and chemotherapy. The 5-year survival was assessed in 147 patients with a rate of 68%. Conclusions: Primary GI lymphoma is seen more in male subjects younger than 60 years of age with non-specific symptoms. Also, DLBCL and MALToma are the main histologic types, and the 5-year survival for all cases is 68.0%. The clinical symptoms showed no specific pattern and accordingly, patients with weight loss and abdominal pain should be considered in in differential diagnosis of malignant lymphoma.

Primary Gastro-Intestinal Lymphoma and Gastro-Intestinal Adenocarcinoma: An Initial Study of CT Texture Analysis as Quantitative Biomarkers for Differentiation

BACKGROUND

To explore the potential role of computed tomography (CT) texture analysis and an imaging biomarker in differentiating primary gastro-intestinal lymphoma (PGIL) from gastro-intestinal adenocarcinoma (GIAC).

METHODS

A total of 131 patients with surgical pathologically PGIL and GIAC were enrolled in this study. Histogram parameters of arterial and venous phases extracted from contrast enhanced modified discrete cosine transform (MDCT) images were compared between PGIL and GIAC by Mann-Whitney U tests. The optimal parameters for differentiating these two groups were obtained through receiver operating characteristic (ROC) curves and the area under the curve (AUC) was calculated.

RESULTS

Compared with GIAC, in arterial phase, PGIL had statistically higher 5th, 10th percentiles (p = 0.003 and 0.011) and statistically lower entropy (p = 0.001). In the venous phase, PGIL had statistically lower mean, median, 75th, 90th, 95th percentiles, and entropy (p = 0.036, 0.029, 0.007, 0.001 and 0.001, respectively). For differentiating PGIL from GIAC, V-median + A-5th percentile was an optimal parameter for combined diagnosis (AUC = 0.746, p < 0.0001), and the corresponding sensitivity and specificity were 81.7 and 64.8%, respectively.

CONCLUSION

CT texture analysis could be useful for differential diagnosis of PGIL and GIAC.

Common Presentation of an Uncommon Small Intestinal Lymphoma: A Rare Case Entity

Primary gastrointestinal NHL accounts for 30-40% of all extranodal NHL. Primary gastrointestinal lymphomas constitute 5% of total gut neoplasms. Bowel perforation is a severe life-threatening complication and sometimes initial presentation of gastrointestinal lymphoma. A 60-year-old man presented with complaints of abdominal pain, distension, nausea and vomiting. There was clinical suspicion of acute intestinal perforation, which was confirmed by radiology. The patient underwent emergency laparotomy. The resected bowel on histopathological examination and immunohistochemistry was diagnosed as the high-grade transformation of follicular lymphoma (FL). The patient received 6 cycles of chemotherapy and is doing well at 3 years of follow-up. Herein, we report this rare malignancy of the small intestine. FL mostly presents as a nodal disease but also involves the extranodal sites. The most common site of primary gastrointestinal-follicular lymphoma (GI-FL) is the small intestine. The cellular and molecular characteristic of GI-FL is different from that of the nodal FL. Extranodal FL is usually localized, but the prognosis of transformed FL is low, and these are managed by surgery followed by chemotherapy. High clinical suspicion and extensive sampling of perforated bowel are essential to diagnose the high-grade transformation of FL.

Primary gastrointestinal diffuse large B-cell lymphoma: A prospective study from South India

Background

Gastrointestinal tract (GIT) is the most common extranodal site for non-Hodgkin's lymphoma (NHL) and constitutes about 10%-15% of all NHL. This was a prospective study to evaluate the epidemiological, clinicopathological characteristics, and treatment outcome of primary GIT diffuse large B-cell lymphoma (PGIL).

Materials and Methods

Newly diagnosed patients of PGIL with DLBCL histology were eligible. Lugano staging system was used. All patients were treated with prephase treatment (1 mg vincristine and 100 mg prednisolone) followed by CHOP-based chemotherapy (with or without rituximab) as definitive treatment.

