- Email: [email protected]
Endoscopic features of mantel cell lymphoma involving the gastrointestinal tract
*4247
*4249
ENDOSCOPIC FEATURES OF MANTEL CELL LYMPHOMA INVOLVING THE GASTROINTESTINAL TRACT Tonya L. Adams, Thian L. Tio, William Mayoral, James H. Lewis, Firas AlKawas, Anupamijit Mehrotra, Georgetown Univ Hosp, Washington, DC; Wyndham Wilson, Upendra Hegde, National Cancer Institute, Bethesda, MD; Elaine Jaffee, David Cassarino, National Inst of Health, Bethesda, MD Background: Mantel cell lymphoma (MCL) is an aggressive, lymphoproliferative disorder with poor responsiveness to conventional therapeutic regimens and median survival of 3 to 4 yrs. Extra-nodal involvement is common in advanced disease, and is reported to occur in the GI tract in 10% to 25% of cases. Early recognition of GI involvement may prove to be useful for staging and the development of anti-tumor vaccine protocols. The endoscopic appearance of these lesions has not been described. Aim: The aim of this study is to characterize the endoscopic findings of MCL involving the GI tract. Methods: We retrospectively reviewed the results of EGD and colonoscopy performed on symptomatic pts with MCL referred to Georgetown Univ Hosp and the NIH over the past eleven years. 18 pts were identified from endoscopy and surgical pathology reports. Subjects included 15 men and 3 females with a mean age of 62 yrs. At the time of endoscopy 17 pts (94%) had established diagnoses of advanced MCL. 50% of pts had received prior conventional chemotherapy. Results: Abd pain (44%) was the most common presenting sx, followed by diarrhea (27%), heme positive stools (11%), hematochezia (11%) and dyspepsia (5%). Mesenteric lymphadenopathy (67%) was the most common CT finding. Retroperitoneal (16%), periaortie (5%), and inguinal (5%) lymphadenopatby and nonspecific colonic thickening (5%) comprised the remaining abd CT findings. The colon and rectum were most frequently involved, with reports of esophageal, gastric and small bowel involvement occurring less commonly. Endoscopy demonstrated submucosal nodularity (66%) and masses with ulceration (16%) or polypoid (11%) appearance. In all cases the submucosal nodularity was irregular, diffuse and patchy in distribution. Ulcerated masses were 2-5 cms in size and all were friable with central depressions. Polypoid masses ranged in size between 0.5 cm and 4 cms. Polyps were often multiple, soft, friable and characterized by a mushroom appearance. Conclusions: 1- Advanced MCL most often involves the colon and rectum, and less commonly, the upper GI tract. 2- Typical endoscopic features include submucosal nodularity and polypoid or ulcerated mass lesions. 3- Early recognition of these lesions may help define prognosis and therapeutic strategies for treatment of MCL.
P R O S P E C T I V E STUDY OF DELAYED POST-POLYPECTOMY B L E E D I N G COMPARED TO O T H E R CAUSES OF S E V E R E HEMATOCHEZIA Dennis M. Jensen, Thomas Og Kovacs, Rome Jutabha, UCLA Sch of Medicine, Los Angeles, CA; Ian M. Gralnek, VA Greater Los Angeles Healthcare Ctr, Los Angeles, CA; Gareth S. Dulal, Gustavo A. Machicado, UCLA Sch of Medicine, Los Angeles, CA Severe hematochezia is a common reason for hospitalization but the causes have changed in the last decade. Our purposes were: 1) to compare demographics of patients with delayed post-polypectomy bleeding (PP bleed) vs. other causes of severe hematochezia & 2) to describe colonoscopic stigmata of hemorrhage, techniques of endoscopic treatment, & outcomes of PP bleed pts. Methods: All patients admitted to our two hospitals (a University & VA) with a principle diagnosis of severe hematochezia were prospectively evaluated by a research coordinator & most by a Hemostasis Group MD. Oral purges were utilized for colon preparation after resuscitation & patients had colonoscopy within 8 hours. Data were prospectively collected until discharge & data management was with SAS. For 201 pts in the last 5 years, 6.0% had PP bleeds