Primary gastrointestinal non-Hodgkin's lymphoma: I. Anatomic and histologic distribution, clinical features, and survival data of 371 patients registered in the German Multicenter Study GIT NHL 01/92

Primary gastric diffuse large B-cell lymphoma: A multicentre retrospective study

Primary gastric diffuse large B-cell lymphoma (PG-DLBCL) accounts for the majority of extra-nodal DLBCL. Even so, literature is lacking on early, localised presentations. We studied a cohort of patients with stage I disease, diagnosed between 2006 and 2018, from six centres between Australia, Canada and Denmark. Our goal was to characterise outcomes, review treatment and investigate the role of interim positron emission tomography (iPET). Thirty-seven eligible patients were identified. The median duration of follow-up was 42.2 months. All received chemoimmunotherapy with 91.9% (n = 34) given rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP). 35.1% (n = 13) underwent consolidative radiotherapy. Eighteen patients were H. pylori positive and 11 had the documentation of H. pylori eradication therapy. The 4-year progression-free survival and overall survival of R-CHOP was 88% (95% CI: 71-95) and 91% (95% CI: 75-97) respectively. All patients who achieved a partial metabolic response or complete metabolic response on iPET went on to achieve complete response at the end of treatment. R-CHOP-based therapy with iPET assessment appears to offer favourable outcomes, with radiotherapy and H. pylori eradication therapy implemented on a case-by-case basis.

Enteric associated T-cell lymphoma in a mule

A 25-year-old female mule weighing 336 kg was referred with a history of lethargy, abdominal discomfort, anorexia, and constipation in the previous 24 hours. On admission, decreased intestinal borborygmi and distended small intestinal loops were detected by auscultation and rectal palpation, respectively. On rectal examination a firm, irregular surface, and pedunculated mass were detected in the middle-caudal region of the abdomen. Transrectal ultrasonography revealed the mass was highly vascularized with heterogeneous tissue density. On exploratory celiotomy two neoplastic masses were observed, one in the jejunoileal junction obstructing the intestinal flow and the second in the dorsal part of the jejunal mesentery, unable to be exposed and resected. An enterectomy was conducted, and the intestinal mass was removed. The mass was pale with hemorrhagic areas and 12 cm in diameter. Histopathology and immunohistochemistry confirmed a diagnosis of enteric associated T cell lymphoma subtype 2. The mule died suddenly 43 days later.

Characterization of primary small intestinal lymphoma: a retrospective study based on double balloon endoscopy

BACKGROUND

The diagnosis of primary small intestinal lymphoma (PSIL) is difficult. This study aimed to evaluate the clinical, radiological and endoscopic characteristics of PSIL and provide clue for diagnosis.

METHODS

A total of 30 patients diagnosed with PSIL who underwent double balloon endoscopy (DBE) in the First Affiliated Hospital of Zhejiang University were retrospectively analyzed. Clinical, radiological and endoscopic data were collected. Univariate analysis was used to determine significant indicators for differentiating three main subtypes of PSIL. Cox regression analysis was performed to assess the risk factors for survival.

RESULTS

In this study, 10 patients were pathologically diagnosed as diffuse large B-cell lymphoma (DLBCL), 11 were indolent B-cell lymphoma (BCL) and 9 were T-cell lymphoma (TCL). Compared with DLBCL patients, the body mass index (BMI) of TCL patients was significantly lower (p = 0.004). Meanwhile, compared with patients with DLBCL, the patients with indolent BCL had lower levels of C-reactive protein, lactate dehydrogenase (LDH), fibrinogen and D-Dimer (p = 0.004, p = 0.004, p = 0.006, and p = 0.002, respectively), and lower proportion of thicker intestinal wall and aneurysmal dilation in CT scan (p = 0.003 and p = 0.020, respectively). In terms of ulcer morphology, patients with DLBCL had significantly higher proportion of deep ulcers than patients with indolent BCL (p = 0.020, respectively). Cox regression analysis showed that drink (p = 0.034), concomitant colonic ulcers (p = 0.034) and elevated LDH (p = 0.043) are risk factors for mortality in patients with PSIL.

CONCLUSIONS

This study provides clinical characteristics of patients with PSIL. Thicker intestinal wall and aneurismal dilation detected on CT scan and deeper ulcer on DBE examination helps to establish a diagnosis of DLBCL.

Sigmoid Colon Perforation in Diffuse Large B-Cell Lymphoma Due to Tacrolimus-Induced Immunodeficiency: A Case Report

The sigmoid colon is an uncommon site for the origin of primary malignant lymphomas in the GI tract. Additionally, immunosuppressive agents, widely used in treating autoimmune diseases, have been associated with the induction of malignancies, including lymphoproliferative disorders. In this report, we present a rare case of GI perforation suggesting a link between immunosuppressive therapy, particularly tacrolimus treatment, and diffuse large B-cell lymphoma (DLBCL). A 75-year-old female patient presented with abdominal pain to our ER. She had a medical history of polymyositis and interstitial pneumonia, treated with the immunosuppressant tacrolimus. An abdominal CT scan revealed free gas in the abdominal cavity, leading to a diagnosis of GI perforation. The patient exhibited generalized peritonitis and underwent emergency surgery the same day. During surgery, a perforation in the sigmoid colon was identified, and a Hartmann procedure was performed. Postoperative pathology showed CD20+, CD30+, CD5-, CD10-, BCL6+, MUM1+, and MIB-1 LI of 50-60%. The diagnosis of DLBCL was confirmed, classified as EBV-positive diffuse large B-cell lymphoma, not otherwise specified (NOS), in the sigmoid colon, with positive EBER-ISH, LMP-1, and EBNA2 findings. Given her history of immunosuppressant use, she was categorized as having other iatrogenic immunodeficiency-associated lymphoproliferative disorders (OIIA-LPD), according to the WHO Classification of 2017. This case highlights the importance for clinicians to consider the risk of oncogenesis associated with the prolonged use of immunosuppressive agents.

Advances in diagnosis, treatment and prognostic factors of gastrointestinal DLBCL

Gastrointestinal diffuse large B-cell lymphoma (GI-DLBCL) is an extremely aggressive form of B-cell non-Hodgkin lymphoma (BNHL) which has complex histological characteristics and manifests a high degree of heterogeneity in terms of clinical, morphological, immunological, and genetic features. GI-DLBCL mainly spreads by infiltrating neighboring lymph nodes, and common gastrointestinal complications (GICS) such as obstruction, perforation, or bleeding, frequently arise during the progression of the disease, posing significant challenges in both diagnosing and treating the condition. Meanwhile, the incidence of GI-DLBCL has been gradually increasing in recent years, and its strong invasiveness makes it prone to being misdiagnosed or completely missed. In clinical practice, over half of the patients diagnosed with the disease are in stage III or stage IV. What makes it worse is that certain patients may not exhibit a favorable response to chemotherapy. All these lead to intricacies in management of this disease. Unfortunately, there is currently no large prospective study or evidence-based medical evidence to provide clear guidance on treatment decisions for this specific type of lymphoma. Neither do physicians have a consensus regarding the optimal approach to address this condition. Recent studies have identified the presence of various prognostic factors that significantly impact survival in GI-DLBCL, which demonstrates the unique particularity of GI-DLBCL, and could help optimize the clinical decision.