Results

A total of 21 patients of PGIL were diagnosed. The median age was 46 years (range: 27-69 years) with male:female ratio of 2:1. Dull aching abdominal pain was the most common presenting complaint. Stomach was the most common site involved (52.4%, n = 11) followed by the colon (23.8%, n = 5). The estimated median survival in patients with Stage IV disease was significantly lower as compared to patients with localized disease (Stage I and II) (6.23 months vs. 23.4 months; P = 0.04). Patients, who did not achieve complete response (CR), had 15.5 times higher risk of death, as compared to those who achieved CR (P = 0.01).

Conclusions

Stomach was the most common site for PGIL. Localized disease and CR after first-line chemotherapy were associated with better survival. A higher cost of rituximab was the prohibitive factor for cure in these patients.

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.

Comparison of the prognostic values of 18F-fluorodeoxyglucose parameters from colon and non-colon sites of involvement in diffuse large B-cell lymphoma of the colon

We examined the prognostic values of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) parameters from colon, non-colon, and total lesions in patients with diffuse large B-cell lymphoma (DLBCL) of the colon. Positron emission tomography/computed tomography (PET/CT) in 50 patients was retrospectively analyzed for maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV) and total lesion glycolysis (TLG). During follow-up, 13 patients showed progression and 9 died from disease. Receiver operating characteristics (ROC) curve analysis showed that non-colon and total lesion MTV and TLG and colon lesion SUVmax were associated with progression or death. Significant univariate predictors of poor event-free survival (EFS) included stage III-IV, greater International Prognostic Index (IPI) score, no resection, high non-colon lesion SUVmax, MTV and TLG, and high total lesion MTV and TLG. Univariate predictors of poor overall survival (OS) included stage III–IV, greater IPI score, no resection, high non-colon lesion MTV and TLG, high total lesion MTV, and low colon lesion SUVmax. Multivariate analysis revealed that high non-colon lesion TLG was independently associated with poor EFS and OS. Low colon lesion SUVmax was also independently associated with poor OS. In a subgroup with colon-dominant involvement (n = 35), non-colon lesion MTV and TLG were associated with events and non-colon lesion MTV was associated with patient death. Univariate analysis showed that high non-colon lesion MTV was a significant predictor of poor EFS and OS, while non-colon lesion TLG was a significant predictor of poor OS. Thus, volumetric FDG parameters of non-colon lesions offered significant prognostic information in patients with DLBCL of the colon.

Mucosa-associated lymphoid tissue lymphoma simulating Crohn's disease: A case report

BACKGROUND

Differential diagnosis between extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue and inflammatory bowel disease is mainly based on histopathologic evaluation of intestinal biopsies, although there is no single definitive diagnostic investigation and that circumstance can lead to misdiagnosis in particular cases. Herein we present a rare, ulcerative form of marginal zone lymphoma which mimics the Crohn's disease (CD) of upper digestive tract.

CASE SUMMARY

A 50-year-old man was presented with recurrent episodes of malaise and melena also weight loss. Enteroscopy of the small bowel demonstrated an ulcer in the jejunum. Microscopically, biopsies showed lymphoplasmacytic infiltrate. Diagnosis of CD was made. Primary treatment consisted of prednisone and azathioprine and was followed by azathioprine 100 mg per day with good clinical response in the following 2 years until relapse. At this time the results of endoscopic biopsies derived from proximal wall of stomach revealed Helicobacter pylori-negative marginal zone lymphoma of the gastric fundus. Immunophenotyping confirmed atypical CD20-positive cell population. Based on these biopsies, marginal zone lymphoma of mucosa-associated lymphoid tissue was diagnosed. Unfortunately, the contact with the patient was lost until one year later he was hospitalized with nausea, vomiting and severe pain because of gastrointestinal perforation. Four months later after laparotomy, the patient was treated with a course of chemotherapy. Complete remission was observed following 6 cycles of treatment.

CONCLUSION

This case report highlights the clinical relevance of knowledge and awareness of marginal zone lymphoma simulating CD.

