Management of gastrointestinal lymphoma

Primary colon lymphomas: An analysis of our experience over the last 18 years

Colon lymphoma is a rare type of gastrointestinal lymphoma and represents 0.2% to -1.2% of all primary colon cancers. This study aimed to retrospectively examine the general characteristics, treatment methods, and survival characteristics of patients with colon lymphoma who were followed-up at our center. This retrospective study included patients diagnosed with colon lymphoma who were followed up at Ankara Numune Training and Research Hospital and Ankara Bilkent City Hospital between December 2005 and June 2023. Clinicopathological features, radiological findings, treatments, and modalities of patients were obtained from their medical records. Fourteen patients with primary colon lymphoma were included in the study. Thirteen patients (92.9%) were diagnosed with diffuse large B-cell lymphoma. The median age of the patients was 55 (28-84) years. The tumor location was the terminal ileum/cecum in 50% of the patients. At the time of diagnosis, 10 patients (7 with stage 1E-2E disease, 2 with stage 3E disease, and 1 with stage 4E disease due to tumor obstruction) underwent surgery. Twelve patients received chemotherapy (6 patients as adjuvant and 6 patients as first-line treatment). The median overall survival (OS) was 10 years (0.1-21.5) years, the 5-year median OS was 71%, and the 10-year median OS was 53%. Primary colon lymphoma is a rare disease and its optimal treatment is not clearly defined. The primary treatment for primary colon lymphoma is a combination of surgery and chemotherapy. A clear consensus on the treatment can be established through prospective studies.

Burkitt Lymphoma Presenting as Ileocolic Intussusception in an Adult

Adult intussusception is rare, highly associated with a malignant lead point, and often requires emergent surgical management. We report the case of a 44-year-old male who presented with generalized abdominal pain and was found to have early ileocolic intussusception secondary to a large ileocecal mass. Biopsies of the mass and an enlarged cardiophrenic lymph node, as well as pleural fluid cytology were all consistent with Burkitt lymphoma (BL). Curiously, the patient's abdominal exam was reassuring, and the intussusception and malignant bowel obstruction resolved over 36 hours with conservative management alone. With a Burkitt lymphoma international prognostic index (BL-IPI) score of 2, the patient proceeded to treatment with combination chemoimmunotherapy and attained a complete response after four cycles. There was no bowel perforation or recurrent intussusception throughout treatment. Thus, this report marks the first reported case of adult BL-associated intussusception to resolve with non-invasive management and establishes a precedent for conservative management in select patients.

Multiple Synchronous Mucosa-Associated Lymphoid Lymphomas Involving in the Stomach, Duodenum, Ileum, and Sigmoid

Gastric MALToma is an extra-nodal marginal-type B-cell lymphoma. MALToma may occur secondary to chronic inflammation and autoimmunity. The most common gastrointestinal (GI) site of MALToma is the stomach, with approximately 50% of lesions occurring there. Synchronous upper and lower GI MALTomas rarely occur, with few cases reported. We present the case of a 67-year-old patient who presented asymptomatic and was found to have synchronous multifocal upper and lower GI MALTomas in the stomach, duodenum, terminal ileum, and sigmoid, which did not respond to H. Pylori eradication therapy.

Iatrogenic Immunodeficiency Associated Lymphoproliferative Disorder in a Patient With Inflammatory Bowel Disease

Primary colorectal lymphoma is incredibly rare and cases of iatrogenic immunodeficiency associated lymphoproliferative disorder (IILPD) isolated to colorectal area are even more uncommon. Immunodeficiency associated lymphoproliferative disorders can occur in association with primary immune disorders such as inflammatory bowel diseases (IBDs) which are often treated with various immunomodulatory drugs. Of the immunomodulatory drugs, thiopurines, in particular, are known to have a significantly increased relative risk for development of IILPDs. Here we present the case of a 43-year-old Caucasian man with a 22-year history of IBD treated with longstanding immunomodulatory therapy who presented with severe rectal pain and drainage. He underwent an examination under anesthesia with rigid proctoscopy and biopsies were taken of a hard exophytic appearing tissue along the posterior wall of the rectosigmoid junction. Pathological investigation of the samples revealed IILPD. He underwent treatment with rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP) and achieved complete remission. Literature demonstrates that the use of immunomodulators such as azathioprine has been shown to significantly improve the quality of life in patients with IBD. However, while the absolute risk of lymphoma for any given patient remains quite low, the relative risk of lymphoma in patients who are actively treated with thiopurines is moderate. Therefore, the decision to proceed with thiopurine treatment, especially in the setting of long-term therapy, requires extensive discussion and patient education of the risks/benefits along with closer monitoring of new or uncharacteristic symptoms.

Primary diffuse large B-cell lymphoma of the sigmoid colon

Introduction

Extranodal lymphomas are commonly encountered in the gastrointestinal tract but lymphomas of colon and rectum are rare. Non-Hodgkin lymphoma is the most common type of colonic lymphoma and represents less than 0.5% of colorectal neoplasms. Chemotherapeutical agents are gateway to disease remission and sometimes cure in most patients but surgery may be necessary in emergent situations.

Case presentation

A 77-year-old male patient presented with abdominal discomfort, constipation, and obstructive defecation symptoms. Radiological imaging revealed a mass in the sigmoid colon extending towards the rectum. Colonoscopy was performed and biopsy of a nearly 10 cm ulcerovegetative lesion was obtained. Histological examination following biopsy revealed it to be a diffuse large B-cell lymphoma of the sigmoid colon. There was no indication for surgery and the patient was referred to medical oncology clinic for chemotherapy treatment.

