Primary ileal plasmacytoma arising in mixed low- and high-grade B-cell lymphoma of mucosa-associated lymphoid tissue type

Mucosa-associated lymphoid tissue lymphoma in the terminal ileum: A case report

BACKGROUND

The lymphoma of the mucosa-associated lymphoid tissue (MALT) is predominantly found in the stomach. The few cases reported in the literature of MALT lymphomas affecting the ileum are in patients who are already symptomatic and with clear advanced endoscopic findings. We present the first case of an asymptomatic female patient who underwent colonoscopy as a routine examination with the findings of an ulcer in the distal ileum region, which histopathological examination and associated immunohistochemistry revealed the diagnosis of MALT lymphoma.

CASE SUMMARY

A 57-year-old asymptomatic female patient underwent a colonoscopy exam for screening. The examination revealed an ulcer of medium depth with well-defined borders covered by a thin layer of fibrin and a halo of hyperemia in the distal ileum portion. Findings are nonspecific but may signal infections by viruses, protozoa, and parasites or inflammatory diseases such as Crohn's disease. Biopsies of the ulcer were taken. The anatomopathological result revealed an atypical diffuse lymphocytic infiltrate of small cells with a characteristic cytoplasmic halo of marginal zone cells. The immunohistochemical study was performed and the results demonstrated a negative neoplastic infiltrate for the expression of cyclin D1 and cytokeratin AE1/AE3 and a positive for BCL60 in the germinal center. The test also revealed CD10 positivity in the glandular epithelium and germinal center of a reactive follicle with dual-labeling of CD20 and CD3 demonstrating the B lymphocyte nature of the neoplastic infiltrate. In BCL2 protein labeling, the neoplastic infiltrate is strongly positive with a negative germinal center. The findings are consistent with immunophenotype B non-Hodgkin's lymphoma, better classified as extranodal MALT. The patient was treated with chemotherapy and showed complete regression of the disease, as evidenced by colonoscopy performed after treatment.

CONCLUSION

MALT lymphomas in the terminal ileum are extremely rare and only 4 cases have been reported in the literature. Given the low sensitivity and specificity of endoscopic images in these cases, the pathology can be confused with other important differential diagnoses such as inflammatory diseases or infectious diseases and which makes the biopsy important, even in asymptomatic patients, paired with anatomopathological analysis and immunohistochemistry which is the gold standard for correct diagnosis.

Mucosa-associated lymphoid tissue lymphoma in the terminal ileum: A case report

BACKGROUND

The lymphoma of the mucosa-associated lymphoid tissue (MALT) is predominantly found in the stomach. The few cases reported in the literature of MALT lymphomas affecting the ileum are in patients who are already symptomatic and with clear advanced endoscopic findings. We present the first case of an asymptomatic female patient who underwent colonoscopy as a routine examination with the findings of an ulcer in the distal ileum region, which histopathological examination and associated immunohistochemistry revealed the diagnosis of MALT lymphoma.

CASE SUMMARY

A 57-year-old asymptomatic female patient underwent a colonoscopy exam for screening. The examination revealed an ulcer of medium depth with well-defined borders covered by a thin layer of fibrin and a halo of hyperemia in the distal ileum portion. Findings are nonspecific but may signal infections by viruses, protozoa, and parasites or inflammatory diseases such as Crohn's disease. Biopsies of the ulcer were taken. The anatomopathological result revealed an atypical diffuse lymphocytic infiltrate of small cells with a characteristic cytoplasmic halo of marginal zone cells. The immunohistochemical study was performed and the results demonstrated a negative neoplastic infiltrate for the expression of cyclin D1 and cytokeratin AE1/AE3 and a positive for BCL60 in the germinal center. The test also revealed CD10 positivity in the glandular epithelium and germinal center of a reactive follicle with dual-labeling of CD20 and CD3 demonstrating the B lymphocyte nature of the neoplastic infiltrate. In BCL2 protein labeling, the neoplastic infiltrate is strongly positive with a negative germinal center. The findings are consistent with immunophenotype B non-Hodgkin's lymphoma, better classified as extranodal MALT. The patient was treated with chemotherapy and showed complete regression of the disease, as evidenced by colonoscopy performed after treatment.