Genome-wide DNA methylation analysis in canine gastrointestinal lymphoma

DNA methylation is the covalent modification of methyl groups to DNA mostly at CpG dinucleotides and one of the most studied epigenetic mechanisms that leads to gene expression variability without affecting the DNA sequence. Genome-wide analysis of DNA methylation identified the signatures that could define subtypes of human lymphoma patients. The objective of this study was to conduct the genome-wide analysis of DNA methylation in dogs with gastrointestinal lymphoma (GIL). Genomic DNA was extracted from endoscopic biopsies from 10 dogs with GIL. We performed Digital Restriction Enzyme Assay of DNA Methylation (DREAM) for genome-wide DNA methylation analysis that could provide highly quantitative information on DNA methylation levels of CpG sites across the dog genome. We successfully obtained data of quantitative DNA methylation level for 148,601–162,364 CpG sites per GIL sample. Next, we analyzed 83,132 CpG sites to dissect the differences in DNA methylation between GIL and normal peripheral blood mononuclear cells (PBMCs). We found 383–3,054 CpG sites that were hypermethylated in GIL cases compared to PBMCs. Interestingly, 773 CpG sites including promoter regions of 61 genes were identified to be commonly hypermethylated in more than half of the cases, suggesting conserved DNA methylation patterns that are abnormal in GIL. This study revealed that there was a large number of hypermethylated sites that are common in most of canine GIL. These abnormal DNA methylation could be involved in tumorigenesis of the canine GIL.

Gastrointestinal lymphoma: the new mimic

Background

Gastrointestinal (GI) lymphomas comprise a group of distinct clinicopathological entities of B- or T- cell type, with primary gastrointestinal Hodgkin lymphoma being extremely uncommon. The GI tract is the predominant site of extranodal non-Hodgkin lymphoma accounting for 30–40% of all extranodal lymphomas. In the Western world, the stomach is the most commonly involved site followed by the small bowel. Several chronic inflammatory and immune-mediated disorders which predispose to accelerated cell turnover may lead to the malignant transformation of gut lymphocytes and ultimately manifest as GI lymphoma. The challenge for the clinical gastroenterologist is that these tumors may have varied presentations, ranging from nonspecific symptoms such as dyspepsia or bloating to abdominal pain, nausea, vomiting, GI bleeding, diarrhea, weight loss or bowel obstruction.

Objective

We illustrate the range of presentations of GI lymphoma with examples based on consecutive cases evaluated at our institution over a 6-month period. These cases demonstrate how appropriately directed endoscopic evaluation with biopsies has the potential to provide a definitive diagnosis and allow the patient to proceed to definitive therapy.

Conclusions

The GI tract is the most commonly involved site for extranodal lymphoma with the stomach being most frequently involved organ. Chronic Helicobacter pylori infection, celiac disease, inflammatory bowel disease and autoimmune disorders may predispose to GI lymphoma. This heterogenous group of diseases has varied presentations that may mimic several other GI clinico-pathologic entities. GI lymphomas may be diagnosed with appropriately directed endoscopic evaluation coupled with generous tissue sampling and expert pathologic assessment. Management may range from antibiotic therapy, in the case of Helicobacter pylori-associated gastric MALT lymphoma, to chemotherapy with or without radiation and, in rare instances, surgery. There are presently no guidelines to direct endoscopic surveillance of GI lymphomas following treatment.

A case of primary gastric diffuse large B-cell lymphoma occurring in chronic myeloid leukemia

Chronic myeloid leukemia (CML) and Non-Hodgkin Lymphoma (NHL) are two different origins of hematological malignancies, which rarely occur at the same time. Moreover, NHL secondary to CML is common in T cell lymphoma, while NHL of B cell origin is rare. Since 1999, only 22 cases with B cell lymphoma have been reported, of which 4 cases have diffuse large B-cell lymphoma (DLBCL). The lesions of DLBCL were in lymph node, liver, jejunum, and soft palate. To our knowledge, it has no report for the primary gastric DLBCL (PG-DLBCL) occurring in CML. Here we reported a 63-year-old man of chronic phase (CP) CML associated with PG-DLBCL. The patient was diagnosed with CML nearly eight years ago and was treated with imatinib and nilotinib successively. However, gastroscopy found malignant lesions in the patient’s stomach in March 2018, and the masses were diagnosed as PG-DLBCL. Subsequently, with the treatment of the RCOP + lenalidomide regimen chemotherapy for 3 cycles, the patient achieved nearly complete remission (CR).

