Gastrointestinal lymphoma: the new mimic

Lymphomas With Primary Gastrointestinal Presentation: A Retrospective Study Covering a Five-Year Period at a Quaternary Care Center in Southern India

Background and objective Lymphomas can involve the gastrointestinal (GI) tract as a primary disease or as a secondary spread of systemic disease. The GI tract is a key site for extranodal lymphomas, with Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) occurring in this region. This study aimed to analyze the demography, anatomic distribution, histological subtypes, and immunomorphological characteristics of all lymphomas with a primary GI presentation at a quaternary care hospital in southern India. Methods We conducted a retrospective study covering the period from 2018 to 2022 involving all cases of lymphomas with primary GI presentation. All the cases were categorized based on morphological and immunophenotypic criteria per the World Health Organization (WHO) 2022 classification of hematopoietic and lymphoid neoplasms. Data were analyzed by using the statistical software SPSS Statistics version 28.0 (IBM Corp., Armonk, NY). Results Out of 2,455 lymphoma cases diagnosed in the five-year study period, 156 presented with primary GI symptoms. Males constituted 113 (72.5%) cases and 43 (27.5%) patients were females. The stomach (n=81; 52%) was the most common site, followed by the small intestine (n=40; 27%), large intestine (n=33; 20%), and esophagus (n=2; 1%). Most lymphomas involving the GI tract were NHL (n=152; 97%), and the remaining included four (3%) cases of HL. Diffuse large B-cell lymphoma (DLBCL) was the most frequent (n=102; 65.3%) B-cell NHL. Eight cases of T-cell lymphomas were noted including rare entities. Conclusions This study is one of the largest of its kind involving lymphomas with primary GI presentation from India. The distribution and incidence of various entities in our study were comparable to various other studies from India and those from Western countries. GI lymphomas are heterogeneous, with distinct prognoses and treatment strategies. Hence, diagnosing them correctly would help in prognostication and providing prompt therapy.

Diffuse large B cell non-Hodgkin lymphoma complicated with jejunal stricture and perforation

INTRODUCTION

DLBCL with gastrointestinal involvement is a relatively rare form of extra-nodal lymphoma, and complications such as spontaneous perforation and jejunal stricture in this disease are even rarer.

CASE PRESENTATION

A 45-year-old male presented with abdominal pain and vomiting. Diagnosis revealed a jejunal stricture with perforation, necessitating resection and anastomosis. Histopathology performed after surgery confirmed DLBCL, and the patient was referred for chemotherapy.

DISCUSSION

DLBCL with gastrointestinal involvement is uncommon and often manifests with nonspecific symptoms, leading to diagnostic delays. Treatment includes addressing both lymphoma and associated complications, with surgical intervention reserved for emergencies.

CONCLUSION

Bowel perforation and jejunal stricture in non-Hodgkin's lymphoma are serious complications requiring prompt treatment to improve outcomes and reduce mortality.

Intestinal Perforation in a Case of Peripheral T Cell Lymphoma after Initiation of Chemotherapy

Non-Hodgkin's lymphoma (NHL) is the most common type of Gastrointestinal (GI) lymphoma with known complications such as bleeding, obstruction and perforation. In this article we present a 59-year-old male patient diagnosed with Peripheral T cell Lymphoma - Not Otherwise Specified (PTCL-NOS) with GI involvement was started on chemotherapy. On day 2 post completion of first cycle of chemotherapy, patient had presented to the emergency department with sudden onset abdominal pain and distension. On evaluation, he was diagnosed with multiple perforations in the small bowel. Patient underwent exploration with primary repair of few perforations and ileal resection with double barrel ileostomy. Chemotherapy plays an important role in the management of NHL. One well-known NHL consequence, intestinal perforation, can happen at the time of initial presentation or after starting chemotherapy. Surgeons should be aware of possibility of such complications and high-risk factors for perforation. At present, there is no role for elective surgery in GI lymphoma and is mainly reserved for complications like uncontrolled bleeding, obstruction or perforation.