Discussion

Non-Hodgkin lymphoma is a lymphoproliferative disorder with the diffuse large B cell lymphoma (DLBCL) being the most common subtype. The DLBCL subtype is rarely observed in the colon and rectum. Chromosomal abnormalities are involved in the pathophysiology and gene rearrangements lead to adjustments in lymphocyte function and differentiation.

Conclusion

In this case report, we present a rare presentation of a Non-Hodgkin lymphoma presenting in the sigmoid colon. The disease can present with nonspecific symptoms and various imaging modalities along with histopathological evaluation is necessary for the correct subtyping of lymphoma. Chemoradiotherapy is key for treatment, and surgery is usually reserved for cases of obstruction, perforation, or bleeding.

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Non-Hodgkin lymphoma is the most common type of colonic lymphoma.

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Extranodal lymphomas of the colon and rectum are rare.

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Histopathological evaluation is important for subtyping of lymphoma.

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Chemotherapy is the main form of treatment but sometimes surgery is required.

Primary Rectal Lymphoma: A Case Report and Review of Literature

Lymphomas represent common hematological malignancy, and depending on site, they are classified as nodal or extranodal lymphoma. The term extranodal disease refers to lymphomatous infiltration of anatomic sites other than the primary lymphatic sites; however, the diagnosis of primary versus secondary extranodal lymphoma remains challenging. Among the extranodal locations, gastrointestinal system is the most frequent site. The involvement of the stomach, small intestine, and colon is noted. Rectum as primary site for lymphoma is rare in adults and extremely rare in children. We describe a case of primary rectal lymphoma (high-grade B-cell non-Hodgkin's lymphoma) in 11-year-old child. We believe that reporting this case will add to the data about clinical presentation, radiological, nuclear medicine findings, and treatment approaches of primary rectal lymphoma.

Primary colonic lymphoma: report of two cases and a literature review

Primary colonic lymphoma is a very rare malignant tumor with no standard treatment. We report two cases of primary colonic lymphoma successfully treated with surgery and chemotherapy, and chemotherapy alone, respectively. The first case was a 61-year-old woman who presented with abdominal pain of more than 1 month. The patient was diagnosed with a colonic tumor, and immunohistochemical examinations confirmed the initial diagnosis of colonic lymphoma. The patient underwent laparoscopic-assisted right hemicolectomy followed by postoperative adjuvant chemotherapy with the cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) regimen, combined with targeted therapy with rituximab (R-CHOP). The second case was a 78-year-old man who presented with a complaint of abdominal distention for more than 1 year. Diffuse large B-cell lymphoma was definitively diagnosed by immunohistochemical examinations, and the patient underwent systemic chemotherapy with the R-CHOP regimen. Primary colonic lymphoma is a rare type of non-Hodgkin's lymphoma (NHL), and the clinical treatment is not standardized, unlike for many other types of lymphoma. Therefore, treatment is mainly based on the patient’s symptoms to determine whether surgery or systemic chemotherapy is appropriate. Rituximab is effective in some patients and may play an important role in the treatment of unresectable or asymptomatic colonic lymphoma.

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.

Evaluation of 22 Primary Gastrointestinal Lymphoma Patients

Objective

Primary gastrointestinal non-hodgkin lymphomas (PGI-NHL) are uncommon diseases with treatment modalities including chemotherapy, surgery, and radiotherapy. Our aim is to analyze the demographic and clinical features and treatment results of PGI-NHL.

Materials and Methods

286 patients diagnosed with lymphoma who referred to Ataturk University Medical Faculty Hospital between July 2001 and April 2014 were surveyed retrospectively and 22 (7.6%) PGI-NHL cases whose primary lesions were in gastrointestinal system were included.

Results

Mean age was 47 (min.25-max.77) and 14 (63.6%) of them were men. The origin was determined as small intestines (50%), stomach (31.8%) and colon (18.2%), respectively. The most common complaint and pathologic subtype were abdominal pain (68.2%) and diffuse large B cell lymphoma (86.4%), respectively. The Lugano Classification was as follows: stage 1 (18.2%), stage 2 (59.1%), and stage 4 (22.7%). Surgery and chemotherapy were administered to 40.9% of patients. Complete and partial response and disease progression were established in 72.1%, 4.5% and 13.6% of the patients, respectively. Mean survival time was 99.6±16 months. Mean overall survival time was determined significantly longer in small bowel group than gastric group (119±15 vs. 50±24 months) (p=0.039). Age, gender, Eastern Cooperative Oncology Group performance status, International Prognostic Index, stage, histological type, tumor size, LDH level, albumin level, Hemoglobin level and treatment options were not associated with survival.

Conclusion

Demographic and clinical characteristics of our series were similar with Middle Eastern and African countries. Optimal treatment options or prognostic factors for PGI-NHL are not clear. There is a need for randomized prospective studies including large number of patients and long follow-up period.

The role of surgical intervention in primary colorectal lymphoma: A SEER population-based analysis

Background

Primary colorectal lymphoma (PCL) is a rare colorectal malignancy. The standard treatment and prognostic factors of PCL remain unexplored. Therefore, a large population-based study should be conducted to provide a detailed review of this disease.

Methods

We extracted the data of eligible patients with PCL registered in the SEER database from 1973 to 2011. All statistical analyses were performed using SPSS 19.0.