Novel Insights of Lymphomagenesis of Helicobacter pylori-Dependent Gastric Mucosa-Associated Lymphoid Tissue Lymphoma

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is the most common subtype of gastric lymphoma. Most gastric MALT lymphomas are characterized by their association with the Helicobacter pylori (HP) infection and are cured by first-line HP eradication therapy (HPE). Several studies have been conducted to investigate why most gastric MALT lymphomas remain localized, are dependent on HP infection, and show HP-specific intratumoral T-cells (e.g., CD40-mediated signaling, T-helper-2 (Th2)-type cytokines, chemokines, costimulatory molecules, and FOXP3+ regulatory T-cells) and their communication with B-cells. Furthermore, the reason why the antigen stimuli of these intratumoral T-cells with tonic B-cell receptor signaling promote lymphomagenesis of gastric MALT lymphoma has also been investigated. In addition to the aforementioned mechanisms, it has been demonstrated that the translocated HP cytotoxin-associated gene A (CagA) can promote B-cell proliferation through the activation of Src homology-2 domain-containing phosphatase (SHP-2) phosphorylation-dependent signaling, extracellular-signal-regulated kinase (ERK), p38 mitogen-activated protein kinase (MAPK), B-cell lymphoma (Bcl)-2, and Bcl-xL. Furthermore, the expression of CagA and these CagA-signaling molecules is closely associated with the HP-dependence of gastric MALT lymphomas (completely respond to first-line HPE). In this article, we summarize evidence of the classical theory of HP-reactive T-cells and the new paradigm of direct interaction between HP and B-cells that contributes to the HP-dependent lymphomagenesis of gastric MALT lymphomas. Although the role of first-line HPE in the treatment of HP-negative gastric MALT lymphoma remains uncertain, several case series suggest that a proportion of HP-negative gastric MALT lymphomas remains antibiotic-responsive and is cured by HPE. Considering the complicated interaction between microbiomes and the genome/epigenome, further studies on the precise mechanisms of HP- and other bacteria-directed lymphomagenesis in antibiotic-responsive gastric MALT lymphomas are warranted.

Transabdominal ultrasonographic features in the diagnosis of gastrointestinal lymphoma

Background

Gastrointestinal (GI) lymphoma is a challenging disease. We aimed to study and characterize the different endoscopic and transabdominal ultrasonography (TUS) features of gut lymphoma and to assess whether TUS has a complementary role to endoscopy in the diagnosis of GI lymphoma.

Methods

This study was conducted on 21 patients with GI lymphoma, attending the GI endoscopy and liver unit, Endemic Medicine Department and Oncology Department in Kasr El Aini Hospital, Cairo University. Patients were subjected to GI endoscopy (upper endoscopy & colonoscopy) and transabdominal ultrasonography. The diagnosis was finally based on histopathology of core biopsies (obtained either endoscopically or by ultrasonography) and immuno-histochemistry.

Results

In all 21 patients with GI lymphoma included in this study, TUS could accurately determine the site of disease affection compared to endoscopy which is considered the gold standard for site localization. The main TUS pathologic features detected were increased wall thickness of the affected bowel segment with a mean value of (15.6±5.9 mm) and loss of layering pattern in 16 patients (76%). While the most common endoscopic features were ulcers and mass lesions accounting for 38% of the patients for each. Diffuse large B-cell lymphoma was found in 19 patients (90%). Because of endoscopic biopsies were conclusive in 14 patients (67%), TUS guided biopsy was resorted to in 7 patients and was diagnostic in all of them.

Conclusions

Transabdominal ultrasonography is a useful tool in the diagnosis of GI lymphoma that is complementary to conventional diagnostic endoscopic procedures.