The prognostic impact of lymphoma perforation in patients with primary gastrointestinal lymphoma - a single-center analysis

Patients with primary gastrointestinal (GI) lymphoma are at risk of GI perforations. Therefore, we aimed to investigate the prognostic impact of non-traumatic GI perforations. 54 patients with a histologically confirmed diagnosis of primary GI lymphoma were included. Non-traumatic lymphoma perforation occurred in ten patients (19%). Perforations occurred only in patients with aggressive B-cell lymphoma. In patients with aggressive B-cell lymphoma, the median overall survival (mOS) was 52 months (95% CI 9.88-94.12) and 27 months (95% CI 0.00-135.48) in patients with and without GI perforation, respectively. The median progression-free survival (mPFS) was 30 months (95% CI 5.6-54.4) in patients with GI perforations. In patients without lymphoma perforation, mPFS was not reached. Both mOS and mPFS did not significantly differ. In conclusion, despite the need for emergency surgery and delay in lymphoma-directed treatment, lymphoma perforation did not negatively impact our study population's OS or PFS.

Clinical, Radiological and Histopathological Evaluation of Primary Colon Lymphoma

BACKGROUND

In this study, we aimed to examine the clinical, radiological, histopathological, immunohistochemical, and prognostic features of a case series undergoing surgery for non-Hodgkin's primary colon lymphoma (NHL).

METHODS

The data of six patients diagnosed with NHL who were operated on in our clinic between January 2010 and January 2020 were retrospectively analyzed. NHL was detected in six of the patients operated on for colon tumors. B (n=5) and T (n=1) cell lymphomas were detected based on their cellular subtypes.

RESULTS

The median age at diagnosis was 66 (52-70). The most common complaints were abdominal pain, weight loss, nausea, and vomiting. One patient underwent emergency surgery, and five underwent elective surgery due to obstruction. While CT was used in all patients, Positron emission tomography-computed tomography (PET/CT) was taken only in patients who underwent elective surgery. The masses were localized in the cecum in two patients, in the right colon in two patients, and in the transverse colon and sigmoid colon in one patient each. All patients underwent mesocolic resection. The mean tumor size was 7.51±2.20 (4.5-11) cm. The median number of total lymph nodes was 33 (18-44), and the median number of metastatic lymph nodes was 15 (4-39).

CONCLUSION

The overall and disease-free survival of the patient with T-cell lymphoma was shorter than that of patients with B-cell colon lymphoma. NHL is a rare disease. The cellular subtype effectively determines the survival time and prognosis of NHL.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Prognosis and complications of patients with primary gastrointestinal diffuse large B-cell lymphoma: Development and validation of the systemic inflammation response index-covered score

BACKGROUND

This study aimed to evaluate the predictive value of systemic inflammation response index (SIRI) in primary gastrointestinal diffuse large B-cell lymphoma (PGI-DLBCL) patients and establish a highly discriminating risk prediction model.

METHODS

This retrospective analysis included 153 PGI-DCBCL patients diagnosed between 2011 and 2021. These patients were divided into a training set (n = 102) and a validation set (n = 51). Univariate and multivariate Cox regression analyses were conducted to examine the significance of variables on overall survival (OS) and progression-free survival (PFS). An inflammation-covered score system was established according to the multivariate results.

RESULTS

The presence of high pretreatment SIRI (≥1.34, p < 0.001) was significantly associated with poorer survival and identified as an independent prognostic factor. Compared with NCCN-IPI, the prognostic and discriminatory capability of the novel model SIRI-PI showed a more precise high-risk assessment with a higher area under the curve (AUC) (0.916 vs 0.835) and C-index (0.912 vs 0.836) for OS in the training cohort, and similar results were obtained in the validation cohort. Moreover, SIRI-PI also showed good discriminative power for efficacy assessment. This new model identified patients at risk of developing severe gastrointestinal complications following chemotherapy.

CONCLUSIONS

The results of this analysis suggested that the pretreatment SIRI may be a potential candidate for identifying patients with a poor prognosis. And we established and validated a better-performing clinical model, which facilitated the prognostic stratification of PGI-DLBCL patients and can serve as a reference for clinical decision-making.

Histopathological Evaluation of Angiogenic Markers in Non-Hodgkin's Lymphoma

Background Angiogenesis plays a key role in the development, maintenance, and progression of tumor. The incidence of non-Hodgkin's lymphoma (NHL) is increasing from the past three decades.

Materials and Methods The aim of the study is to evaluate microvessel density (MVD) using CD34 monoclonal antibody and vascular endothelial growth factor (VEGF) using monoclonal antibody that were studied in pretreatment paraffin-embedded tissue samples of 60 cases.

Results MVD was found to be increased in parallel with increasing grade of tumor. B-NHL had a mean MVD of 79.5 ± 8.8 (no./mm2), while T-NHL had a mean MVD of 183 ± 37.6 (no./mm2). VEGF expression was seen in 42 cases (70%), 20 cases (33.3%) showed strong VEGF expression, and the remainder showed either weak (36.6%) or no (30%) staining. Strong VEGF expression is seen in 100% cases of T-NHL and 77.7% cases of B-NHL. Mean MVD and VEGF expression was found to be correlated significantly with the histological grade of NHL (p = 0.001 and p = 0.000, respectively). Average microvessel counts were 53, 82.9, and 130.8 vessels (no./mm2) for negative, weak, and strong VEGF staining, respectively. These differences were statistically significant (p = 0.005 for strong vs. negative and p = 0.091 for strong vs. weak VEGF staining individually).

Conclusion As the grade of tumor progresses, the angiogenic potential also advances which seems to depend on VEGF. The presence of higher MVD in high-grade lymphomas can be utilized for antiangiogenic drugs.

A study on the prevention of hemorrhage and perforation in patients with primary gastric diffuse large-B cell lymphoma during treatment with immunochemotherapy

BACKGROUND

Stomach hemorrhage and perforation are very severe and common complications in patients with primary gastric diffuse large B-cell lymphoma (PG-DLBCL) during treatment with immunochemotherapy. However, no relevant clinical studies have been performed on the prevention of these serious complications.

METHODS

Patients diagnosed with PG-DLBCL were enrolled in this retrospective study. The prevention group received standard rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) treatment without prednisone combined with antacids and anti-Helicobacter pylori (Hp) therapy. These patients received R-CHOP-based treatment until the complete recovery of gastric ulcers, as proven by gastroscopy. The control group received a standard R-CHOP regimen. Toxicity and survival were the main endpoints.

RESULTS

A total of 52 patients received preventative treatment, while 146 patients did not. Among patients with stage I, II-1, and II-2 disease, the prevention group had a lower rate of hemorrhage and perforation (0/40) than the control group (10/78, p = 0.044). At a median follow-up time of 25 months, the 5-year event-free survival (EFS) rates were 97.1% in the prevention group and 66.1% in the control group (p = 0.025), and the 5-year overall survival (OS) rates were 100% and 72.0%, respectively (p = 0.021). However, the differences in the 5-year EFS and OS of patients with disseminated disease were not statistically significant.