Results

A total of 2050 (61.3%) of the 3342 patients with PCL underwent surgical intervention, and 1292 (38.7%) patients received no surgical treatment. The median overall survival was 95 months, and patients receiving surgery exhibited significantly prolonged survival (adjusted HR =0.69, P <0.001). Young age, early tumor stage, and indolent lymphoma were independent predictors of improved survival. Further survival analyses demonstrated the potential benefit of surgery in patients with early tumor stage, right-sided lesions, or diffuse large B-cell PCL. Conversely, surgical intervention did not improve the survival of patients with advanced-stage, left-sided, or indolent PCL.

Conclusion

PCL is a rare tumor that can be effectively treated. Surgical intervention may play an important role in the treatment of PCL. Early tumor stage, a right-sided lesion, and diffuse large B-cell histological PCL seem to be the clinical characteristics of optimal surgical candidates.

Uptake Patterns of Untreated Primary Gastrointestinal Extranodal Lymphomas on Initial Staging 18F-FDG PET/CT and Metabolic Tumor Parameters

Objective:

Non-Hodgkin’s lymphomas arising from tissues other than primary lymphatic sites are classified as primary extranodal lymphomas (PEL). PELs of the gastrointestinal system (PGISL) originate from the lymphatic tissues within the gastrointestinal tract. The prognostic value of ¹⁸F-FDG PET/CT in lymphomas is high in terms of both overall survival (OS) and disease-free survival (DFS). Our aim was to investigate the uptake patterns and properties of low-grade and high-grade PGISL on primary staging ¹⁸F-FDG PET/CT, as well as the prognostic significance of metabolic tumor parameters in high grade PGISL.

Methods:

Thirty-nine patients with PGISL were enrolled in this retrospective cohort study between 2004-2015. Primary staging ¹⁸F-FDG PET/CT have been performed and quantitative parameters of SUV_max, SUV_mean, metabolic tumor volume (MTV), total lesion glycolysis (TLG) have been calculated for all patients prior to treatment. Low-grade and high-grade PGISL were compared in terms of metabolic tumor parameters. Cox regression models were performed to determine factors that correlate with DFS in high-grade PGISL.

Results:

There were statistically significant differences between high-grade and low-grade PGISL in terms of SUV_max, SUV_mean, MTV, TLG, recurrence, mortality, DFS and OS. None of the potential risk factors (sex, age, site, SUV_max, SUV_mean, MTV, TLG) for recurrence and metastasis in high grade PGISL was identified as a risk factor on univariate and multivariate Cox regression analysis.

Conclusion:

Metabolic tumor parameters are not predictive markers in high-grade PGISL, especially in diffuse large B cell variant and primary gastric lymphoma. The first implications suggest they will not play a role in patient management.

Primary Follicular Lymphoma in the Rectum Incidentally Found on Screening Colonoscopy

The gastrointestinal tract is the most common site of extra-nodal non-Hodgkin lymphoma. However, the incidence of primary rectal lymphoma is extremely rare. Among the primary gastrointestinal lymphomas, follicular lymphoma has been described as a rare disease. It is difficult to diagnose rectal lymphoma due to its variable growth patterns and inadequate biopsies. Majority of patients with rectal lymphoma have non-specific symptoms or negative biopsies, often delaying the diagnosis. Our patient is a 62-year-old female. Two sessile and smooth subepithelial lesions with a yellowish normal mucosa were found on a screening colonoscopy. The initial mucosal biopsy finding was chronic inflammation, but we were highly suspicion of malignancy; we performed an endoscopic mucosal resection. Herein, we present a rare case of rectal follicular lymphoma diagnosed by endoscopic mucosal resection with a literature review.

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

Persistent Afebrile Abdominal Pain: An Unusual Case of Segmental Colitis in an Immunocompromised Host

In this report we describe a case of a 66-year-old woman who presented with right upper quadrant abdominal pain and bloody diarrhea. A workup revealed immunodeficiency, an immunologic profile with low complement levels resembling systemic lupus erythematosus, and a circumferential colonic wall lesion located in the ascending colon. After endoscopy and biopsy, the mass lesion was attributed to "double hit" diffuse large B-cell lymphoma, categorized as high grade large B-cell non-Hodgkin lymphoma according to the most recent revised 2016 World Health Organisation classification and considered to be a rare and highly aggressive tumor. The diagnosis of colonic lymphoma can be challenging due to a diversity of clinical presentation and requires a high index of suspicion. As the literature of such documented reports is limited, this case suggests further investigations.

ABBREVIATIONS

GI: gastrointestinal tract, DLBCL: diffuse large B cell lymphoma, DH: double hit lymphoma, SLE: systemic lupus erythematosus, ANA: antinuclear antibodies, anti-ssDNA: anti-single-stranded DNA, BCL: B-cell lymphoma protein, MUM-1/IRF4: multiple myeloma oncogene 1/interferon regulatory factor 4, HGBL: high grade B-cell lymphoma, anti-dsDNA: anti-double-stranded DNA.

Adult ileocolic intussusception caused by Burkitt lymphoma

Ileocolic intussusception due to Burkitt lymphoma is extremely rare in adults. A man aged 17 years presented with a history of recurrent abdominal pain over the past 3 weeks. The abdomen was distended with diffuse tenderness, and bowel sounds were present. Abdominal ultrasound and CT scans showed evidence of small bowel obstruction with marked wall thickening in the ileocecal region and 'target' signs suggestive for intussusception. At laparoscopy, a mass involving the caecum and the terminal ileum was found, along with multiple locoregional nodes, which was highly suggestive of malignancy. A typical en bloc right colectomy with intracorporeal ileocolic anastomosis was performed. Histopathological examination showed a high-grade B-cell Burkitt lymphoma that was confirmed by immunohistochemistry. The patient was subsequently treated with adjuvant combination chemotherapy and is alive and disease-free at the 3-year follow-up.