Enhancing treatment strategies for small bowel cancer: a clinical review of targeted therapy and immunotherapy approaches

Small bowel cancer (SBC) is a rare and aggressive disease with a poor prognosis, necessitating the exploration of novel treatment approaches. This narrative review examines the current evidence on targeted therapy and immunotherapy for SBC, focusing on the two most common subtypes: adenocarcinoma and neuroendocrine tumor. A comprehensive search of PubMed, Scopus, and Google Scholar databases was conducted to identify relevant clinical trials and case reports published in English up to September 2023. The review includes 17 clinical trials and 10 case reports, indicating that targeted therapy and immunotherapy can have the potential to improve survival rates in patients with SBC. Notably, promising targeted medicines include bevacizumab, cetuximab, and trastuzumab, while pembrolizumab and nivolumab show potential as immunotherapies. However, it should be noted that the magnitude of the increase in survival rates with these interventions was small. Further research is needed to determine the optimal combination of targeted therapy and immunotherapy for individual patients with SBC.

A Case of an Unusual Bleeder: Small Bowel Lymphoma

This case report highlights an uncommon presentation of small bowel lymphoma as gastrointestinal bleeding in an 87-year-old female with a history of ulcerative colitis. Despite non-specific symptoms and negative findings on upper endoscopy and colonoscopy, ileoscopy revealed a distal ileal mass with a solitary non-bleeding ulcer, confirmed by biopsy as diffuse large B-cell lymphoma (DLBCL). The patient opted for palliative management. Small intestinal lymphomas, particularly DLBCL, pose diagnostic challenges due to their varied presentations. Timely detection is crucial for optimal outcomes, emphasizing the importance of prompt utilization of diagnostic methods in suspected cases.

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.

Partial Small Bowel Obstruction and Volvulus Due to B-cell Lymphoma in a Common Variable Immunodeficiency Patient

This case report presents a 43-year-old female with a history of common variable immunodeficiency (CVID) and a recent diagnosis of mesenteric volvulus. The patient presented with symptoms of partial small bowel obstruction and was diagnosed with obstruction and mesenteric volvulus primarily affecting the proximal jejunum. During the exploratory laparotomy, a probable polyposis syndrome and a possible adenocarcinoma of the small bowel were identified. Pathological examination confirmed the presence of B-cell lymphoma in the proximal jejunum. The patient underwent treatment with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (RCHOP) chemotherapy and showed improvement in symptoms. The case highlights the increased risk of malignancies, particularly lymphomas, in individuals with CVID and the challenges in diagnosing and treating lymphoid neoplasms in this population.

Small Bowel Lymphoma Complicated With Ischemic Colitis: A Case Report

Ischemic colitis is thought to be an injury to the colon as a result of reduced blood flow. Certain infectious diseases such as the Epstein-Barr virus can aid in the reduction of blood flow. The insult can range from inflammation and superficial injury to full-thickness necrosis. The typical regions affected are the "watershed" areas of the colon: the splenic flexure, the rectosigmoid junction, and the right colon. Because patients can present with a wide spectrum of symptoms from vague abdominal discomfort to complete abdominal catastrophe, the diagnosis of ischemic colitis is sometimes challenging to make. Patients typically present with the acute onset of crampy abdominal pain and usually pass blood mixed with stool within 24 hours. Endoscopically, ischemia is suspected in the presence of bluish hemorrhagic nodules from submucosal bleeding, cyanotic or necrotic mucosa with bleeding ulcerations, or a segmental distribution with an abrupt transition point between injured and normal mucosa. We present a case of an 80-year-old male with a history of hypertension, hyperlipidemia, and basal cell carcinoma of the scalp diagnosed with ischemic colitis associated with positive Epstein-Barr virus B cell lymphoma.