CONCLUSIONS

Preventative treatment can decrease the risk of hemorrhage and perforation in patients with localized PG-DLBCL during immunochemotherapy, leading to better EFS and OS in these patients. However, preventative treatment failed to reduce the risk of gastric hemorrhage and perforation and did not improve survival (EFS and OS) in advanced-stage patients.

A rare case of diffuse large B-cell lymphoma presenting as a malignant mass in both duodenum and ascending colon

Lymphoma in the gastrointestinal tract most commonly occurs in the stomach, small intestine and around the ileocecal region. Usually gastrointestinal lymphoma occurs secondary to widespread nodal disease and is rarely found to be the primary site. Of the different types of lymphoma, diffuse large B-cell non-Hodgkin's lymphoma makes up the majority of lymphomas in the gastrointestinal tract. Primary colorectal lymphoma is even less common and accounts for 3% of all gastrointestinal lymphomas and to our knowledge, gastrointestinal lymphoma involving 2 different regions in the GI tract has not been discussed in the literature. Herein, we are presenting a rare case of diffuse large B-cell lymphoma presenting as a malignant mass in both the duodenum and ascending colon.

Isolated unconjugated hyperbilirubinemia in adults: the Gilbert’s versus Criggler Najar Syndrome Type 2 conundrum

Gilbert’s syndrome is a genetic disorder characterised by non-hemolytic unconjugated hyperbilirubinemia. It is caused by mutations in the UGT1A1 gene which codes for the enzyme uridine diphosphate glucoronosyl transferase-1, which conjugates bilirubin for excretion. Affected individuals are usually asymptomatic apart from a mild jaundice and investigations reveal a mild isolated indirect hyperbilirubinemia. This may be exacerbated in the face of environmental and physical stressors. It is very similar in presentation to Criggler-Najjar syndrome (CNS) type 2. There is a small risk of kernicterus in patients with CNS type 2 needing daily phenobarbitone therapy. This risk is miniscule in Gilbert’s syndrome. Genetic testing for polymorphisms of the UGT1A1 gene is the diagnostic clincher for Gilbert’s syndrome, but it can also be picked up by evaluating the response to phenobarbitone and fasting, particularly in resource poor settings. Due to limited availability, case reports documenting the genetic mutational analysis are sparse. We reported one such rare case with an unusually high indirect hyperbilirubinemia in Gilbert’s syndrome confirmed by both phenobarbitone response and genetic analysis.

Persistent Stomach Pain In The young Age Patient: A Case Of Primary Gastric Burkitt's Lymphoma

Lymphoma is the second most common gastric cancer, following gastric adenocarcinoma. Most gastric lymphomas are mucosa-associated lymphoid tissue lymphomas or diffuse large B-cell lymphomas. Primary gastric Burkitt’s lymphoma is a subtype of non-Hodgkin lymphoma and represents an aggressive and rare malignity with the fewest cases reported globally. Primary gastrointestinal non-Hodgkin lymphoma is a rare condition. Burkitt’s lymphoma is an aggressive form of B-cell lymphoma endemic to Africa while it is not endemic to the rest of the world. Here we presented a young immunocompetent male patient who had weight loss and was admitted with a stomachache. Upper gastrointestinal endoscopy and biopsy detected a large primary gastric Burkitt’s lymphoma. While long-term survival rates are possible with early diagnosis and timely appropriate treatment, delay in treatment can be fatal for such patients.

Unusual presentation of aggressive high‐grade B‐cell lymphoma of colonic origin: A case report and review of the literature

Colonic lymphoma is a rare disease. The presented case is unique, being manifested with abrupt onset, including circulatory shock and lactic acidosis as the initial presentation.

Although rare, colorectal lymphoma should be included in the DD of patients with abdominal symptoms. Shock and lactic acidosis can be an initial presentation of colonic lymphoma. Diagnosis is mostly based on pathology and the evaluation of ascites.

Endoscopic features of colorectal lymphoma according to histological type

Background and Aim

This study aimed to investigate the relationship between the histological type of colorectal lymphoma and its endoscopic features.

Methods

We retrospectively analyzed patients with primary colorectal lymphoma who were diagnosed using colonoscopy and biopsy specimens at the National Cancer Center Hospital, Tokyo, Japan. The lesions were macroscopically classified into the following types via colonoscopy: polypoid, ulcerative, multiple lymphomatous polyposis, diffuse, and mixed.

Results

A total of 117 lesions were identified in 90 patients enrolled in this study. Of these, 59 (50%) were located in the ileocecal region, 23 (20%) in the rectum, 9 (8%) in the transverse colon, 8 (7%) in the sigmoid colon, 7 (6%) in the descending colon, and 4 (3%) in the ascending colon. Moreover, the most common histological subtypes were diffuse large B‐cell lymphoma (DLBCL) in 39 patients (43%) and mantle cell lymphoma (MCL) in 23 patients (26%), followed by follicular lymphoma (FL; 17%), mucosa‐associated lymphoid tissue (MALT) lymphoma (9%), peripheral T‐cell lymphoma‐NOS (2%), monomorphic epitheliotropic intestinal T‐cell lymphoma (MEITL; 2%), and Burkitt lymphoma (1%). More than half of the DLBCL (52%), MCL (52%), and MALT (56%) lymphomas were macroscopically classified as polypoid types. In contrast, FL lesions showed various macroscopic types. The majority of DLBCL (62%) and FL (78%) lesions were distributed in the ileocecal region. MCL lesions tended to be widely spread in various sites of the large intestine.

Conclusions

Colorectal lymphomas showed macroscopically distinctive features depending on the histological type. Understanding the macroscopic classification of the lesions by colonoscopy and its distribution may be helpful in diagnosing the type of lymphoma and determining the malignant grade based on the histological types.

A Favorable Outcome of Grade 3 Follicular Lymphoma Treated With Surgery and Obinutuzumab Combined With Chemotherapy: A Case Report and Literature Review

Follicular lymphoma is the most common type of low-grade non-Hodgkin lymphoma and the second most common type of lymphoma. Primary extranodal follicular lymphoma is rare compared with nodular follicular lymphoma involving the gastrointestinal (GI) tract. There has been uncertainty regarding follicular lymphomas due to the heterogeneous presentation and severity in which they present. However, studies showed that patients diagnosed with primary gastrointestinal follicular lymphoma do not typically differ in their presentation from those diagnosed with nodular follicular lymphoma involving the GI tract. Furthermore, recent literature identifies that patients diagnosed with grade 3 follicular lymphoma tend to have similar genetic and molecular entities to those diagnosed with diffuse large B-cell lymphoma (DLBCL). Based on these results, current studies have shown that patients with grade 3 follicular lymphoma who are treated with anthracycline-based regimens have similar outcomes to those with diffuse large B-cell lymphoma. However, additional studies are warranted to demonstrate the benefit of managing grade 3 follicular lymphoma with more aggressive anthracycline/rituximab-based regimens. Here, we present a case of a 44-year-old male diagnosed with grade 3 follicular lymphoma involving the gastrointestinal tract, who demonstrated an excellent treatment response following therapy similar to the treatment of bulky diffuse large B-cell lymphoma despite a tumor burden size below 7.5 cm.