as the cause of severe hematochezia. Results: See table. Index polyps of 12 PP bleed pts were peduculated for 5 & sessile for 7; median diameter was 20 mm (range 10-40); 5 were adenomas, 3 tubulovillous, 2 villous, & 2 CA's. 2* hemorrhage occurred a median of 9 days (range 1-73) after initial polypectomy. At F/U colonoscopy, ulcers (mean size 11+1.9 mm) were found in all patients & stigmata (% and #) were: active bleeding 33.3% (4), non-bleeding visible vessel 25% (3), clot 33.3% (4), & spot 9.1% (1). Two pts were treated with heater probe±epinephrine (& 1 perforated), 5 pts with Gold probe (GP) alone (1 rebled), & 4 with injection-GP (no rebleeds or complications). Three pts had surgery (2 CA's, 1 perforation). Conclusions: For patients hospitalized with severe hematochezia: 1) 6% had bleeds from ulcers @ previous polypectomies, a median of 9 days earlier, 2) coagnlopathies from ASA &/or coumadin (in 83%) were more prevalent in PP bleed pts than in other causes of hematochezia, 3) major stigmata of hemorrhage in ulcers were seen & treated via colonoscopy in 92% of post-polypectomy patients, & 4) Within the limitations of small numbers, higher rates of perforation with heater probe & of rebleeding with Gold Probe alone were seen than with injection+GP. Partial funding from NIH 1K24-DK02650 & DK41301. N
Mean Age
% Males
ASA before
Mean URBC
Endo Rx
Other Rx
12 189
69-1:2.9 64+1.1
92%* 61%
75%" 33%
2 0-+06 2.5_+0.2
92%° 23%
• p < 025
*3 on cournadin
Post-Polyp*
*4248
NEW DETECTION METHOD F O R SUBMUCOSAL INVASIVE COLORECTAL CANCER USING MAGNIFYING ENDOSCOPY Shun-Ichi Hayaslii, Saiseikai Niigata Hosp, Niigata Japan; Yoichi Ajioka, Yutaka Suzuki, Niigata Univ Sch of Medicine, Niigata Japan; Yasuyuki Baba, Hironobu Ohta, Toshiaki Yoshida, Tomoteru Kaminmra, Noriko Ishihara, Yasuo Sakai, Saiseikai Niigata Hosp, Niigata Japan; Masaaki Kobayashi, Terasu Honma, Hitoshi Asakura, Niigata Univ Sch of Medicine, Niigata Japan Background: The volume of submucosal invasion should be carefully evaluated before treatment for early colorectal cancers, because the greater the invasion of cancer, the more frequent the occurrence of vascular permeation and lymph node metastasis. Our previously reported data indicates that when cancers invade more than 1000 pm in vertical length from the muscularis mucosae, the incidence of lymph node metastasis increases up to 20%, which is a markedly higher value than the 0% incidence for cancers invading less than 1000 ~tm. Consequently, it is of paramount clinical importance to detect the cancers invading more than 1000 pm because these cancers have been confirmed as a contraindication of endoscopic removal. Aim: To clarify the effectiveness of the detection method for cancers invading more than 1000 pm in vertical length using magnifying endoscopy. Methods: 31 submucosal invasive cancers (sm cancers), 18 mucosal cancers and 35 adenomas were investigated. The surface of these lesions were stained with 0.02% crystal violet and examined using a magnifying endoscope (Olympus 240Z). Staining patterns were classified into one of 3 types: homogenous (HP), speckled (SP) or fine speckled (FSP) patterns. Correlation between staining patterns and histological findings were investigated. Statistical significance was determined by the chi-square test. Results: Adenomas and mucosal cancers showed an HP staining, whereas only 57% of sm cancerous lesions had HP, with 83% of those that had a SP and 100% of those with an FSP having invaded more than the 1000 pm (p=0.027). Furthermore, 86% of HP lesions had a preserved covering epithelium while none of the SP or FSP lesions did (p<0.0001). Desmoplasia in the superficial layer was detected in 14% of HP lesions, 33% of SP and 80% of FS lesions (p=0.008). Conclusions: There was a close correlation between staining pattern and histological findings. Magnifying endoscopic findings of SP and FSP lesions were a valuable marker of the contraindication of endoscopic tumor removal.