Anatomic distribution, clinical features, and survival data of 87 cases primary gastrointestinal lymphoma

Background

The purpose of this study is to analyze the anatomic distribution, clinical features, therapeutic methods, and prognosis factors of primary gastrointestinal lymphoma (PGIL).

Methods

Clinical data of 87 cases PGIL in the First Affiliated Hospital of Dalian Medical University from January 1999 to December 2010 were collected. Follow-ups were made according to the clinical feature, pathological pattern, clinical stage, and therapeutic method. Kapan Meier method was used for the survival analysis. Log-rank test was used to perform univariate survival analysis. COX multivariate analysis was carried out to analyze factors of P < 0.05 in univariate survival analysis.

Results

The incidence of PGIL significantly increased in patients more than 40 years old (87.4 %). Clinical symptoms of PGIL were indistinguishable from other digestive system diseases, which included abdominal pain or discomfort (72.4 %), lack of appetite (16.3 %), gastrointestinal hemorrhage (14.9 %), and diarrhea (12.8 %). Some patients presented with systemic symptoms or complications, such as weight loss (35.6 %) and digestive tract obstruction (13.8 %). Primary gastric lymphoma (PGL) was the most common, followed by primary intestine lymphoma (PIL). The majority of PGIL were single lesion, which included 40 cases (87 %) PGL and 35 cases (94.5 %) PIL. The most frequent site of PGL was antrum of the stomach (43.5 %), as to PIL, the small intestine (90.2 %) was the most frequent site, especially within 100 cm far away from ileocecal valve. Most of PGIL were derived from B cell (93.1 %). The most common pathological type was mucosa-associated lymphoid tissue (MALT) (67.4 %) in the PGL group and diffuse large B cell lymphoma (DLBCL) (46.3 %) in the PIL group. Surgical treatment had been performed in most of PGIL, which included 32 cases in the PGL group and 38 cases in the PIL group. The 1-year overall survival (OS) and the 3-year OS were 82 and 77 %, respectively. Analysis of single factor affecting prognosis showed that lesion location, sources of cells, and clinical stage were associated with OS. PGL group had better OS than that of PIL group (1-year 89 vs 62 %, 3-year 84 vs 50 %, P = 0.03). B cell-originated group had better OS than that of T cell-originated group (1-year 89 vs 36 %, 3-year 85 vs 0 %, P = 0.008). Stage I + II group had better OS than that of stage III + IV group (1-year 89 vs 38 %, 3-year 87 vs 0 %, P = 0.007). Multivariate analysis showed that clinical stage and sources of cells were the significant independent prognostic factors.

Conclusions

It was more common to find location of PGIL in the stomach than that in the intestine. The most common pathological type was MALT in the PGL and DLBCL in the PIL. The treatment of PGL was focused on chemotherapy. It was noting that since PIL was not only difficult to make confirmed diagnosis but also likely to develop with complications, so it was usually needed surgical excision. Clinical stage and pathological pattern were related to prognosis of PGIL.

Diagnosis and treatment of primary gastrointestinal Burkitt-like lymphoma in adults

AIM: To investigate the epidemiological and clinicopathological characteristics, diagnosis and treatment of primary gastrointestinal Burkitt-like lymphoma in adults.

METHODS: Relevant articles published since 1995 were retrieved in 15 English databases such as MEDLINE/PubMed, Web of Science, Directory of Open Access Journals (DOAJ) and SpringerLink and in China National Knowledge Infrastructure (CNKI) database. Data of six patients with primary gastrointestinal Burkitt-like lymphoma were obtained from six articles.

RESULTS: Four cases of adult primary gastrointestinal Burkitt-like lymphoma were from East Asia (Japan and China, 66.7%). All six patients were male with an average age of 57.6 years. Two cases occurred in the ileocecum, one in the stomach, one in the hepatic flexure of the colon, one in the terminal ileum, and one in the stomach and small intestine simultaneously. Four cases were admitted to the hospital because of abdominal mass, along with B symptoms: weight loss in four cases and fatigue in two cases. All patients underwent alimentary endoscopy (CT scan in 5 cases and B-ultrasound in 3 cases). Four cases underwent surgery, 5 cases underwent combined chemotherapy, and 3 cases underwent surgery plus postoperative chemotherapy. One case died within 1 year, and one case was followed for 5 years and is still alive. Immunohistochemically, CD20 and CD10 staining was positive in 4 cases, Ki-67 staining positive in 3 cases, Bcl-2 staining negative in 3 cases, CD23 and CD5 staining negative in 2 cases.

CONCLUSION: Adult primary gastrointestinal Burkitt-like lymphoma is a highly malignant non-Hodgkin's lymphoma and is extremely rare clinically with rapid development and high mortality. Its clinical manifestations are non-specific, so comprehensive examination should be conducted to confirm the diagnosis before clinical intervention. Final diagnosis still relies on fine-needle aspiration biopsy or surgical excision biopsy. Surgical treatment and multi-drug combination adjuvant chemotherapy postoperatively should be implemented as soon as possible after making a diagnosis. Clinicians should raise their awareness of the disease and pay more attention to the diagnosis and treatment of the disease, which could improve the outcome of the patients.