Development of Organ-Preserving Radiation Therapy in Gastric Marginal Zone Lymphoma

Simple Summary

Gastric marginal zone lymphoma of the stomach is a rare cancer type primarily treated with oral proton pump inhibitors. If the disease does not respond to this, radiation is the treatment of choice. This review presents the development of radiation therapy over the last decades. Earlier, the stomach was surgically removed and irradiation was performed using large-field techniques and high doses of radiation. Currently, the standard treatment is the use of small-volume radiation therapy (with few side effects) with the preservation of the stomach, which provides excellent outcomes. In addition, this paper provides an outlook on current studies and possible future developments.

Abstract

Gastric marginal zone lymphoma (gMZL) of mucosa-associated lymphoid tissue (MALT) may persist even after H. pylori eradication, or it can be primarily Helicobacter pylori (H. pylori) independent. For patients without the successful eradication of lymphoma, or with progressive disease, treatment options have historically included partial or total gastrectomy. Presently, in these instances, curative radiation therapy (RT) is the current standard of care. This review emphasizes the historically changing role of radiation therapy in gMZL, progressing from large-volume RT without surgery, to localized RT, on its own, as a curative organ-preserving treatment. This overview shows the substantial progress in radiation therapy during the recent two to three decades, from high-dose, large-field techniques to low-dose, localized target volumes based on advanced imaging, three-dimensional treatment planning, and advanced treatment delivery techniques. RT has evolved from very large extended field techniques (EF) with prophylactic treatment of the whole abdomen and the supradiaphragmatic lymph nodes, applying doses between 30 and 50 Gy, to involved-field RT (IF), to the current internationally recommended involved site radiation therapy (ISRT) with a radiation dose of 24–30 Gy in gMZL. Stage-adapted RT is a highly effective and safe treatment with excellent overall survival rates and very rare acute or late treatment-related toxicities, as shown not only in retrospective studies, but also in large prospective multicenter studies, such as those conducted by the German Study Group on Gastrointestinal Lymphoma (DSGL). Further de-escalation of the radiation treatments with low-dose 20 Gy, as well as ultra-low-dose 4 Gy radiation therapy, is under investigation within ongoing prospective clinical trials of the International Lymphoma Radiation Oncology Group (ILROG) and of the German Lymphoma Alliance (GLA).

Surgery and Chemotherapy versus Chemotherapy Only in Older Persons with Primary Intestinal Diffuse Large B-Cell Lymphoma

Background

The management of primary intestinal diffuse large B cell lymphoma (PI-DLBCL) in elderly patients (aged >60 years) remains controversial. We conducted a retrospective study to assess the efficacy of different treatment strategies and prognostic factors for elderly Chinese patients with PI-DLBCL.

Patients and Methods

Forty-six untreated elderly patients with PI-DLBCL were included in this retrospective study. Twenty-four patients were treated with surgery (prior to chemotherapy) plus chemotherapy (SCT). The other 22 patients did not undergo surgery before chemotherapy (CT).

Results

Patients treated with SCT had a higher overall response rate of 91.7% than patients receiving CT, but the difference between groups was not significant (P=0.581). Regarding survival, SCT resulted in a greater 3-year overall survival (OS) rate (87.3% vs 56.9%, P=0.130) and significantly higher 3-year event-free survival (EFS) rate (74.1% vs 27.3%, P=0.002) than CT. The univariate analysis showed that male sex, advanced Lugano stage, poor performance status and chemotherapy alone were associated with a shorter EFS. Only the male sex was correlated with a shorter OS. The multivariate analysis showed that sex (P=0.040) and treatment strategy (P=0.022) were independent prognostic factors for EFS.

Conclusion

Surgery plus chemotherapy produced a better outcome for EFS, but not OS, than chemotherapy alone in elderly Chinese patients with PI-DLBCL.

Development and validation of prognostic scoring in primary intestinal diffuse large B-cell lymphoma: a single-institution study of 184 patients

Background

The incidence of primary intestinal diffuse large B-cell lymphoma (PI-DLBCL) is much lower than primary gastric DLBCL, and large-scale analyses on the clinical characteristics, molecular features, therapeutic strategies, and risk stratification have been seldomly performed in PI-DLBCL.

Methods

To assess prognostic model development, 107 PI-DLBCL patients diagnosed before 2014 were studied for prognosis factors including different primary involved sites and treatment strategies. For internal validation, a non-random split sample set with 77 PI-DLBCL patients after 2014 was included for validation of the prognosis factors.

Results

Patients with an ileocecal lesion presented with better survival time than those with non-ileocecal sites, with surgical resection significantly influencing the prognosis. Non-ileocecal patients who underwent surgery with lymphadenectomy had superior overall survival (OS) and progression-free survival (PFS) compared to those receiving surgery without lymphadenectomy or those not receiving (without) surgery. For ileocecal patients, surgery with or without lymphadenectomy resulted in better OS and PFS than those without surgery. For biomarker analysis, only BCL-2 >50% or Ki67 >80% on tumor cells indicated poor clinical outcome. In multivariate analysis, age, Eastern Cooperative Oncology Group (ECOG) score, and site of origin were independent prognostic factors for inferior OS in PI-DLBCL. A prognosis model was set up based on age, ECOG score, and site of origin, and validated well.

Conclusions

The prognosis in patients with PI-DLBCL with ileocecal involvement showed was better than those with non-ileocecal involvement. Surgical strategy can impact the clinical outcome of PI-DLBCL patients.

Primary Intestinal Lymphoma: Clinicopathological Characteristics of 55 Patients

Introduction

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

Materials and methods

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

Results

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

Conclusion

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

How to cite this article

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

A systematic review of primary gastric diffuse large B-cell lymphoma: Clinical diagnosis, staging, treatment and prognostic factors

Primary gastric lymphoma (PGL) is a rare clinical entity accounting for the majority of extra-nodal non-Hodgkin lymphoma (EN-NHL). The most common histological subtype is the primary gastric diffuse large B-cell lymphoma (PG-DLBCL) with a media age of 50-60 years old, mostly in male. Pathogenesis is often related to some bacterial infection such as Helicobacter pylori (H. pylori) infection. However, due to various available staging system, there is still no consensus on the staging of PG-DLBCL. The international prognostic index (IPI) is the most valuable used for the stratification of almost all subtype of NHL and as well as for PG-DLBCL. As for treatment strategies, surgery, chemotherapy, radiation therapy and antibiotic therapy in various combinations have been applied in clinical treatment. There are a few well-known prognostic factors and some of them may constitute prognostic models. Due to the increasing incidence of this neoplasm, it is necessary for clinicians to make deep insight of the diagnosis, staging, treatment and prognostic factors of PG-DLBCL.

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

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

Contrast-enhanced ultrasound imaging for intestinal lymphoma

BACKGROUND

Intestinal lymphoma is a rare tumor. Contrast-enhanced ultrasound (CEUS) findings of intestinal lymphoma have not been reported previously, and the relationship between CEUS and clinicopathological features and prognostic factors is still unknown.