Updates in the diagnosis and management of small-bowel tumors

Small-bowel tumors represent a rare entity comprising 0.6% of all new cancer cases in the US, and only 3% of all gastrointestinal neoplasms. They are a heterogenous group of neoplasms comprising of about forty different histological subtypes with the most common being adenocarcinoma, neuroendocrine tumors, stromal tumors and lymphomas. Their incidence has been reportedly increasing over recent years, partly owing to the advances and developments in the diagnostic modalities. Small-bowel capsule endoscopy, device assisted enteroscopy and dedicated small-bowel cross-sectional imaging are complimentary tools, supplementing each other in the diagnostic process. Therapeutic management of small-bowel tumors largely depends on the histological type and staging at diagnosis. The aim of the present review article is to discuss relevant advances in the diagnosis and management of small-bowel tumors.

Isolated gastric involvement of recurrent Hodgkin lymphoma: a case report and review of the literature

BACKGROUND

Although the gastrointestinal tract is one of the most common sites for extranodal lymphoma, gastrointestinal lymphoma is a rare disease that is almost exclusively non-Hodgkin lymphoma.

CASE PRESENTATION

We present a rare condition of Hodgkin lymphoma relapse after 12 years as isolated gastric involvement caused massive gastrointestinal bleeding in a 34-year-old Iranian woman. According to the result of the upper endoscopy, laparotomy was performed, and a large mass in the upper part of the fundus, alongside the esophagogastric junction, was seen, so gastrectomy was performed.

CONCLUSION

All symptoms and paraclinical findings for gastrointestinal Hodgkin lymphoma are nonspecific. Therefore, the preoperative diagnosis is challenging. It seems that surgery is a suitable diagnostic and therapeutic method in this field.

Primary Gastrointestinal T-cell Lymphoma Presenting as Spontaneous Perforation Peritonitis

Primary T-cell non-Hodgkin lymphoma (NHL) of the gastrointestinal tract (GIT) is a rare, poorly-characterized clinical entity. A well-known complication of intestinal NHL is perforation due to chemotherapy, but perforation as a presenting sign of GIT lymphoma is extremely rare. Here we present a case of spontaneous intestinal perforation secondary to primary intestinal T-cell lymphoma and highlight the importance of early recognition of this uncommon cause of perforation as a crucial step to ensure expedited hematology referral and initiation of appropriate treatment.

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.

Mimics of Crohn's Disease

Crohn's disease is a chronic inflammatory disease that can affect any portion of the gastrointestinal tract. Associated symptoms can vary based on the severity of disease, extent of involvement, presence of extraintestinal manifestations, and development of complications. Diagnosis is based on a constellation of findings. Many diseases can mimic Crohn's disease and lead to diagnostic conundrums. These include entities associated with the gastrointestinal luminal tract, vascular disease, autoimmune processes, various infections, malignancies and complications, drug- or treatment-induced conditions, and genetic diseases. Careful consideration of possible causes is necessary to establish the correct diagnosis.

Small bowel lymphoma: clinical update and challenges for the gastroenterologist

PURPOSE OF REVIEW

The diagnosis of small bowel lymphoma (SBL) can be challenging, as they are very rare and also have a varied presentation. In this review, we aim to provide a broad overview of the types of SBL and also about the various modalities used for their diagnosis. We also discuss the overview of treatment strategies for a gastroenterologist.

RECENT FINDINGS

Small bowel capsule endoscopy (SBCE) and devise-assisted enteroscopy (DAE) has revolutionized the way we investigate the small bowel. DAE also makes it possible to obtain histological samples for further characterization of SBL. This has led to a significant improvement in diagnosis and management of the disease in conjunction with cross-sectional imagining.

SUMMARY

The diagnosis and management of small bowel lymphoma remains challenging despite the development of newer techniques such as SBCE and DAE. The current available diagnostic modalities have limitations; in the absence of a gold standard, the current investigative modalities compliment each other in reaching the final diagnosis.

Intestinal T-cell lymphoma: A rare entity presenting with severe acute upper quadrant pain

Primary gastrointestinal T-cell lymphomas are rare. Presenting symptoms can be non-specific, and imaging studies can show overlap with nonmalignant processes. Definitive diagnosis requires clinical suspicion and histologic evaluation with ancillary studies for appropriate disease classification and therapeutic intervention.

