Rare gastrointestinal lymphomas: The endoscopic investigation

Endoscopic and Histopathological Characteristics of Gastrointestinal Lymphoma: A Multicentric Study

Background: Extranodal non-Hodgkin lymphoma (NHL) is more prevalent in the gastrointestinal (GI) tract than in other sites. This study aimed to determine the endoscopic characteristics of primary gastrointestinal non-Hodgkin lymphomas. Methods: We investigated 140 patients from three tertiary referral hospitals with primary malignant lymphoma of the gastrointestinal tract. Characteristics of the lesions were evaluated and analyzed using image-enhanced endoscopy, endoscopic ultrasound, and histopathology. Results: The median age was 60.5 (range: 11-99), and 59 (42.1%) were female. The most frequent complaint was abdominal pain (74.3%), followed by bloody feces (10%) and diarrhea (2.9%). B symptoms were observed in 15 (10.7%) patients. GI obstruction was the most common complication (10.0%), followed by hemorrhage (7.9%) and perforation (1.5%). Regarding endoscopic findings, the identified sites were the following: the stomach (61.4%), colon (10%), small intestine (10%), ileocecum (8.6%), rectum (6.4%), and duodenum (3.6%). Diffuse large B-cell lymphoma (DLBCL) and mucosa-associated lymphoid tissue (MALT) lymphoma are most prevalent in the stomach. Helicobacter pylori was identified in 46 cases (39.0%), with MALT lymphoma being the most infected subtype. Nearly all gastrointestinal non-Hodgkin lymphomas manifested as superficial type (25-59.6%) and ulcer type (15.6-50%) under endoscopy. We found that fungating type and protruding with ulcer type were more frequent types of aggressive lymphomas (diffuse large B-cell lymphoma, mantle cell lymphoma, and T-cell lymphoma) compared to the indolent types (MALT lymphoma, follicular lymphoma, duodenal-type follicular lymphoma, and small lymphocytic lymphoma) (p < 0.05). Conclusions: This study showed that most subtypes of gastrointestinal non-Hodgkin lymphomas exhibited same endoscopic features (superficial type and ulcer type). Aggressive gastrointestinal non-Hodgkin lymphomas (diffuse large B-cell lymphoma, mantle cell lymphoma, and T-cell lymphoma) were highly suspected when fungating lesions and protruding with ulcer lesions were encountered under endoscopy. Endoscopists should be aware of the connection between enhanced endoscopic characteristics and histological varieties of gastrointestinal lymphoma to improve diagnosis.

Rare Presentation of Primary Classical Hodgkin Lymphoma of a Rectosigmoid Colon in a 79-Year-Old With a History of Irritable Bowel Syndrome

We discuss the case of a 79-year-old immunocompetent male who presented with weight loss and diarrhea and ultimately was found to have a rectosigmoid mass on a colonoscopy. Even though initial biopsies obtained during colonoscopy were non-diagnostic, considering the likelihood of malignancy, lower anterior resection was performed, and pathology confirmed the diagnosis of primary Hodgkin's lymphoma of the sigmoid colon. Hodgkin's lymphoma typically presents as painless supra-diaphragmatic lymphadenopathy with B symptoms such as fever, unexplained weight loss, and drenching night sweats. Due to the rarity of primary Hodgkin lymphoma in the colon and its non-specific initial presentation, we believe sharing this case will bring awareness to the atypical presentation of Hodgkin lymphomas.

Rare Jejunal Large B-cell Lymphoma Mimicking a Crohn's Disease Without Terminal Ileum Involvement

This case describes a 49-year-old man who presented with a several-month history of melena, and unintentional weight loss. Prior esophagogastroduodenoscopy and colonoscopy were unrevealing. Further evaluation with capsule endoscopy showed patchy erythematous mucosa in the jejunum creating suspicion for Crohn's Disease. Subsequent push enteroscopy found nodular and congested patchy mucosa of jejunum, and stigmata of bleeding in the proximal and mid-jejunum. Repeat colonoscopy showed a diffuse area of erythematous mucosa in the recto-sigmoid colon, and moderately congested mucosa in the ascending colon, but a normal terminal ileum. A small bowel biopsy eventually revealed large B-cell lymphoma. This is one of the first seven reported cases of small bowel lymphoma mimicking Crohn's Disease and the first to not have any ileal involvement.