MALT lymphoma: epidemiology, clinical diagnosis and treatment

Primary gastric lymphoma (PGL) represents a rare pathology, which can be easily misdiagnosed because of unspecific symptoms of the digestive tract. Histologically, PGL can vary from indolent marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) to aggressive diffuse large B-cell lymphoma (DLBCL). During the years, clinical trials revealed the important role of Helicobacter pylori (H. pylori) in the pathogenesis of gastric MALT lymphoma. Infection with Helicobacter pylori is an influential promoter of gastric lymphomagenesis initiation. Long-term studies revealed that eradication therapy could regress gastric lymphomas.

Efficiency of All-Trans Retinoic Acid on Gastric Cancer: A Narrative Literature Review

Gastric cancer (GC) is the third leading cause of cancer-related death worldwide with a five-year survival rate of around 25%, and 4% when diagnosed at a metastatic stage. Cancer stem cells (CSC) have recently been characterized as being responsible for resistance to radio/chemotherapies and metastasis formation, opening up perspectives for new targeted therapies. Those CSCs express biomarkers such as cluster of differentiation 44 (CD44) and display high aldehyde dehydrogenase activity that converts vitamin A-derived retinal into retinoic acids. All-trans retinoic acid (ATRA), which has pro-differentiating properties, has revolutionized the prognosis of acute promyelotic leukemia by increasing its remission rate from 15% to 85%. Recent studies have started to show that ATRA also has an anti-tumoral role on solid cancers such as GC. The purpose of this review is therefore to summarize the work that evaluated the effects of ATRA in GC and to evaluate whether its anti-cancerous action involves gastric CSCs targeting. It has been demonstrated that ATRA can block the cell cycle, enhance apoptosis, and decrease gastric CSCs properties in GC cell lines, tumorspheres, and patient-derived xenograft mice models. Therefore, retinoids and new synthetic retinoids seem to be a promising step forward in targeted therapy of gastric CSC in combination with existing chemotherapies. Future studies should probably focus on these points.

Primary diffuse large B-cell lymphoma of the ileal conduit created after radical cystectomy

Introduction

Creation of an ileal conduit is associated with complications. A few cases have been reported on tumor development in an ileal conduit; diffuse large B‐cell lymphoma originating from an ileal conduit is extremely rare.

Case presentation

A 62‐year‐old Japanese man who had undergone radical cystectomy and ileal conduit diversion 6 years previously presented with a whitish bulge that had developed on the surface of the ileal conduit during follow‐up visit. Mass biopsy was performed and the histological diagnosis was diffuse large B‐cell lymphoma. Positron emission tomography showed no metastatic lesions. We attempted chemotherapy because the tumor cells tested positive for CD20; after six courses of a regimen involving rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone; diffuse large B‐cell lymphoma of the ileal conduit resolved gradually. The patient is alive and remains free from the diagnosed diffuse large B‐cell lymphoma.

Conclusion

We reported an extremely rare case of diffuse large B‐cell lymphoma originating from the ileal conduit created after radical cystectomy.

Detecting a rare composite small bowel lymphoma by Magnetic Resonance Imaging coincidentally: A case report with radiological, surgical and histopathological features

INTRODUCTION

Diagnosing lymphoma continues to prove challenging in the clinical practice. Composite lymphoma (CL) is defined by the coexistence of different lymphoma subtypes in the same anatomical location. This condition has seldom been witnessed in the gastrointestinal (GI) tract. We weren't able to find previous cases in the literature about small bowel CL with follicular lymphoma (FL) and classical Hodgkin lymphoma (CHL). Surgery is the treatment of choice to obtain accurate histology, to manage and prevent acute complications. We state that this work has been reported in line with the SCARE criteria.

CASE PRESENTATION

We describe an extremely rare case of small bowel CL, presenting as an intestinal bulky mass with circumferential infiltration of bowel loops. The small bowel tumor was incidentally detected by abdominal Magnetic Resonance Imaging (MRI) in a 64-year-old man who suffered from rectal discomfort and non-specific clinical symptoms. After this radiological finding, the patient underwent multiphase contrast computed tomography (MDCT) for initial staging and to study vascular involvement. Surgery was recommended to obtain an accurate diagnosis both due to initial symptoms of the intestinal obstruction and to avoid small bowel complications. The histopathological examination revealed a small bowel CL composed mainly of B cells FL with also CHL components.