AB182
GASTROINTESTINAL ENDOSCOPY
*4250
THE DIAGNOSTIC VALUE OF COLONOSCOPY AND ANALYSIS OF PATHOGENS USING BIOPSY SPECIMEN AND INTRALUMINAL FLUID IN ACUTE INFECTIOUS COLITIS Ka Eun Woo, Sung Ae Jung, Misson Ju, Young-Sun Kim, Jeong-Eun Shin, Sun Young Yi, Kwon Yoo, I1-Hwan Moon, Ewha Womans Univ Coll of Medicine, Seoul South Korea AIMS: The Aim of this study was to investigate the value of eolonoscopy for the assessment of location, extent and character of colonic mueosal lesions and for culture of biopsy specimen and intraluminal fluid during colonoscopy in the patients with acute diarrhea. METHODS: From March 2000 to July 2000, forty-one patients with watery or bloody diarrhea lasting less than 15 days were included among the sixty patients after exclusion of the patients with previous history or presumption of inflammatory bowel disease, HIV infection, radiation colitis, ischemie colitis, or pseudomembranous colitis. The biopsy specimen was taken from the most severely inflamed mucosal areas, and luminal fluid was aspirated during the colonoscopy for bacterial cultures. RESULTS: Among 41 patients, male and female ratio was 22:19 and mean age was 45±20 years (range, 16-88 years). Abdominal pain was the most frequently associated symptom (75.6%) and possible causative foods were meat (24.4%), vegetables (14.6%), and fishes (9.8%). Pancolitis was the most common finding (68.3%), and the localized lesion of ascending, descending, and transverse colon were 12.2%, 4.9%, and 2.4%, respectively. The colonoscopic finding was grossly normal in five cases (12.2%). The erythemateus swollen mucosa was the most frequent finding (87.8%), and hemorrhage or ulcers were seen in 22 cases (53.7%). In culture study, identification of the pathogen was possible in 14 cases (34.1%), and the most common pathogen was Salmonella species (14.6%) and Acinetebacter calcoaceticus-baumannii complex (14.6%). The pathogen was identified by culture in 11.1% with stool, 50.5% with biopsy specimen, and 50.5% with intraluminal fluid (p<0.05, vs. stool}. The identification of the pathogen was more likely when the involved mucosa showed hemorrhage or ulcers. There was no complication associated with colonoscopy. CONCLUSIONS: These findings suggest that specimen obtained during colonoscopy may be helpful to identify the pathogen and the severity of colitis may be suggested by colonoscopic finding. We conclude that colonoscopy can be a useful and safe method for the diagnosis of acute infectious colitis.
VOLUME 53. NO. 5. 2001
*4249
ENDOSCOPIC FEATURES OF MANTEL CELL LYMPHOMA INVOLVING THE GASTROINTESTINAL TRACT Tonya L. Adams, Thian L. Tio, William Mayoral, James H. Lewis, Firas AlKawas, Anupamijit Mehrotra, Georgetown Univ Hosp, Washington, DC; Wyndham Wilson, Upendra Hegde, National Cancer Institute, Bethesda, MD; Elaine Jaffee, David Cassarino, National Inst of Health, Bethesda, MD Background: Mantel cell lymphoma (MCL) is an aggressive, lymphoproliferative disorder with poor responsiveness to conventional therapeutic regimens and median survival of 3 to 4 yrs. Extra-nodal involvement is common in advanced disease, and is reported to occur in the GI tract in 10% to 25% of cases. Early recognition of GI involvement may prove to be useful for staging and the development of anti-tumor vaccine protocols. The endoscopic appearance of these lesions has not been described. Aim: The aim of this study is to characterize the endoscopic findings of MCL involving the GI tract. Methods: We retrospectively reviewed the results of EGD and colonoscopy performed on symptomatic pts with MCL referred to Georgetown Univ Hosp and the NIH over the past eleven years. 18 pts were identified from endoscopy and surgical pathology reports. Subjects included 15 men and 3 females with a mean age of 62 yrs. At the time of endoscopy 17 pts (94%) had established diagnoses of advanced MCL. 50% of pts had received prior conventional chemotherapy. Results: Abd pain (44%) was the most common presenting sx, followed by diarrhea (27%), heme positive stools (11%), hematochezia (11%) and dyspepsia (5%). Mesenteric lymphadenopathy (67%) was the most common CT finding. Retroperitoneal (16%), periaortie (5%), and inguinal (5%) lymphadenopatby and nonspecific colonic thickening (5%) comprised the remaining abd CT findings. The colon and rectum were most frequently involved, with reports of esophageal, gastric and small bowel involvement occurring less commonly. Endoscopy demonstrated submucosal nodularity (66%) and masses with ulceration (16%) or polypoid (11%) appearance. In all cases the submucosal nodularity was irregular, diffuse and patchy in distribution. Ulcerated masses were 2-5 cms in size and all were friable with central depressions. Polypoid masses ranged in size between 0.5 cm and 4 cms. Polyps were often multiple, soft, friable and characterized by a mushroom appearance. Conclusions: 1- Advanced MCL most often involves the colon and rectum, and less commonly, the upper GI tract. 2- Typical endoscopic features include submucosal nodularity and polypoid or ulcerated mass lesions. 3- Early recognition of these lesions may help define prognosis and therapeutic strategies for treatment of MCL.