AIM

To describe the B-mode US and CEUS features of intestinal lymphoma and investigate the correlation of CEUS and histopathological features.

METHODS

This was a single-center retrospective study. Eighteen patients with histologically confirmed intestinal lymphoma underwent B-mode US and CEUS examinations between October 2016 and November 2019. We summarized the features of B-mode US and CUES imaging of intestinal lymphoma and compared the frequency of tumor necrosis in intestinal lymphomas with reference to different pathological subtypes (aggressive or indolent) and clinical stage (early or advanced). The time-intensity curve parameters of CEUS were also compared between patients with normal and elevated serum lactate dehydrogenase.

RESULTS

In B-mode imaging, four patterns were observed in intestinal lymphoma: Mass type (12/18, 66.7%), infiltration type (1/18, 5.6%), mesentery type (4/18, 22.2%) and mixed type (1/18, 5.6%). All cases were hypoechoic and no cystic areas were detected. On CEUS, most cases (17/18, 94.4%) showed arterial hyperechoic enhancement. All cases showed arterial enhancement followed by venous wash out. A relatively high rate of tumor necrosis (11/18, 61.1%) was observed in this study. Tumor necrosis on CEUS was more frequent in aggressive subtypes (10/13, 76.9%) than in indolent subtypes (1/5, 20.0%) (P = 0.047). There were no correlations between tumor necrosis and lesion size and Ann Arbor stage. There was no significant difference in time-intensity curve parameters between normal and elevated lactate dehydrogenase groups.

CONCLUSION

B-mode US and CEUS findings of intestinal lymphoma are characteristic. We observed a high rate of tumor necrosis, which appeared more frequently in aggressive pathological subtypes of intestinal lymphoma.

Gastrointestinal lymphoproliferative lesions: a practical diagnostic approach

The gastrointestinal tract (GI) is the primary site of lymphoproliferative lesions, spanning from reactive lymphoid hyperplasia to overt lymphoma. The diagnosis of these diseases is challenging and an integrated approach based on clinical, morphological, immunohistochemical and molecular data is needed. To reach to confident conclusions, a stepwise approach is highly recommended. Histological evaluation should first assess the benign versus neoplastic nature of a given lymphoid infiltrate. Morphological and phenotypic analyses should then be applied to get to a definite diagnosis.

This review addresses the key histological features and diagnostic workup of the most common GI non-Hodgkin lymphomas (NHLs). Differential diagnoses and possible pitfalls are discussed by considering distinct groups of lesions (i.e. small to medium B-cell NHLs; medium to large B-cell NHLs; T-cell NHLs; and mimickers of Hodgkin lymphoma). The key clinical and epidemiological features of each entity are also described.

Increased MALAT1 expression predicts poor prognosis in primary gastrointestinal diffuse large B-cell lymphoma

Metastasis-associated lung adenocarcinoma transcript 1 (MALAT1) is involved in the pathogenesis and progression of several cancers. However, the potential effect of MALAT1 in primary gastrointestinal diffuse large B-cell lymphoma (PGI-DLBCL) has not been elucidated. This study aimed to explore the prognostic value of MALAT1 in patients with PGI-DLBCL. Quantitative real-time polymerase chain reaction (qRT-PCR) was performed to determine the expression of MALAT1 in 90 patients with PGI-DLBCL. MALAT1 was remarkably upregulated in PGI-DLBCL tissues compared to paired adjacent non-tumor tissues (P < 0.001), and the area under the receiver operating characteristic (ROC) curve (AUC) was 0.838. MALAT1 expression was further increased in the non-germinal center B-cell-like (non-GCB), advanced stage (stages IIE-IV) and International Prognostic Index (IPI) score (3-5) groups (P = 0.01, P < 0.001 and P < 0.001, respectively). Furthermore, Kaplan-Meier analysis showed that elevated MALAT1 expression correlated with inferior overall survival (OS) and progression-free survival in PGI-DLBCL patients (P < 0.001 and P < 0.001, respectively), and our multivariate analysis results suggested that upregulation of MALAT1 and high IPI score (3-5) were two unfavorable prognostic factors for PGI-DLBCL. In conclusion, our results demonstrate that MALAT1 may serve as a novel prognostic biomarker and an ideal therapeutic target for patients with PGI-DLBCL.

Need to Inspect the Total Gastrointestinal Tract of Patients With Malignant Lymphomas

BACKGROUND/AIM

Malignant lymphoma (ML) cases with overlapping gastrointestinal (GI) lesions are often encountered. We aimed to elucidate the importance of examining the GI tract in patients with ML and assess the overlap rate.

PATIENTS AND METHODS

We analysed 190 patients diagnosed with GI MLs. We compared the overlap rates among the different histopathological types.

RESULTS

Twenty-five (13.2%) patients had overlapping GI lesions in more than two segments. The overlap rates were 100% in mantle cell lymphomas (MCL), 27.6% in follicular lymphomas (FL), and 16.3% in diffuse large B-cell lymphomas (DLBCL). MCL, FL, and DLBCL cases showed significantly higher overlap rates than mucosa-associated lymphoid tissue lymphoma cases (p<0.01). About 64.0% of cases of ML with overlapping lesions involved the small intestine.

CONCLUSION

In GI ML cases, it is ideal to examine the entire GI tract by esophagogastroduodenoscopy, colonoscopy, and capsule endoscopy and/or balloon-assisted endoscopy, especially in MCL, FL, and DLBCL.

Update on B-cell lymphoproliferative disorders of the gastrointestinal tract

The gastrointestinal (GI) tract is home to a significant portion of the immune system, which interacts daily with the antigenic milieu of its contents. Therefore, the presence of white blood cells within the walls of the GI tract upon histologic examination is a familiar sight on GI biopsies-both in health and disease. The GI tract is the most common site of extranodal lymphomas, most of which are B-cell neoplasms. Here, we review common and uncommon B-cell neoplasms of the GI tract - extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma), mantle cell lymphoma, duodenal-type follicular lymphoma, diffuse large B-cell lymphoma, plasmablastic lymphoma, EBV-positive mucocutaneous ulcer, and post-transplant lymphoproliferative disorders - with special focus on literature published during the past five years. Along with the other articles in this edition of Seminars in Diagnostic Pathology, it is the authors' hope that this review proves to be a useful resource in the workup of the array of hematopoietic processes that can involve the GI tract.

Intestinal perforation secondary to intestinal Burkitt lymphoma

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We experienced a case of small intestinal perforation caused by intestinal Burkitt lymphoma.

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Pretreatment BL may present with bowel perforation.

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This is the first report of such a case.

Introduction and importance

Small intestinal perforation in patients with Burkitt lymphoma is extremely rare. We present the first report of such a case.

Case presentation

A 53-year-old woman was admitted with abdominal pain and vomiting. Abdominal examination revealed rigidity and tenderness in the upper abdomen.