Recurrent, Multisubtype Posttransplant Lymphoproliferative Disorder Masquerading as Inflammatory Bowel Disease

Posttransplant lymphoproliferative disorder (PTLD) is a severe posttransplant complication that occurs because of immunosuppression within the first year; however, recurrent PTLD or development of multiple histologic subtypes are rare. Our case demonstrates a renal transplant recipient with rare, recurrent PTLD with multiple histologic subtypes (monomorphic and polymorphic PTLD) despite a previous response to rituximab and resolution of inflammatory changes on endoscopy. It is essential that clinicians maintain a high suspicion for PTLD when caring for patients with previous transplantation and that they have a lower threshold for biopsy with endoscopic findings of nonspecific inflammatory changes.

Gastrointestinal Tract Lymphomas: A Review of the Most Commonly Encountered Lymphomas

CONTEXT.—

The gastrointestinal (GI) tract is the most common site of extranodal non-Hodgkin lymphoma, accounting for 20% to 40% of all extranodal lymphomas. The majority of these are systemic processes secondarily involving the GI tract. Primary GI lymphomas are less common, accounting for approximately 10% to 15% of all non-Hodgkin lymphoma. Most non-Hodgkin lymphoma involving the GI tract are of B-cell lineage, of which diffuse large B-cell lymphoma is the most common subtype, irrespective of location.

OBJECTIVE.—

To review the lymphoproliferative neoplasms of B-cell and T-cell lineage involving the luminal GI tract according to the most prevalent subtypes at each anatomic site.

DATA SOURCE.—

Systematic search of the PubMed database for updated literature on GI lymphomas epidemiology, subtypes, clinical, endoscopic, and genetic findings. Histologic images are derived from our collection of clinical cases.

CONCLUSIONS.—

The GI tract is the most common site of extranodal lymphoproliferative neoplasms. Recognition of the most frequently encountered GI lymphomas is imperative for patient management and treatment.

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

Background

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

Methods

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

Results

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

Conclusions

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

Practical Approach to the Histologic Diagnosis of Gastrointestinal Lymphomas Through the First-line Marker Battery of CD20, CD3, CD30, and Epstein-Barr Virus-encoded RNAs

The gastrointestinal (GI) tract is a prevalent site for extranodal lymphomas. Some subtypes of GI tract lymphomas are aggressive and have dismal clinical outcomes. Therefore, prompt histopathologic detection of such types can be very important. We thus introduce a practical approach in the histopathologic diagnosis of GI lymphomas according to the revised World Health Organization (WHO) classification. When lymphocyte proliferation is found in the GI tract, a stepwise approach can help narrow down the differential diagnoses. When considering subtype incidence, macroscopic findings, and microscopic patterns, applying a first-line marker battery of CD20, CD3, CD30, and Epstein-Barr virus-encoded RNAs can effectively narrow down the top differential diagnoses at the initial step. Generally, the most common subtype among GI tract lymphomas is B-cell non-Hodgkin lymphoma identified by CD20 expression, followed by T-cell and NK-cell non-Hodgkin lymphomas identified by the CD3 expression, and some subtypes are defined by Epstein-Barr virus infection or CD30 expression. Macroscopically, lymphomas present as various gross types, such as large masses, small lesions, superficial and shallow lesions, polyp-like or polyposis-like features, or ulcer/necrosis/perforation. Microscopically, large pleomorphic cells or small to medium-sized tumor cells grow with various architectures and tumor microenvironments. Incorporation of macroscopic and microscopic features and the stepwise immunophenotyping may be a practical approach to the differential diagnosis of aggressive lymphoma, indolent/low-grade lymphoma, or benign to indolent lymphoproliferative disease. Exceptions always exist; this approach focuses on the relatively prevalent circumstances of lymphomatous lesions initially encountered in the GI tract.