CONCLUSION

It is important to note that involvement of the proximal ileal loops is very rare in small bowel lymphoma. MRI represents a precious diagnostic tool to evaluate the intra and extramural extent of the tumor.

Mast cell sarcoma: new cases and literature review

Mast cell sarcoma (MCS) is a rare form of mastocytosis characterized by the presence of solid tumor(s) comprising malignant mast cells that harbor destructive infiltration capability and metastatic potential. Here, we present an extensive literature review and report on 23 cases of MCS, including 3 new cases from the French National Reference Center for Mastocytosis. From our analysis, it appears that MCS can occur at any age. It can manifest de novo or, to a lesser extent, may evolve from a previously established mastocytosis. Bone tumor is a frequent manifestation, and symptoms of mast cell activation are rare. Histological diagnosis can be difficult because MCS is frequently composed of highly atypical neoplastic mast cells and can thus mimic other tumors. Unexpectedly, the canonical KIT D816V mutation is found in only 21% of MCS; therefore, complete KIT gene sequencing is required. The prognosis of patients with MCS is poor, with a median survival time of less than 18 months, and progression to mast cell leukemia is not unusual. Because conventional chemotherapies usually fail, the role of targeted therapies and bone marrow transplantation warrants further investigation in such aggressive neoplasms.

The clinical manifestation, survival outcome and predictive prognostic factors of 137 patients with primary gastrointestinal lymphoma (PGIL): Strobe compliant

This retrospective study aimed to investigate clinical characteristics and prognostic factors in patients with primary gastrointestinal lymphoma (PGIL) of Chinese population.From January 2001 to December 2015, 137 patients diagnosed with PGIL were recruited. The clinical features, treatment, and follow-up information were analysed.The median patient age was 62.3 years. With 18.47 months follow-up, the 2-year progress-free survival and overall survival rate was 74.9% and 75.5%, respectively. The overall response rate was 33.6%. Age≥60 years, advanced Lugano staging (≥stage IIE), elevated lactate dehydrogenase (LDH) levels, ≥2 extra-nodal involved sites, National Comprehensive Cancer Network International Prognostic Index (NCCN-IPI)≥4, Ki-67≥50% were associated with worse prognosis in univariate analysis (P < .05). By multivariate analyses, we determined that the involvement of extra-nodal involved sites was the only statistically significant poor prognostic factor in PGIL.Age, staging, LDH levels, NCCN-IPI, Ki-67 especially involvement of multiple extra-nodal sites were associated with poor overall survival of PGIL.

Radiological and clinical features of primary NK/T-cell lymphoma involving the whole length of the esophagus: A case report

Primary esophageal natural killer (NK)/T-cell lymphoma is a markedly rare tumor. There were only 6 cases of the disease identified prior to June 2015. In the present study, the aforementioned cases were validated, and relevant computed tomography (CT) results and clinical features of primary esophageal NK/T-cell lymphoma were determined, to increase awareness of this type of tumor. CT features and clinical presentations of a patient with pathologically confirmed esophageal NK/T-cell lymphoma was analyzed. The patient exhibited non-specific clinical symptoms and CT images revealed diffuse thickening of the entire length of the esophagus. The patient received cycles of systemic chemotherapy and subsequent chest CT images demonstrated prompt and marked shrinkage of the tumor. At the time of writing, the patient has survived for 24 months and experiences a good quality of life without postprandial fullness or difficulty swallowing solid food. In addition, the characteristics of 6 patients with complete clinical features of this type of tumor, on the basis of a review of published studies (online PubMed, Medline, Google Scholar, Chinese Biomedicine Database and China Journal Full Text Database search), were retrospectively analyzed. Although primary esophageal NK/T-cell lymphoma is a markedly rare tumor, it is considered to be included in differential diagnosis of patients presenting with a fungal or viral infection, therapy-related mucositis or reflux esophagitis. The final diagnosis of primary esophageal NK/T-cell lymphoma is on the basis of a combination of clinical, CT and histopathological results.

Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma of the Colon: A Case Report and a Literature Review

Patient: Female, 56

Final Diagnosis: Colonic MALT lymphoma

Symptoms: Epigastric pain

Medication: —

Clinical Procedure: Colonoscopy and biopsy

Specialty: Gastroenterology and Hepatology

Primary Intestinal Extranodal Natural Killer/T-Cell Lymphoma, Nasal Type: A Comprehensive Clinicopathological Analysis of 55 Cases

Purpose

To investigate the clinicopathological features, survival and prognostic factors of primary intestinal extranodal natural killer/T-cell lymphoma, nasal type (PI-ENKTCL).

Methods

Clinical and histological characteristics of PI-ENKTCL cases were retrospectively evaluated. Immunohistochemical phenotype and status of Epstein-Barr virus (EBV) and T-cell receptor (TCR) gene rearrangement were examined. The overall survival and prognostic parameters were also analyzed.

Results

Fifty-five (2.7%) cases with PI-ENKTCL were identified out of 2017 archived ENKTCL cases, with a median age of 39 years and a male to female ratio of 2.1:1. The most common symptom was abdominal pain (90.9%), accompanied frequently with fever and less commonly with intestinal perforation or B symptoms. Small intestine (50.9%) was the most common site to be involved. 47.3% and 36.4% cases presented with stage I and II diseases, respectively. Histologically, most cases displayed characteristic morphologic changes of ENKTCL. Cytoplasmic CD3, TIA-1 and CD56 expression was found in 100%, 94.5% and 89.1% of cases, respectively. In situ hybridization detection for EBV demonstrated positive results in all cases. Monoclonal TCR gene rearrangement was found in 52.9% of tested cases. Chemotherapy with a DICE or L-asparaginase/peg-asparginase-containing regimen was most often employed. Both advanced tumor stage and B symptoms were independent inferior prognostic factors (p = 0.001 and p = 0.010). Noticeably, 6 cases demonstrated a CD4-positive phenotype. These cases featured a relatively older median age (58 years), predominance of small/medium-sized neoplastic cells, a higher rate of TCR rearrangement and slightly favorable outcome.

Conclusion

We reported by far the largest series of PI-ENKTCL, and demonstrated its heterogeneity, aggressive clinical behavior and unsatisfying response to the current therapeutic strategies. Those CD4-positive cases might represent a unique subtype of PI-ENKTCL or distinct entity. Further investigations are required for the better understanding and management of this unusual disease.

Ileo-ileal Intussusception and Bowel Obstruction Caused by Plasmablastic Lymphoma of Small Bowel- A Rare Entity in Rare Location

Intussusception of small bowel is considered a rare cause of bowel obstruction in adults accounting for only about 1% of bowel obstruction in adults. Intussusception in adults is uncommon with 95% cases of intussusceptions occurring in children. Adult intussusception from small intestinal lymphoma is also rare with only 36 cases reported in the literature between 2000 and 2011. Plasmablastic lymphoma (PBL) is an aggressive lymphoid neoplasm usually seen in the oral cavity in the clinical setting of human immunodeficiency virus (HIV) infection. Plasmablastic lymphoma of the small intestine is extremely rare. Here, we report a case of plasmablastic lymphoma of small bowel with ileoileal intussusception in an HIV-negative immunocompetent male patient.

Primary gastric natural killer/T-cell lymphoma with diffuse CD30 expression and without CD56 expression: A case report