Primary lymphomas in the gastrointestinal tract

Primary gastrointestinal (GI) lymphomas are uncommon diseases that can involve the whole GI tract. The etiologies of the disease remain unclear, and potential risk factors include celiac disease, Helicobacter pylori infection, use of immunosuppressive agents, human immunodeficiency virus (HIV) or Epstein-Barr virus (EBV) infection and inflammatory bowel disease, etc. Diffuse large B-cell lymphoma (DLBCL) and mucosa-associated lymphoid tissue (MALT) lymphoma are the most common subtypes of GI lymphomas. B-cell lymphomas of the GI tract are more common in Western countries, while in Asia-Pacific region T-cell lymphomas are more frequently reported. In this review, lymphomas in the esophagus, stomach and intestine are described, including their epidemiology, histology, clinical manifestations, endoscopic findings, radiological features and treatment.

Primary lymphomas of the stomach, duodenum and colon: A case report

Synchronous gastric, duodenal and colonic primary lymphomas have a low incidence. Due to the lack of specific symptoms, missed diagnosis or misdiagnosis is easily caused. The present case was initially considered to have gastrointestinal cancer and multiple gastrointestinal polyps, but synchronous gastric, duodenal and colonic primary lymphomas were finally diagnosed by gastrointestinal endoscopy combined with pathological biopsy. Clinicians should raise their awareness of this condition, and comprehensive analysis of clinical characteristics, endoscopic manifestations, pathological characteristics, and imaging findings can help improve the level of diagnosis and treatment.

Endoscopic features of gastro-intestinal lymphomas: From diagnosis to follow-up

Many progresses have been done in the management of gastrointestinal (GI) lymphomas during last decades, especially after the discovery of Helicobacter pylori-dependent lymphoma development. The stepwise implementation of new endoscopic techniques, by means of echoendoscopy or double-balloon enteroscopy, enabled us to more precisely describe the endoscopic features of GI lymphomas with substantial contribution in patient management and in tailoring the treatment strategy with organ preserving approaches. In this review, we describe the recent progresses in GI lymphoma management from disease diagnosis to follow-up with a specific focus on the endoscopic presentation according to the involved site and the lymphoma subtype. Additionally, new or emerging endoscopic technologies that have an impact on the management of gastrointestinal lymphomas are reported. We here discuss the two most common subtypes of GI lymphomas: the mucosa-associated lymphoid tissue and the diffuse large B cell lymphoma. A general outline on the state-of-the-art of the disease and on the role of endoscopy in both diagnosis and follow-up will be performed.

Primary colorectal non-Hodgkin's lymphoma in a retropositive patient

A 43-year-old man known case of retropositive illness presented with abdomen pain of 15 days and loose stools for 10 days. Loose stools were foul smelling and blood stained. The patient was a known case of type 2 diabetes and retroviral illness on highly active antiretroviral therapy (HAART). General physical examination was normal. On examination an irregular mass was palpable in the right iliac fossa and right flank. The mass was hard in nature; irregular with restricted mobility. There was no palpable liver or spleen. CT of the abdomen and pelvis revealed a well-defined heterogeneously enhancing hypodense mass lesion measuring 16 × 11.7 × 12 cm involving the ileocaecal region and extending medially and inferiorly to sigmoid colon and rectum. A colonoscopy showed a proliferative highly vascular mass 15 cm from anal verge at the rectosigmoid junction. Histopathology revealed sheets of neoplastic lymphoid cells in rectal wall suggestive of non-Hodgkins lymphoma.

Primary gastrointestinal lymphoma in an Egyptian district: a study using a population-based cancer registry

INTRODUCTION

Gastrointestinal lymphoma (GIL) is the most common extranodal form of non-Hodgkin's lymphoma (NHL) with geographical and age variation of its various subtypes.

AIM

To study GIL in Gharbiah, Egypt and to recognize the treatments employed and their outcomes including survival.

METHODS

This is a retrospective study. Between 2000 and 2002, 40 adult patients with GIL were identified in the Gharbiah population based cancer registry (GPBCR); 26 cases of whom were treated at Tanta Cancer Center (TCC).

RESULTS

GIL in Gharbiah, Egypt represented 6.2% of all GIT cancers. The median age was 47 years with slight male predominance. The commonest primary site was the stomach followed by the colon/rectum then the small intestine (67.5%, 25% and 7.5%, respectively). The commonest histological subtypes were the diffuse large B-cell (41.5%) followed by marginal zone B-cell (39%). The commonest symptoms were abdominal pains followed by vomiting. Only 18% of GILs were surgically resected. Most patients (77%) received chemotherapy with a 60% complete response (CR) rate. Once in CR, relapses are occasional. The median overall survival (OS) and progression free survival (PFS) were 31 and 14 months (95% CI, 13.2-48.7 and 6.4-21.6 months, respectively). Gastric primary site and diffuse large B cell subtype carry a non-significant worse OS and PFS than those of other sites and subtypes.

CONCLUSIONS

GILs in Gharbiah, Egypt are characterized by predominance of male gender, gastric site and marginal zone histology. Survival is worse for gastric and diffuse large B-cell GILs compared to other sites and histologies.

Colorectal lymphoma

Extranodal lymphomas account for a third of all cases of non-Hodgkin lymphoma with the gastrointestinal tract being the most common extranodal site. The most common location is the stomach followed by the small intestine, colon and rectum. Colorectal lymphomas are rare and comprise 10-20% of all gastrointestinal lymphomas and only 1% of all colorectal malignancies. Presenting symptoms include abdominal pain, weight loss, and anorexia. Diagnosis depends on the clinical setting with elective cases being diagnosed with colonoscopy and emergent cases being diagnosed in the operating room. Colonic lymphomas are frequently located proximal to the hepatic flexure. Management depends on the aggressiveness of the lymphoma subtype. Indolent tumors, which are resistant to standard chemotherapeutic regimens, are treated with surgical resection. Aggressive lymphoma subtypes are managed with chemotherapy and surgery with late-stage disease patients being referred to clinical trials.