P R O S P E C T I V E STUDY OF DELAYED POST-POLYPECTOMY B L E E D I N G COMPARED TO O T H E R CAUSES OF S E V E R E HEMATOCHEZIA Dennis M. Jensen, Thomas Og Kovacs, Rome Jutabha, UCLA Sch of Medicine, Los Angeles, CA; Ian M. Gralnek, VA Greater Los Angeles Healthcare Ctr, Los Angeles, CA; Gareth S. Dulal, Gustavo A. Machicado, UCLA Sch of Medicine, Los Angeles, CA Severe hematochezia is a common reason for hospitalization but the causes have changed in the last decade. Our purposes were: 1) to compare demographics of patients with delayed post-polypectomy bleeding (PP bleed) vs. other causes of severe hematochezia & 2) to describe colonoscopic stigmata of hemorrhage, techniques of endoscopic treatment, & outcomes of PP bleed pts. Methods: All patients admitted to our two hospitals (a University & VA) with a principle diagnosis of severe hematochezia were prospectively evaluated by a research coordinator & most by a Hemostasis Group MD. Oral purges were utilized for colon preparation after resuscitation & patients had colonoscopy within 8 hours. Data were prospectively collected until discharge & data management was with SAS. For 201 pts in the last 5 years, 6.0% had PP bleeds as the cause of severe hematochezia. Results: See table. Index polyps of 12 PP bleed pts were peduculated for 5 & sessile for 7; median diameter was 20 mm (range 10-40); 5 were adenomas, 3 tubulovillous, 2 villous, & 2 CA's. 2* hemorrhage occurred a median of 9 days (range 1-73) after initial polypectomy. At F/U colonoscopy, ulcers (mean size 11+1.9 mm) were found in all patients & stigmata (% and #) were: active bleeding 33.3% (4), non-bleeding visible vessel 25% (3), clot 33.3% (4), & spot 9.1% (1). Two pts were treated with heater probe±epinephrine (& 1 perforated), 5 pts with Gold probe (GP) alone (1 rebled), & 4 with injection-GP (no rebleeds or complications). Three pts had surgery (2 CA's, 1 perforation). Conclusions: For patients hospitalized with severe hematochezia: 1) 6% had bleeds from ulcers @ previous polypectomies, a median of 9 days earlier, 2) coagnlopathies from ASA &/or coumadin (in 83%) were more prevalent in PP bleed pts than in other causes of hematochezia, 3) major stigmata of hemorrhage in ulcers were seen & treated via colonoscopy in 92% of post-polypectomy patients, & 4) Within the limitations of small numbers, higher rates of perforation with heater probe & of rebleeding with Gold Probe alone were seen than with injection+GP. Partial funding from NIH 1K24-DK02650 & DK41301. N
Mean Age
% Males
ASA before
Mean URBC
Endo Rx
Other Rx
12 189
69-1:2.9 64+1.1
92%* 61%
75%" 33%
2 0-+06 2.5_+0.2
92%° 23%
• p < 025
*3 on cournadin
Post-Polyp*
*4248
NEW DETECTION METHOD F O R SUBMUCOSAL INVASIVE COLORECTAL CANCER USING MAGNIFYING ENDOSCOPY Shun-Ichi Hayaslii, Saiseikai Niigata Hosp, Niigata Japan; Yoichi Ajioka, Yutaka Suzuki, Niigata Univ Sch of Medicine, Niigata Japan; Yasuyuki Baba, Hironobu Ohta, Toshiaki Yoshida, Tomoteru Kaminmra, Noriko Ishihara, Yasuo Sakai, Saiseikai Niigata Hosp, Niigata Japan; Masaaki Kobayashi, Terasu Honma, Hitoshi Asakura, Niigata Univ Sch of Medicine, Niigata Japan Background: The volume of submucosal invasion should be carefully evaluated before treatment for early colorectal cancers, because the greater the invasion of cancer, the more frequent the occurrence of vascular permeation and lymph node metastasis. Our previously reported data indicates that when cancers invade more than 1000 pm in vertical length from the muscularis mucosae, the incidence of lymph node metastasis increases up to 20%, which is a markedly higher value than the 0% incidence for cancers invading less than 1000 ~tm. Consequently, it is of paramount clinical importance to detect the cancers invading more than 1000 pm because these cancers have been confirmed as a contraindication of endoscopic