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.

Complicaciones quirúrgicas del linfoma con compromiso gastrointestinal

Introducción. El linfoma puede afectar el tracto gastrointestinal de manera primaria o secundaria, y representa hasta el 2 % de todas las neoplasias malignas del intestino delgado y colon. El tracto gastrointestinal es la ubicación extraganglionar primaria más común en el linfoma no Hodgkin. Métodos. Se realizó una búsqueda de la literatura en las principales bases de datos académicas, con revisión de textos publicados sobre el tema en los últimos 5 años. Discusión. La presentación clínica del linfoma con compromiso gastrointestinal es inespecífica y, hasta en la mitad de los pacientes, se puede presentar de manera inicial con complicaciones que requieran manejo quirúrgico. Entre las principales se encuentran la perforación intestinal, el sangrado digestivo y la obstrucción intestinal.

Aggressive primary gastric lymphoma (PGL) masquerading as hepatocellular cancer (HCC) in alcoholic cirrhosis

Background

The gastrointestinal tract is sa well-known site for extranodal Non-Hodgkin lymphomas, with the stomach is known to be the most common site on lymphoma, primary gastric lymphoma (PGL). The lymphoproliferative disorder rarely occurs in patients with cirrhosis. We report a unique case of metastatic PGL in a patient with cirrhosis.

Case presentation

A middle-aged male with decompensated alcoholic cirrhosis presented with two weeks of epigastric abdominal pain, abdominal distension, and jaundice. Abdominal triple-phase CT scan was consistent with cirrhosis, ascites, and multiple new hypodense liver lesions classified as an intermediate probability for HCC based on the LI-RADS classification system (LI RADS 3). Due to the CT findings in the setting of cirrhosis, a provisional diagnosis of HCC was made. Upper endoscopy revealed new multiple umbilicated submucosal nodules in the gastric body. Biopsy and immunostaining consistent with high-grade B-cell lymphoma. Targeted liver biopsy with similar morphology and immunostaining profile consistent with metastatic primary gastric DLBCL.

Conclusions

The case highlights the importance of recognizing metastatic PGL in patients with underlying cirrhosis to differentiate lymphoma from hepatocellular cancer. Targeted liver biopsies with lymphoma immunostaining are required to make a diagnosis.

A Complicated Case of Diffuse Large B-Cell Lymphoma in an Elderly Presenting with Massive Gastrointestinal Bleeding Successfully Treated with R-mini CHOP

Gastrointestinal lymphoma accounts for up to 20% of all extranodal lymphoma cases. Among them, the ileum is the second most commonly affected site after the stomach. The majority of gastrointestinal lymphoma originates from the B cell lineage. We report the case of 60-year-old male with persistent anemia, hematochezia, and poor performance status (PS). After thorough workup, imaging, and pathological study, the patient was diagnosed with diffuse large B-cell lymphoma of the terminal ileum. He was treated with R-CHOP based chemotherapy with dose tailoring to accommodate his poor PS. His symptoms promptly subsided after the first chemotherapy cycle. After eight cycles of chemotherapy, terminal ileum wall thickening was gone and the patient was disease-free for 6 months. This case report shows that chemotherapy can be beneficial in patients with gastrointestinal lymphoma despite poor PS. Therefore, it should be given when possible with proper dose tailoring.

Ileo-colonic lymphoma: presentation, diagnosis, and management

PURPOSE OF REVIEW

The gut-associated lymphoid tissue (GALT), the bulk of which is located in the ileo-colonic region comprises the lymphoid cells of the gastrointestinal tract and confers specific immunological responses. Repetitive antigenic stimulation of these cells predispose to a monoclonal proliferation of this tissue and the eventual development of lymphoma. The gastrointestinal tract is the most commonly involved site of extranodal lymphomas. This review will focus primarily on lymphomas of the ileo-colonic region (defined as the terminal ileum, the colon, and the rectum). We will discuss the epidemiology, pathogenesis, and presentation as well as current practices in diagnosis and management.