CONCLUSION

MALT lymphomas in the terminal ileum are extremely rare and only 4 cases have been reported in the literature. Given the low sensitivity and specificity of endoscopic images in these cases, the pathology can be confused with other important differential diagnoses such as inflammatory diseases or infectious diseases and which makes the biopsy important, even in asymptomatic patients, paired with anatomopathological analysis and immunohistochemistry which is the gold standard for correct diagnosis.

Discovery of a rare ileocecal plasmacytoma

Here we report the discovery of an extramedullary ileocecal plasmacytoma, a rare entity reported only ∼60 times in the literature. This finding occurred during management of a patient who had sustained an occult perforation during diagnostic colonoscopy. We explored the patient finding a large ileocecal perforation, and thus a right hemicolectomy was performed. Interestingly, the pathology of the mass was consistent with an extramedullary plasmacytoma, which is a very rare gastrointestinal diagnosis. We end by summarizing the presentation and work-up of extramedullary plasmacytoma.

Extramedullary plasmacytoma of the small intestine: clinical features, diagnosis and treatment

Extramedullary plasmacytoma (EMP) of the small intestine is an unusual plasma cell neoplasm in this anatomic region with only 61 cases described so far. Clinical suspicion is infrequent owing to its location and nonspecific manifestations such as abdominal pain, obstructive symptoms or even bleeding. Diagnosis is reached through histopathological examination coupled with immunohistochemistry of the endoscopic biopsy or surgical resection specimens. Nevertheless, the differential diagnosis between EMP, lymphoma and other kinds of tumors can sometimes be troublesome. The managements include surgery, radiotherapy or chemotherapy. Generally, the prognosis of EMP is favorable, but occasionally it may relapse, or progress to a plasma cell myeloma. EMP should therefore be followed-up for a long period after treatment. In this comprehensive review of the current literature, the patients' characteristics, clinical manifestations, diagnosis, differential diagnosis, treatment and outcome were discussed.

Gastric mucosa-associated lymphoid tissue lymphoma

The connection between Helicobacter pylori and gastric mucosa-associated lymphoid tissue (MALT) lymphoma is well established. H. pylori infection causes an immunological response, leading to chronic gastritis with formation of lymphoid follicles within the stomach. These lymphoid follicles resemble nodal tissues found throughout the body and are composed of reactive T cells and activated plasmal cells and B cells. The B cells are responsible for initiating a clonal expansion of centrocyte-like cells that form the basic histology of MALT lymphoma. Early diagnosis of MALT lymphoma is difficult but essential for adequate treatment. Clinical symptoms are vague and varied, with abdominal pain being a common presenting complaint. The endoscopic appearance of this tumor is varied and can be infiltrative, exophytic, or ulcerative. In addition, the tumor can have a multifocal distribution, and therefore aggressive tissue sampling is crucial for diagnosis. Endoscopic ultrasound is essential to document the extent of disease and is more accurate than CT scan in detection of spread to perigastric lymph nodes. Lesions that are confined to the mucosa or submucosa of the gastric wall are believed to be dependent on H. pylori stimulation and therefore can be successfully treated with H. pylori eradication. Those MALT lymphomas that present at more advanced stages require more aggressive management and can be treated with surgical resection, radiation, or chemotherapy. Follow-up is critical in all patients who have been treated with H. pylori eradication and consists of multiple endoscopic biopsies for histological and molecular studies as well as endoscopic ultrasound at 3, 6, and 12 months after treatment. The reappearance of MALT lymphomas has been seen years after treatment, and therefore follow-up of these patients should be indefinite.