Computed tomography scan showed thickening of the wall of the jejunum, intra-abdominal free gas, and ascites; the patient was diagnosed with small intestinal perforation, and underwent emergency surgery on the same day. Laparoscopic findings were a 50 mm jejunal perforation and perforation in the transverse mesocolon. A partial jejunal resection of the perforated area, partial transverse colectomy, temporary colostomy, and intra-abdominal drainage were performed. Histological examination showed diffuse infiltration of medium-sized atypical lymphocytes in the perforated area, exhibiting a “starry sky” appearance.

Immunostaining results showed that the atypical lymphocytes were CD20 and virtually 100% Ki-67 positive, and CD56, CD30, and EBER negative. The lesion was identified as Burkitt lymphoma (BL). The postoperative course was favorable. On postoperative day 18 the patient began chemotherapy through the hematology department. Currently, the patient is in remission.

Clinical discussion

The majority of the malignant lymphomas occurring in the digestive tract are identified in the stomach; over 90% are B-cell lymphomas and mucosa-associated lymphoid tissue lymphoma Nakamura et al. BL originating from the small intestine accounts for only about 9%.

Conclusion

The incidence of BL in the small intestine is low. Pretreatment BL can lead to bowel perforation. Prompt involvement of the hemato-oncologist after definitive diagnosis, and commencing chemotherapy as early as possible after surgery, are thought to improve prognosis.

How we treat mature B-cell neoplasms (indolent B-cell lymphomas)

Mature B cell neoplasms, previously indolent non-Hodgkin lymphomas (iNHLs), are a heterogeneous group of malignancies sharing similar disease courses and treatment paradigms. Most patients with iNHL have an excellent prognosis, and in many, treatment can be deferred for years. However, some patients will have an accelerated course and may experience transformation into aggressive lymphomas. In this review, we focus on management concepts shared across iNHLs, as well as histology-specific strategies. We address open questions in the field, including the influence of genomics and molecular pathway alterations on treatment decisions. In addition, we review the management of uncommon clinical entities including nodular lymphocyte-predominant Hodgkin lymphoma, hairy cell leukemia, splenic lymphoma and primary lymphoma of extranodal sites. Finally, we include a perspective on novel targeted therapies, antibodies, antibody-drug conjugates, bispecific T cell engagers and chimeric antigen receptor T cell therapy.

Management of an uncommon T-Cell lymphoma revealed by an anastomotic dehiscence in Crohn's disease: A case report

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The association of cancer and crohn’s disease is well known.

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Immunosuppressants are associated with a carcinological risk.

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The onset of T-cell Lymphoma in the course of crohn’s disease is a very rare finding.

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The revelation of non-hodgkin lymphoma by anastomotic dehiscence in crohn’s disease is not well documented in literature.

Introduction and importance

T-cell lymphoma degeneration in pancolic crohn’s disease is scarce. It is mostly related to long-standing inflammatory bowel disease in patients under immunosuppressants. We reviewed the clinical, endoscopic, radiological and histologic data of the patient as well as the literature dealing with T-cell lymphoma arising from pancolic crohn’s disease.

Case presentation

We describe in this paper an unusual case of a female young patient who underwent emergency surgery for per endoscopic perforation of the right colon while being under azathioprine. She had a subtotal colectomy with ileostomy and sigmoidostomy. After six months, we restored the digestive continuity through an ileorectal anastomosis. She was kept in remission on azathioprine. After one year, she presented with a pelvic abscess revealing a dehiscence of the ileorectal anastomosis leading to a surgical drainage and resection of the anastomosis associated with terminal ileostomy and closure of the rectal stump. Pathology examination revealed T cell lymphoma arising from the ileorectal anastomosis.

Discussion

Patients with long-standing IBD have an increased risk of developing colorectal cancer. The onset of a malignant lymphoma during the course of the CD is scarce. Some studies haves failed to identify crohn’s disease as a risk factor of lymphoma whereas other ones have succeeded to. Immunosuppressants are reported to have carcinogenic effect. Rarely, lymphoma degeneration can be revealed by intestinal complications such as perforation like in our case.

Conclusion

Many studies reported lymphoma degeneration of crohn’s disease after long-term immunosuppressant therapy. However, rapid T-cell lymphoma degeneration revealed by anastomotic dehiscence in crohn’s disease made our case unique and interesting.

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.

Recent advances upper gastrointestinal lymphomas: molecular updates and diagnostic implications

Approximately one-third of extranodal non-Hodgkin lymphomas involve the gastrointestinal (GI) tract, with the vast majority being diagnosed in the stomach, duodenum, or proximal small intestine. A few entities, especially diffuse large B-cell lymphoma and extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue, represent the majority of cases. In addition, there are diseases specific to or characteristic of the GI tract, and any type of systemic lymphoma can present in or disseminate to these organs. The recent advances in the genetic and molecular characterisation of lymphoid neoplasms have translated into notable changes in the classification of primary GI T-cell neoplasms and the recommended diagnostic approach to aggressive B-cell tumours. In many instances, diagnoses rely on morphology and immunophenotype, but there is an increasing need to incorporate molecular genetic markers. Moreover, it is also important to take into consideration the endoscopic and clinical presentations. This review gives an update on the most recent developments in the pathology and molecular pathology of upper GI lymphoproliferative diseases.

Synchronous colonic mucosa-associated lymphoid tissue lymphoma found after surgery for adenocarcinoma: A case report and review of literature

BACKGROUND

Mucosa-associated lymphoid tissue (MALT) lymphoma is a subtype of non-Hodgkin lymphoma that is mainly involved in the gastrointestinal tract. The synchronous occurrence of colonic MALT lymphoma and adenocarcinoma in the same patient is extremely rare. We here report a case of synchronous colonic MALT lymphoma found on surveillance colonoscopy five months after surgery and chemotherapy for sigmoid adenocarcinoma.

CASE SUMMARY

A 67-year-old man was admitted because of hematochezia for two months. Colonoscopy suggested a colonic tumor before hospitalization. Abdominal computed tomography (CT) revealed local thickening of the sigmoid colon. The patient underwent a left hemicolectomy with local lymph node dissection. The histopathology revealed moderately differentiated adenocarcinoma and partially mucinous adenocarcinoma. The pTNM stage was T3N1Mx. The patient received chemotherapy with six cycles of mFOLFOX6 after surgery. Colonoscopy was performed five months later and revealed single, flat, polypoid lesions of the colon 33 cm away from the anus. Subsequently, the patient underwent endoscopic mucosal resection for further diagnosis. The pathological diagnosis was MALT lymphoma. Positron emission tomography /CT suggested metastasis. The patient refused further treatment and died ten months later.

CONCLUSION

Colonic MALT lymphoma may occur after surgery and chemotherapy for adenocarcinoma as a synchronous malignancy. Regular surveillance colonoscopy and careful monitoring after surgery are critical.

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

Background

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

Materials and Methods

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

Results

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

Conclusions

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

Comparison of clinicopathological features and treatment outcomes in aggressive primary intestinal B- and T/NK-cell lymphomas

BACKGROUND

Primary intestinal lymphomas (PILs) are rare, and this study compared the clinical outcomes of aggressive primary intestinal B-cell lymphomas (aB-PILs) and T/natural killer-cell lymphomas (T/NK-PILs).