RECENT FINDINGS

Despite the majority of the GALT to be located in the ileo-colonic region of the gut, the lymphomas in this location are relatively rare. However, the overall annual incidence of ileo-colonic lymphomas is steadily increasing. This entity has a varied spectrum of clinical presentations. Ileo-colonoscopy with adequate targeted biopsies can serve as a gold standard for definitive diagnosis. Ileo-colonic lymphomas may be managed with chemotherapy alone while surgery is reserved for highly aggressive tumors or clinical emergencies. Radiation is not a preferred adjuvant treatment for lymphomas in this location of the gut. Adequate endoscopic surveillance measures and tools to potentially prevent recurrence and improve the overall prognosis of this disease are lacking.

SUMMARY

Ileo-colonic lymphomas are rare and can present with varied symptoms and signs. Endoscopy with adequate sampling can aid in making a definitive diagnosis. Chemotherapy can be highly effective in management while surgery is indicated for emergency presentations. Adequate endoscopic surveillance tools are lacking, yet imperative to prevent recurrence and improve prognosis.

A Case Study on the Customized Nutrition Intervention for a Patient with Primary Gastrointestinal Non-Hodgkin Lymphoma Underlying Chronic Kidney Disease

Non-Hodgkin lymphoma comprises 2.1% of the total number of cancers in South Korea. Among those, diffuse large B cell lymphoma (DLBCL) comprises the largest percentage. Nutrition interventions have been highlighted because nutritional status in non-Hodgkin's lymphoma patients has a significant impact on treatment and prognosis, but relevant studies are inadequate. Therefore, the aim of this study was to share the case of a nutrition intervention for a patient with primary gastrointestinal non-Hodgkin lymphoma underlying chronic kidney disease who was comorbid with tumor lysis syndrome, which was a complication of a specific chemotherapy. The subject is a 76-year-old patient who was diagnosed with DLBCL. He had abdominal pain, constipation, and anorexia. After chemotherapy, he experienced the tumor lysis syndrome. The patient's condition was continuously monitored, and various nutrition interventions, such as nutrition counseling and education, provision of therapeutic diet, oral nutritional supplement, change of meal plans, and parenteral nutrition support were attempted. As a result of the nutrition intervention, oral intake was increased from 27% of the energy requirement to 70% and from 23% of the protein requirement to 77%. Despite the various nutrition interventions during the hospitalization, there were no improvements in weight and nutrition-related biochemical parameters or malnutrition. However, it was meaningful in that the patient was managed to prevent worsening and the planned third chemotherapy could be performed. These results can be used as the basis for establishing guidelines for nutritional interventions customized to patients under the same conditions.

Endoscopic diagnosis of primary and recurrent mantle cell lymphomas

A 64-year-old male presented to our center with epigastric pain, anorexia, fatigue, weight loss and anemia on a laboratory study. An abdominal ultrasound revealed thickening of the gastric walls. Upper endoscopy demonstrated a 40 mm ulcerated lesion at the incisura angularis. A biopsy of the lesion revealed a lymphocytic infiltrate expressing CD5, CD20 and cyclin D1, typical of mantle-cell lymphoma (MCL).

The Role of Gastric Mucosal Immunity in Gastric Diseases

Gastric mucosa plays its immune function through innate and adaptive immunity by recruiting immune cells and releasing corresponding cytokines, which have an inseparable relationship with gastric diseases. Whether infective gastric diseases caused by Helicobacter pylori, Epstein-Barr virus or other microbe, noninfective gastric diseases, or gastric cancer, gastric mucosal immunity plays an important role in the occurrence and development of the disease. Understanding the unique immune-related tissue structure of the gastric mucosa and its role in immune responses can help prevent gastric diseases or treat them through immunotherapy. In this review, we summarize the basic feature of gastric mucosal immunity and its relationship with gastric diseases to track the latest progress of gastric mucosal immunity, update relevant knowledge and provide theoretical reference for the prevention and treatment of gastric diseases based on the gastric mucosal immunity.