The majority of natural killer (NK)/T-cell lymphomas occur in the nasal cavity and rarely involve the stomach. They possess a specific immunophenotype, with the expression of cluster of differentiation (CD)56, CD2 and CD3ε, but without CD3 expression. Few cases of NK/T-cell lymphoma have partial CD30 expression. The present study reveals a unique case of a 41-year-old female patient with gastric NK/T-cell lymphoma that did not express CD56 and diffusely expressed CD30. Immunohistochemical staining demonstrated that the tumor cells expressed CD3ε, CD43, CD30 and granzyme B and did not express CD2, CD4, CD5, CD7, CD8, CD56, anaplastic lymphoma kinase, CD20, paired box-5 or pan cytokeratin. Based on the immunostaining profile and morphological features, the initial diagnosis considered was gastric anaplastic large cell lymphoma. However, following a consultation with other pathologists, the Epstein-Barr virus (EBV) status of the patient was investigated to exclude a diagnosis of NK/T-cell lymphoma. Notably, the signal for EBV RNA was diffuse positive. Therefore, the final diagnosis was corrected to NK/T-cell lymphoma. To the best of our knowledge, the present study is the first to report NK/T-cell lymphoma in the stomach with a diffuse CD30-positive and CD56-negative phenotype.

Localized primary gastrointestinal diffuse large B cell lymphoma received a surgical approach: an analysis of prognostic factors and comparison of staging systems in 101 patients from a single institution

Background

Diffuse large B cell lymphoma (DLBCL) represents the most common histological subtype of primary gastrointestinal lymphoma and is a heterogeneous group of disease. Prognostic characterization of individual patients is an essential prerequisite for a proper risk-based therapeutic choice.

Methods

Clinical and pathological prognostic factors were identified, and predictive value of four previously described prognostic systems were assessed in 101 primary gastrointestinal DLBCL (PG-DLBCL) patients with localized disease, including Ann Arbor staging with Musshoff modification, International Prognostic Index (IPI), Lugano classification, and Paris staging system.

Results

Univariate factors correlated with inferior survival time were clinical parameters [age >60 years old, multiple extranodal/gastrointestinal involvement, elevated serum lactate dehydrogenase and β2-microglobulin, and decreased serum albumin], as well as pathological parameters (invasion depth beyond serosa, involvement of regional lymph node or adjacent tissue, Ki-67 index, and Bcl-2 expression). Major independent variables of adverse outcome indicated by multivariate analysis were multiple gastrointestinal involvement. In patients unfit for Rituximab but received surgery, radical surgery significantly prolonged the survival time, comparing with alleviative surgery. Addition of Rituximab could overcome the negative prognostic effect of alleviative surgery. Among the four prognostic systems, IPI and Lugano classification clearly separated patients into different risk groups. IPI was able to further stratify the early-stage patients of Lugano classification into groups with distinct prognosis.

Conclusions

Radical surgery might be proposed for the patients unfit for Rituximab treatment, and a combination of clinical and pathological staging systems was more helpful to predict the disease outcome of PG-DLBCL patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12957-015-0668-5) contains supplementary material, which is available to authorized users.

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.

Ileal mucosa-associated lymphoid tissue lymphoma presenting with small bowel obstruction: a case report

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT Lymphoma) of the gastrointestinal tract commonly involves the stomach in the setting of concurrent Helicobacter pylori (H. pylori) infection. Primary ileal MALT lymphoma is rare, and has not been associated with a specific infectious disease. We report a case of a 58-year-old man who presented to the emergency department with constipation and abdominal distension, and signs of an obstructing mass on computed tomography scan. A small bowel resection was performed which revealed an 8 cm saccular dilatation with thickened bowel wall and subjacent thickened tan-yellow tissue extending into the mesentery. Histologically, there was a diffuse lymphoid infiltrate consisting of small atypical cells with monocytoid features. These cells were CD20-positive B-lymphocytes that co-expressed BCL-2 and were negative for CD5, CD10, CD43, and cyclin D1 on immunohistochemical studies. Kappa-restricted plasma cells were also identified by in situ hybridization. The overall proliferation index was low with Ki-67 immunoreactivity in approximately 10 % of cells. No areas suspicious for large cell or high grade transformation were identified. The pathologic findings were diagnostic of an extranodal marginal zone lymphoma involving the ileum, with early involvement of mesenteric lymph nodes. Small hypermetabolic right mesenteric and bilateral hilar lymph nodes were identified by imaging. The bone marrow biopsy showed no evidence of involvement by lymphoma. The patient was clinically considered advanced stage and opted for therapy with rituximab infusions. After six months of therapy, follow-up radiologic studies demonstrated significant decrease in size of the mesenteric lymph nodes.