METHODS

The clinical information of patients diagnosed with aggressive PILs at our institution between 1995 and 2015 were retrospectively investigated. Pathological subtypes were confirmed according to the 2016 revision of the World Health Organization classification. The correlation between clinicopathological features and overall survival (OS) was determined using univariate and multivariate analyses.

RESULTS

Cases of T/NK-PILs had higher initial bowel perforation incidence (67% vs. 7%, P < 0.001) and lower complete response rate to first-line chemotherapy regimens (22% vs. 69%, P = 0.009) than aB-PILs. Patients with aB-PILs had a better 5-year event-free survival rate (55.8% vs. 13.9%, P = 0.026) and a 5-year OS rate (74.3% vs. 29.6%, P = 0.036) than those with T/NK-cell lymphomas. Multivariate analysis identified that female gender and stage III/IV were unfavorable prognostic factors. Among the 54 patients with diffuse large B-cell lymphoma (DLBCL), those with International Prognostic Index (IPI) scores of 0-2 had a better 5-year OS rate than those with scores of 3-5 (84.2% vs. 46.8%, P = 0.002). IPI scores of 3-5 (P = 0.026) and tumors located in the large intestine (P = 0.015) were poor prognostic factors based on the multivariate analysis.

CONCLUSION

The prognosis of T/NK-PILs was less favorable than that of aB-PILs. Female gender, stage III/IV disease, DLBCL with IPI scores of 3-5, or tumors in the large intestine were poor prognostic factors.

Value of 18F-FDG PET/CT for prognostic stratification in patients with primary intestinal diffuse large B cell lymphoma treated with an R-CHOP-like regimen

PURPOSE

The prognostic value of ¹⁸F-FDG PET/CT for primary intestinal diffuse large B-cell lymphoma (PI-DLBCL) patients has not been determined. This prompted us to explore the value of ¹⁸F-FDG PET/CT for prognostic stratification in patients with PI-DLBCL treated with an R-CHOP-like regimen.

MATERIALS AND METHODS

Seventy-three PI-DLBCL patients who underwent baseline PET/CT between January 2010 and May 2019 were included in this retrospective study. Total metabolic tumor volume (TMTV) and total lesion glycolysis (TLG) were computed using the 41% SUV_max thresholding method. Progression-free survival (PFS) and overall survival (OS) were used as endpoints to evaluate prognosis.

RESULTS

During the follow-up period of 3-117 months (29.0 ± 25.5 months), high TLG, non-germinal center B-cell-like (non-GCB) and high National Comprehensive Cancer Network International Prognostic Index (NCCN-IPI) were significantly associated with inferior PFS and OS. TLG, cell-of-origin and NCCN-IPI were independent predictors of PFS, and both TLG and NCCN-IPI were independent predictors of OS. The grading system was based on the number of risk factors (high TLG, non-GCB, high NCCN-IPI) and patients were divided into 4 risk groups (PFS: χ² = 33.858, P < 0.001; OS: χ² = 29.435, P < 0.001): low-risk group (none of the 3 risk factors, 18 patients); low-intermediate risk group (1 risk factor, 24 patients); high-intermediate risk group (2 risk factors, 16 patients); and high-risk group (all 3 risk factors, 15 patients).

CONCLUSIONS

High TLG, non-GCB and high NCCN-IPI can identify a subset of PI-DLBCL patients with inferior survival outcomes. Furthermore, the grading system can identify PI-DLBCL patient groups with markedly different prognoses, which might contribute to the adjustment of the therapeutic regime.

Ileocecal Burkitt's Lymphoma Presenting as Acute Abdominal Pain

Primary gastrointestinal non-Hodgkin's lymphomas are rare tumors which account for about 0.9% of all gastrointestinal tract tumors. They are usually associated with inflammatory bowel disease, previous radiotherapy, and renal transplantation. We report a case of non-Hodgkin's lymphoma involving the ileocecal region in a 46-year-old gentleman who presented with acute abdominal pain that mandated emergency laparotomy.

Primary small cell type of non-Hodgkin lymphoma of the colon: a case report

Introduction

Primary lymphoma of the colon is exceedingly rare and comprises 0.2–1% of all colon tumors. The most common subtype of lymphoma in the colon is non-Hodgkin lymphoma. Symptoms are often nonspecific, and treatment varies between chemotherapy alone and a combination of surgery and chemotherapy.

Case presentation

We describe a case of a Ashkenazi Jew patient who presented in the typical way that carcinoma of the colon might present but turned out to have a very rare type of tumor in both its histology and its location.

Conclusion

There was apparent discordance between the relative bulkiness and gross appearance of the tumor with the unrevealing result of the biopsies, demanding a high level of suspicion as to the actual presence and possible type of such a tumor in the future.

Primary Colonic Lymphoma With Paraneoplastic Hypercalcemia

Primary colonic lymphoma is a rare tumor accounting for 0.1%–0.5% of all colorectal malignancies. We describe a 63-year-old man whose initial presentation was altered mental status due to hypercalcemia. Physical examination revealed a hard, right-sided abdominal mass. Abdominal computed tomography showed a mass in the ascending colon, which on further evaluation with colonoscopy and biopsy was diagnosed as diffuse large B-cell lymphoma. A diagnosis of primary colonic lymphoma was made based on the Dawson criteria, after ruling out any extracolonic involvement. Workup for hypercalcemia showed elevated calcitriol levels, which is a paraneoplastic manifestation of the lymphoma.

Incidence rates and clinical characteristics of primary gastrointestinal non-Hodgkin lymphoma: a population study

BACKGROUND & AIMS

After the rise of lymphoma incidence in the 1990's, there is a paucity of epidemiologic studies describing the characteristics of primary gastrointestinal non-Hodgkin's lymphoma (PGIL). This epidemiologic survey aims to identify recent trends in PGIL.

METHODS

A retrospective, population-based study describing adult patients with PGIL in the Israeli Negev region between 1998 and 2013.

RESULTS

131 patients were diagnosed with PGIL, representing an annual incidence rate of 22.42/100,000, compared to 35.87/100,000 in the overall Israeli population. Both incidence rates did not significantly change during the study period. The median age was 66 years, and the most common presentation was in the stomach (49.6%) and oral cavity (18.3%). Histologically, diffuse large B cell lymphoma (DLBCL) was predominant (55.0%). Most patients (66.4%) had early stage disease. Only T-cell lymphoma showed a male predominance (14.7% versus 5.4%, P=0.008). Fifty patients (44.2%) had H. pylori testing, and 35 (70.0%) were positive. Of these, 91.4% received eradication treatment, and 57.1% were negative thereafter.Most patients received CHOP or RCHOP protocols (16.0% and 48.1%, respectively). Complete response was achieved in 53.4%. Median follow-up was 48 months, and 62 patients (47.3%) died during the study period. Liver involvement had a worse prognosis, (33.0% 5-year survival) compared to upper and lower GI disease(70.5% and 46.8% respectively, P=0.003 for the comparison between liver and other locations). T-cell lymphoma had worse survival (11 months vs. not reached, P=0.003).