The management of primary small bowel and colon lymphoma--a review

AIMS

The management of primary small bowel and colon lymphoma is controversial. A review of the literature was therefore undertaken to evaluate the evidence for the classification, staging, diagnosis, and treatment of primary small bowel and colon lymphoma and guide management.

METHODS

A literature search was performed utilising Embase, Medline, and Pubmed and papers were evaluated on an individual basis.

RESULTS

Consensus opinion favours the WHO classification scheme and the TNM staging systems for primary small bowel and colon lymphoma. CT enteroclysis and barium enterolysis are recommended for the diagnosis of primary small bowel lymphoma and capsule endoscopy and double-balloon enteroscopy maybe useful diagnostic tools. In terms of the diagnosis and staging of primary colonic lymphoma, the evidence is scarce and CT is to be recommended. The mainstay of treatment for primary GI lymphoma is surgery and/or chemotherapy. For primary small bowel and colonic lymphoma, there was no definitive evidence regarding the benefits of either strategy; however, chemotherapy seemed to give a survival benefit over surgery alone for primary small bowel lymphoma and colonic lymphoma was skewed towards surgery plus chemotherapy due to the large number of patients presenting as an emergency.

CONCLUSION

Published data regarding the management of primary small bowel and colon lymphoma is very limited. Classification and staging should be standardised to enable accurate evaluation of investigations and treatments and a large RCT undertaken to compare chemotherapy and surgery. Currently, we would recommend that management should involve chemotherapy with surgery reserved for those with clinical indication.

Primary colorectal lymphoma: An overview

Lymphomas represent common hematological malignancies with increasing incidence in recent years. The major site of extranodal non-Hodgkin lymphoma is the gastrointestinal tract. Involvement of the large intestine is rare in comparison to the stomach or small bowel. The disease appears later in life, predominantly in the male population. Complaints are nonspecific, requiring a high index of suspicion in order to establish the diagnosis. The treatment varies from chemotherapy alone to multimodal therapies combining surgery, chemotherapy and radiotherapy. The small number of patients with various histological subtypes and different stage at presentation results in unclear protocol for the treatment of primary colorectal lymphoma. The purpose of this paper is to review current data on primary lymphoma of the colon and rectum while analyzing reported case series and published material on the subject.

Surgery does not adversely affect survival in primary gastrointestinal lymphoma

OBJECTIVE

To evaluate the impact of surgery on gastrointestinal lymphoma.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried from 1973 to 2005.

RESULTS

A total of 17,222 cases of PGIL were identified. The overall incidence of PGIL was approximately 1.505 cases per 100,000. A significantly increasing incidence for PGIL was observed (APC = +4.67, P < 0.05). In the cases for which treatment data was available, resection occurred in roughly half of the patients. In univariate analysis, surgical extirpation did not improve survival (47 months vs. 76 months, P < 0.001), while radiation treatment improved median survival (77 months vs. 59 months, P < 0.001). Multivariate analysis revealed increasing age and male gender as independent predictors of decreased overall survival. Tumor location also was a significant predictor of outcome. Large B-cell lymphoma type PGIL had a poorer prognosis than marginal zone B-cell lymphoma. By multivariate analysis, surgery was not found to increase the risk of death (HR = 0.99).

CONCLUSIONS

No associated survival benefit for surgery in the treatment in gastrointestinal lymphoma was observed. Determination of lymphoma should preclude surgical resection. Nonetheless, inadvertent extirpative surgery or in association with perforation does not appear to increase mortality.

[Primary colorectal lymphomas]

BACKGROUND/AIM

Colorectal lymphoma is a rare tumor representing 1.4% of human lymphomas, 10-20% of gastrointestinal lymphomas, namely 0.2-0.6% of all malignancies in the colon. The aim of this study was to review clinical characteristics of primary colorectal lymphoma and overall survival.

METHODS

A detailed analysis of 16 surgically treated patients included patients age, symptoms and signs, tumor site, type of surgery, histopathologic findings, diagnosis of the disease, disease stage, type of surgery related to the degreee of emergency (elective or urgent), applied adjuvant therapy, patient follow-up and treatment outcomes. Survival was expressed by the Kaplan-Meier curve, while the difference in survival among the two groups by the Log-rank test.

RESULTS

The all patients were on an average followed-up for a median of 29 months (range 2-60 months), while those with chemotherapy 48 months (range 4-60 months). An overall mean survival time was 38.65 months.

CONCLUSION

Primary colorectal lymphoma is a rare malignant tumor of the large bowel. Therapy usually involves resection of the affected colon or rectum and regional lymphovascular structures, followed by adjuvant therapy. Survival period is short and, therefore, timely diagnosis is crucial in early disease stages when the probability of cure is high.

The role of surgical intervention in the management of duodenal lymphoma

BACKGROUND AND OBJECTIVES

The role of surgical management in duodenal lymphoma is controversial due to the rarity of this tumor subtype. A retrospective review of a provincial cancer registry was performed to assess the rationale for surgical management in duodenal lymphoma.

METHODS

Patient demographics, presentations, pathologies, surgical interventions, treatment, and associated disease-specific survival were assessed and descriptively presented.