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

BACKGROUND

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

CASE SUMMARY

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

CONCLUSION

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

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.

An unusual presentation of adult T-cell leukemia/lymphoma

Adult T-cell Leukemia/Lymphoma (ATL) is a rare disease, related to human T-lymphotropic virus-1 (HTLV-1) and presented mainly in adulthood by generalised lymphadenopathy, hepatosplenomegaly, skin lesions and hypercalcaemia, with rare gastrointestinal and/or oral manifestations. We reported this case to raise awareness and demonstrate the therapeutic challenges of this rare disease. A 49-year-old Japanese female presented with skin papules on both forearms, painful mouth ulcers and multiple neck swellings since early February 2017. Initial clinical examination and laboratory investigations were misleading and her condition was diagnosed as candidiasis. Because of un-improvement of the case, a screening upper endoscopy was requested 2 months later and revealed characteristic oropharyngeal ulcers which were biopsied, and its pathologic examination confirmed smouldering type ATL. This case report should raise awareness of doctors and endoscopists about this disease especially in HTLV-1 endemic areas to avoid late diagnosis and help achieve earlier therapeutic decisions.

Gastrointestinal involvement by mantle cell lymphoma identified by biopsy performed during endoscopy: A case report

RATIONALE

Primary gastrointestinal mantle cell lymphoma is rare, and histopathological examination and specific immunohistochemical staining are still the gold standard for diagnosis. Therefore, it is necessary to find a new way to improve positive biopsy rates.

PATIENT CONCERNS

A 58-year-old man was admitted to our hospital with epigastric pain, abdominal distension, nausea, and melena. Endoscopy identified submucosal neoplasms and diffuse gastrointestinal tract involvement including the esophagus.

DIAGNOSES

A false-negative diagnosis was first determined by ordinary endoscopy. However, a large tissue biopsy was subsequently performed using endoscopic mucosal resection based on endoscopic ultrasonography (EUS). Pathological examination of the biopsy specimens taken from the lesions of the duodenum and rectum revealed diffuse lymphocytic proliferation and obscure nodular and small cleaved cells with irregularly shaped nuclei. Immunohistochemistry showed that the cells were positive for CyclinD1, BCL-2, CD20, CD21, and CD5; however, they were negative for CD3, CD6, CD10, and CD43.

INTERVENTIONS

The patient refused to receive further treatment.

OUTCOMES

Mantle cell lymphoma was conclusively diagnosed.

CONCLUSIONS

EUS has an important role in the diagnosis and management of gastrointestinal submucosal tumors. Performing a pathological biopsy including EUS may be useful for identifying the unknown nature of tumors of the digestive tract.

Mantle cell lymphoma with late onset gyrus-like colorectal infiltration: A rare case and literature review

Mantle cell lymphoma (MCL), characterized by t (11; 14) (q13; q32) translocation and cyclin D1 overexpression, is still a challenging subtype of non-Hodgkin's lymphoma. The majority of MCL cases are discovered in male elderly people and in advanced stages with extranodal infiltration especially the gastrointestinal tract. Multiple lymphomatous polyposis is a typical manifestation of MCL infiltrating the gastrointestinal tract, and the colon is the most commonly involved site. In this paper, we report a case of MCL with late onset colorectal infiltration in a 53-year-old female patient presenting with gyrus-like thickened mucosal folds instead of multiple polyps as revealed by colonoscopic examination. Remarkably, the patient developed colorectal infiltration presenting with intermittent bloody stool after being diagnosed with classical MCL for two years and treated with several cycles of combined chemotherapy. Immunohistochemical staining showed that the lymphoid infiltrate in the colorectal mucosa was positive for cyclin D1, CD5, CD19, CD20, CD21, CD43, CD79a, Bcl-2, PAX-5, and SOX11 (scattered), but negative for CD2, CD3, CD7, CD10, CD23, Bcl-6, c-myc, and Mum-1. The Ki-67 proliferation index was around 15%.