CONCLUSIONS

This study demonstrates the incidence, and clinical characteristics of PGIL in the Negev region. It is important to identify disease characteristics, thus facilitating better disease detection and prognostication.

Renaissance of Radiotherapy in Intestinal Lymphoma? 10-Year Efficacy and Tolerance in Multimodal Treatment of 134 Patients: Follow-up of Two German Multicenter Consecutive Prospective Phase II Trials

Purpose

This article reports on the long‐term impact of radiotherapy adapted to stage, histology, and previous resection in a large cohort of patients with intestinal lymphoma (iL) treated with definitive or adjuvant curative‐intent radiation therapy (RT) ± chemotherapy (CHOP, MCP, or COP).

Patients and Methods

In two consecutive prospective study designs, 134 patients with indolent (stage IE–IIE) or aggressive (stage IE–IVE) iL were referred to 61 radiotherapeutic institutions between 1992 and 2003. Patients with indolent iL received extended field (EF) 30 Gy (+10 Gy boost in definitive treatment); patients with aggressive iL received involved field (IF) (EF) 40 Gy by means of stage‐, histology‐, and operation‐adapted radiation fields.

Results

The patients had median age 58 years and were predominantly male (2:1). Histology showed aggressive prevalence (1.6:1), stage IE–to–stage IIE ratio of iL 1.04:1, and localized stages–to–advanced stages ratio of aggressive lymphoma 23:1. Median follow‐up was in total 11.7 years: 10.0 years in the first study, GIT (GastroIntestinal‐Tract) 1992, and 11.8 years in the second study, GIT 1996. Lymphoma involvement was predominantly a single intestinal lesion (82.1%). Decrease of radiation field size from EF to IF in stage I aggressive iL from GIT 1992 to GIT 1996 resulted in a nonsignificant partial reduction of chronic toxicity while maintaining comparable survival rates (5‐year overall survival 87.9 vs. 86.7%, 10‐year overall survival 77.4 vs. 71.5%) with nonsignificant difference in event‐free survival (5‐year event‐free survival 82.6 vs. 86.7%, 10‐year event‐free survival 69.7 vs. 71.5%) and lymphoma‐specific survival (5‐year lymphoma‐specific survival 90.1 vs. 91.9%, 10‐year lymphoma‐specific survival 87.6% vs. 91.9%). Comparative dose calculation of two still available indolent duodenal lymphoma computed tomography scans revealed lower radiation exposure to normal tissues from applying current standard involved site RT (ISRT) 30 Gy in both cases.

Conclusion

RT adapted to stage, histology, and resection in multimodal treatment of iL, despite partially decreasing field size (EF to IF), achieves excellent local tumor control and survival rates. The use of modern RT technique and target volume with ISRT offers the option of further reduction of normal tissue complication probability.

Implications for Practice

Although patients with intestinal lymphoma (iL) are heterogeneous according to histology and subtype, they benefit from radiotherapy. Prospective study data from 134 patients with indolent iL (stage IE–IIE) or aggressive iL (stage IE–IVE) show 100% tumor control after definitive or adjuvant curative‐intent radiation therapy ± chemotherapy. Radiation treatment was applied between 1992 and 2003. Median follow‐up in total was 11.7 years. No radiotherapy‐associated death occurred. Relapse developed in 15.7% of the entire cohort; distant failure was more frequent than local (4:1). Normal tissue complication probability can be further improved using modern involved site radiation therapy techniques.

This article reports the details of radiation therapy in the therapeutic multimodality approach for treatment of patients with intestinal lymphoma.

miR-150 is a negative independent prognostic biomarker for primary gastrointestinal diffuse large B-cell lymphoma

A number of studies suggest an association between miRNAs and diffuse large B-cell lymphoma (DLBCL). The present study aimed to investigate the prognostic value of microRNA (miR-150) in primary gastrointestinal (PGI)-DLBCL, by assessing the association between miR-150 expression and clinicopathological characteristics in patients with PGI-DLBCL. A total of 84 patients diagnosed with PGI-DLBCL were recruited and both tumor and adjacent non-tumor tissue samples were collected. miR-150 expression was assessed via reverse transcription-quantitative (RT-q)PCR analysis. The results demonstrated that miR-150 expression was significantly lower in PGI-DLBCL tissues compared with adjacent non-tumor tissues. Furthermore, receiver operating characteristic (ROC) curve analysis indicated that the optimal cut-off value of miR-150 for predicting survival was 8.965 with high sensitivity (79.8%) and specificity (77.1%). Patients were divided into two groups according to this cut-off value, as follows: High (n=18) and low expression (n=66) groups. Low miR-150 expression was significantly associated with clinical stage, International Prognostic Index (IPI), Eastern Cooperative Oncology Group status and use of rituximab. RT-qPCR analysis demonstrated that miR-150 expression was significantly lower in patients with high IPI scores compared with patients with low IPI scores. Downregulated miR-150 expression was significantly associated with shorter overall survival (OS) time and progression-free survival (PFS) time in patients with PGI-DLBCL. Furthermore, miR-150 level and IPI score were identified as two risk factors for OS and PFS. The diagnostic value of miR-150 was evaluated via ROC curve analysis, with an area under the curve value of 0.882. Taken together, the results of the present study suggest that miR-150 is a potential diagnostic marker of PGI-DLBCL, and may also serve as a useful prognostic factor for survival outcomes in patients with PGI-DLBCL.

Clinicopathological Features, Treatment Strategy, and Prognosis of Primary Non-Hodgkin's Lymphoma of the Duodenum: A SEER Database Analysis

OBJECTIVE

Primary duodenum lymphoma (PDL) is extremely rare with limited data available in the literature. In this study, we sought to describe clinical features and identify factors affecting survival in patients with PDL using a large population cohort.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried from 1998 to 2015.

RESULTS

A total of 1060 cases of PDLs were identified. Clinicopathological features as well as survival data of PDLs were analyzed and compared with 10573 primary gastric lymphomas (PGLs) and 3239 primary small intestinal lymphomas (PSILs) from the SEER database. PDL patients were younger in age (60.96 ± 15.205), and the proportion of stage I (53.21%) was higher in Ann Arbor staging. The proportion of PDLs treated by surgery (8.68%) is the lowest among PDLs, PGLs, and PSILs. The DSS of PDLs were significantly better than those of PGLs and PSILs, respectively (10-year survival rate: 21.24% vs. 20.40%, P=0.027; 10-year survival rate: 21.24% vs. 16.79%, P=0.001). Age, gender, Ann Arbor staging, and histological type were regarded as independent prognostic factor for the DSS by multivariate analysis (all P < 0.05). Patients with <65 years, female, stage I, and FL were found to be significantly associated with good DSS. The treatment modality (surgery vs. conservative treatment) was not statistically related to DSS. The proportion of PDL patients who received surgical treatment gradually decreased from 15.60% in period 2 to 5.26% in period 4.

CONCLUSIONS

The clinicopathologic features of duodenal lymphoma were significantly different from those of gastric lymphoma and small intestinal lymphoma. The prognosis of PDLs was significantly better than those of the other two groups, and there was no statistical survival benefit from surgery in PDLs.