RESULTS

From 1985 to 2005, 23 patients (mean age 58 years [22-82]) were diagnosed. The most common histology was large B-cell lymphoma (74%). A significant proportion presented in a complicated fashion: obstruction (30%), perforation (17%), and hemorrhage (4%). Eight patients (35%) were treated with surgery alone, eight (35%) with surgery and chemotherapy, five (22%) with chemotherapy alone, and two (9%) with supportive care. Of those treated with surgery, indications were mostly emergent conditions including obstruction (58%), perforation (33%), and hemorrhage (8%). Overall median follow-up was 14 months (1-168 months) and overall median survival was 12 months (1-168 months). There were no significant differences in survival by histology, stage, or treatment type.

CONCLUSIONS

Chemotherapy continues to represent the therapeutic mainstay for GI lymphomas. However, in duodenal lymphoma, a high proportion of patients require surgery mainly because of complicated presentations.

Primary non-Hodgkin's lymphoma of rectum presenting with rectal prolapse

Involvement of the rectum by primary or secondary malignant lymphoma is uncommon in adults. Primary lymphoma of the rectum in children is an extremely rare occurrence. We describe a 12-year-old boy with a localized rectal tumor that presented with rectal prolapse and bleeding, mimicking a juvenile polyp. He underwent transrectal local wide excision of the tumor, and the pathologic condition proved to be non-Hodgkin's lymphoma of diffuse large B-cell type. This case illustrates the importance of considering the possibility of a rectal malignancy manifesting as a rectal prolapse even in children and the surgical strategy used.

Clinicopathologic features of primary gastrointestinal lymphoma: an analysis of 14 cases

AIM: To study the clinicopathologic features of primary gastrointestinal lymphoma (PGIL).

METHODS: Clinical data of 14 cases with pathologically or endoscopically confirmed PGIL at our hospital from January 1994 to March 2008, were retrospectively analyzed.

RESULTS: The study comprised 8 patients with primary gastric lymphoma (PGL group), 5 with primary intestinal lymphoma (PIL group) and 1 with both primary gastric and intestinal lymphoma (mixed group). The main clinical symptom was abdominal pain, and others included emaciation, poor appetite, abdominal mass and anaemia. Two patients were classified as low-grade malignant lymphoma, and 12 patients high-grade lymphoma including 2 diffused large B-cell lymphoma and 10 diffused large B-cell lymphoma plus MALT lymphoma. Nine patients had stage Ⅰ disease, 3 had stageⅡE disease, 2 had stage Ⅲ disease. The average age of patients in the PIL plus mixed group was significantly younger than that in PGL group (49.00 ± 13.05 vs 69.12 ± 7.7, P < 0.01).

CONCLUSION: PGIL has no specific clinical symptoms, but deserves highly attention in clinical practice for its late-stage and high-grade lymphoma incidence and early age of onset in PIL and mixed group lymphoma.

Ophthalmic lymphoma: epidemiology and pathogenesis

With a lifetime risk of 1% and 700 new cases per year, Non-Hodgkin lymphoma (NHL) is the seventh most frequent type of cancer in Denmark. The incidence of NHL has increased considerably in Western countries over the last decades; consequently, NHL is an increasing clinical problem. Ophthalmic lymphoma, (lymphoma localized in the ocular region, i.e. eyelid, conjunctiva, lacrimal sac, lacrimal gland, orbit, or intraocularly) is relatively uncommon, accounting for 5%-10% of all extranodal lymphomas. It is, however, the most common orbital malignancy. The purpose of this thesis was to review specimens from all Danish patients with a diagnosis of ophthalmic lymphoma during the period 1980-2005, in order to determine the distribution of lymphoma subtypes, and the incidence- and time trends in incidence for ophthalmic lymphoma. Furthermore, an extended analysis of the most frequent subtype, extranodal marginal zone lymphoma (MALT lymphoma), was done to analyse clinical factors and cytogenetic changes with influence on prognosis. A total of 228 Danish patients with a biopsy-reviewed verified diagnosis of ocular adnexal-, orbital-, or intraocular lymphoma were identified. We found that more than 50% of orbital- and ocular adnexal lymphomas were of the MALT lymphoma subtype, whereas diffuse large B-cell lymphoma (DLBCL) predominated intraocularly (Sjo et al. 2008a). Furthermore, lymphoma arising in the lacrimal sac was surprisingly predominantly DLBCL (Sjo et al. 2006). Incidence rates were highly dependent on patient age. There was an increase in incidence rates for the whole population from 1980 to 2005, corresponding to an annual average increase of 3.4% (Sjo et al. 2008a). MALT lymphoma arising in the ocular region was found in 116 patients (Sjo et al. 2008b). One third of patients had a relapse or progression of disease after initial therapy and relapses were frequently found at extra-ocular sites. Overall survival, however, was not significantly poorer for patients with relapse. Furthermore, we found that the frequency of translocations involving the MALT1- and IGH-gene loci is low in ocular region MALT lymphoma (2 of 42, 5%), but may predict increased risk of relapse (Sjo et al. 2008b). In conclusion the incidence of ophthalmic lymphoma is increasing at a high rate in Denmark. Ophthalmic lymphoma consists primarily of MALT lymphoma. The molecular pathogenesis of MALT lymphoma arising in the ocular region rarely involves translocations in the MALT1- and IGH-gene loci.