removal. Aim: To clarify the effectiveness of the detection method for cancers invading more than 1000 pm in vertical length using magnifying endoscopy. Methods: 31 submucosal invasive cancers (sm cancers), 18 mucosal cancers and 35 adenomas were investigated. The surface of these lesions were stained with 0.02% crystal violet and examined using a magnifying endoscope (Olympus 240Z). Staining patterns were classified into one of 3 types: homogenous (HP), speckled (SP) or fine speckled (FSP) patterns. Correlation between staining patterns and histological findings were investigated. Statistical significance was determined by the chi-square test. Results: Adenomas and mucosal cancers showed an HP staining, whereas only 57% of sm cancerous lesions had HP, with 83% of those that had a SP and 100% of those with an FSP having invaded more than the 1000 pm (p=0.027). Furthermore, 86% of HP lesions had a preserved covering epithelium while none of the SP or FSP lesions did (p<0.0001). Desmoplasia in the superficial layer was detected in 14% of HP lesions, 33% of SP and 80% of FS lesions (p=0.008). Conclusions: There was a close correlation between staining pattern and histological findings. Magnifying endoscopic findings of SP and FSP lesions were a valuable marker of the contraindication of endoscopic tumor removal.
AB182
GASTROINTESTINAL ENDOSCOPY
*4250
THE DIAGNOSTIC VALUE OF COLONOSCOPY AND ANALYSIS OF PATHOGENS USING BIOPSY SPECIMEN AND INTRALUMINAL FLUID IN ACUTE INFECTIOUS COLITIS Ka Eun Woo, Sung Ae Jung, Misson Ju, Young-Sun Kim, Jeong-Eun Shin, Sun Young Yi, Kwon Yoo, I1-Hwan Moon, Ewha Womans Univ Coll of Medicine, Seoul South Korea AIMS: The Aim of this study was to investigate the value of eolonoscopy for the assessment of location, extent and character of colonic mueosal lesions and for culture of biopsy specimen and intraluminal fluid during colonoscopy in the patients with acute diarrhea. METHODS: From March 2000 to July 2000, forty-one patients with watery or bloody diarrhea lasting less than 15 days were included among the sixty patients after exclusion of the patients with previous history or presumption of inflammatory bowel disease, HIV infection, radiation colitis, ischemie colitis, or pseudomembranous colitis. The biopsy specimen was taken from the most severely inflamed mucosal areas, and luminal fluid was aspirated during the colonoscopy for bacterial cultures. RESULTS: Among 41 patients, male and female ratio was 22:19 and mean age was 45±20 years (range, 16-88 years). Abdominal pain was the most frequently associated symptom (75.6%) and possible causative foods were meat (24.4%), vegetables (14.6%), and fishes (9.8%). Pancolitis was the most common finding (68.3%), and the localized lesion of ascending, descending, and transverse colon were 12.2%, 4.9%, and 2.4%, respectively. The colonoscopic finding was grossly normal in five cases (12.2%). The erythemateus swollen mucosa was the most frequent finding (87.8%), and hemorrhage or ulcers were seen in 22 cases (53.7%). In culture study, identification of the pathogen was possible in 14 cases (34.1%), and the most common pathogen was Salmonella species (14.6%) and Acinetebacter calcoaceticus-baumannii complex (14.6%). The pathogen was identified by culture in 11.1% with stool, 50.5% with biopsy specimen, and 50.5% with intraluminal fluid (p<0.05, vs. stool}. The identification of the pathogen was more likely when the involved mucosa showed hemorrhage or ulcers. There was no complication associated with colonoscopy. CONCLUSIONS: These findings suggest that specimen obtained during colonoscopy may be helpful to identify the pathogen and the severity of colitis may be suggested by colonoscopic finding. We conclude that colonoscopy can be a useful and safe method for the diagnosis of acute infectious colitis.
VOLUME 53. NO. 5. 2001