Non-Hodgkin's lymphomas of the large bowel-clinical characteristics, prognostic factors and survival

The aims of this study were to review the clinical presentation of non-Hodgkin's lymphomas of the large bowel, to analyze the prognostic factors using univariate and multivariate methods, as well as the overall survival. We identified 24 cases at our clinic between 1991 and 2005, based on pathohistological analysis and standard diagnostic criteria established by Dawson et al. They accounted for 1.2% of all cases of the large bowel malignancies (24/2021) during this period. The following clinical information such as age, gender, symptoms, tumor localization, operation performed, histology grade, stage of disease, and adjuvant chemotherapy was obtained. Survival function was expressed by Kaplan-Meier curve and Log-rank test was performed for the difference in survival between two patient groups. Multivariate analysis was carried out using the Cox proportional hazard model. Overall mean survival time was 41.91 months. According to the univariete analysis, the factors influencing overall survival rate was operation type (elective and emergent). Tumor stage and operation type were independent prognostic factors for survival, as determined by multivariate analysis. Our results showed that tumor stage and operation type should be considered as the most important prognostic factors in patients with primary non-Hodgkin's lymphomas of the large bowel.

Duodenal Lymphoma: A Rare and Morbid Tumor

We conducted a retrospective tumor registry review of a 36-year experience in a university center and identified 10 patients with duodenal lymphoma (five localized, five disseminated). Histologic types included diffuse large B-cell in four patients, mucosa-associated lymphoid tumor in three, and Hodgkin, follicular, and unclassified (one each). Treatments included chemotherapy in four patients, radiation therapy (RT) in two patients, Helicobacter pylori treatment in two, and observation in one. Five patients underwent operations (emergent in two, elective in three) for indications including massive bleeding in two patients, obstruction in two, or both in one. Survival for surgical group was 25 per cent at 1 year. One-year survival for nonsurgical group was 100 per cent, and all nonoperated patients lived at least 5 years, except for one who is alive 2 years after diagnosis. Surgical patients were younger and had more advanced lesions and less favorable cell types. When operation is required for bleeding or obstruction from secondary tumors in younger patients with disseminated disease, surgical challenges are formidable and survival is very limited. Tumors of less aggressive histology have far better prognosis.

The role of surgical intervention in non-Hodgkin's lymphoma of the colon and rectum

BACKGROUND

Gastrointestinal involvement of non-Hodgkin's lymphoma (NHL), although rare, may require surgical intervention. The purpose of the current study was to determine the incidence, presentation, and management of patients with NHL of the colon or rectum.

METHODS

Demographic data, signs, symptoms, disease stage, and treatment of patients with a primary gastrointestinal lymphoma treated between 1973 and 2005 were identified.

RESULTS

Forty-three of 244 gastrointestinal lymphoma patients (18%) had colon or rectal involvement. Most common symptoms on presentation were pain (49%), hematochezia (49%), change in bowel habits (23%), and weight loss (19%). Most common site of involvement was the ileocecum. Twenty-six patients (60%) required surgery. The majority (56%) had urgent or emergent operations.

CONCLUSIONS

Colorectal involvement by NHL occurred in 18% of patients with gastrointestinal lymphoma. Surgery was required for pain, obstruction, and/or bleeding. Physicians caring for patients must be aware of the potential need for surgery in treating this patient population.

Pediatric Burkitt's lymphoma: CT findings

PURPOSE

To review and analyze all CT scans of the cases of Burkitt's lymphoma (BL) in children diagnosed in our institution.

MATERIALS AND METHODS

A retrospective analysis of 33 children with BL between the years 2003 and 2005 seen in our institution was undertaken. Twenty-nine male and four female patients from age 3 to 16 years (with a mean age 5.9 years) were reviewed.

RESULTS

The gastrointestinal tract was involved in 19 patients (57.5%), kidneys in 9 (27.2%), peritoneum in 8 (24.2%), liver in 4 (12.1%), spleen in 3 (9%), adrenals in 3 (9%), and pancreas in 1 patient (3%). Extra-nodal head and neck involvement was seen in eight patients (24.2%). Bone involvement in four (12.1%), lung in three (9%), heart in two (6%), skin in two (6%), and testis in one (3%) of these patients. Abdominal lymph nodes were enlarged in 21 children (63.6%), while cervical lymph nodes were enlarged in 8 (24.2%).

CONCLUSION

CT proved to be an invaluable tool in the characterization of the disease processes in these children. In addition, it provided us with useful information about the anatomical distribution, patterns of involvement, as well as complications of BL.

Primary tumors of jejunum and ileum as a cause of intestinal obstruction: a case control study

BACKGROUND

Small-bowel tumors are rare and account for 1-2% of all gastrointestinal neoplasms. Most of these tumors are found at surgery indicated for other diagnosis or intestinal obstruction. The rarity, unclear presentation and diagnostic difficulty of these tumors stimulated our interest to review our experience with emergency surgery for intestinal obstruction secondary to jejunoileal tumors.

METHODS

We reviewed 17 patients operated on for intestinal obstruction secondary to benign and malignant primary tumors of jejunum and ileum at our institution the last 10 years.

RESULTS

The series comprised 8 male and 9 female patients, most of them younger than 49 years of age. The most frequent tumors found were GIST (36%) followed by lymphomas (24%) and adenocarcinomas (18%). Most tumors (65%) were located in the ileum. Mean survival for patients with malignant tumors was 19.5+/-13 months, and for patients with benign tumors 72+/-20 months (p<0.05).

CONCLUSION

Jejunoileal tumors present frequently in patients younger than 49 years of age. Ileal tumors are more likely to develop intestinal obstruction than jejunal tumors. Emergency surgery for these patients precludes a complete and negative margin resection and constitutes a risk factor for residual disease and short-term survival.