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An Unusually Located Colonic Mass
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI An Unusually Located Colonic Mass Joseph Geffen,1 Kaitlin McCurdy,1 and Emely Eid2 Department of Internal Medicine, and 2Division of Gastroenterology, University of Florida College of Medicine – Jacksonville, Jacksonville, Florida 1
Question: A 71year-old man presented to the emergency department with episodic bright red blood per rectum. He reported that these episodes occur for 15-20 minutes per day for 1- to 2week periods and usually resolve spontaneously, but that when he bleeds, he has to wear pads or toilet paper to avoid soiling his clothing with blood. These episodes have been occurring for months. He denies any alleviating or exacerbating factors, and denies any pain associated with his bleeding. His past medical history includes diagnoses of rheumatoid arthritis, external hemorrhoids, tubular adenomatous polyps, permanent atrial fibrillation on Coumadin, diabetes mellitus type 2, hypertension, and coronary artery disease. The gastroenterology service was consulted in light of his hematochezia. A colonoscopy was performed that demonstrated nonbleeding internal hemorrhoids and multiple diverticula in the sigmoid, transverse, and ascending colon that were thought to be the source of the patient’s bleeding. Incidentally, a cecal sessile polyp measuring 4 mm was found and retrieved, 4 sessile polyps measuring 3-4 mm were identified and retrieved within the descending colon, and one 5-mm polyp in the sigmoid colon was resected. One polyp from the descending colon and the (Figure A) sigmoid colon polyp were investigated microscopically and immunohistochemically by pathology. Microscopic examination demonstrated predominately small to (Figure B) medium monocytoid lymphocytes that (Figure C) stained positive for CD20 (Figure D) and bcl-2, but were negative for CD10, bcl-6, cyclin D-1, CD3, and CD43. The patient was tested for Helicobacter pylori infection with a stool assay, which was negative. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2016 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2016.04.012
Gastroenterology 2016;151:e11–e12
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to: Image 4: Extranodal Marginal Zone Lymphoma of Mucosa-associated Lymphoid Tissue Mucosa-associated lymphoid tissue (MALT) lymphomas are a type of extranodal non-Hodgkin lymphomas that rarely arise in the gastrointestinal tract,2 and are usually diffuse large B-cell lymphomas. When they do occur in this organ system, however, they are usually found within the stomach or the small bowel. Rarely do they present in the colon, although case studies have suggested that, when they do occur, they typically arise in the rectosigmoid segment as opposed to the transverse or ascending colon. They are usually found incidentally while investigating other gastrointestinal complaints. At least 1 study has suggested that the incidence rate of primary gastrointestinal non-Hodgkin lymphoma may be rising in North America, from 0.25 to 0.45 per 100,000 people between 2000 and 2008, although these changes may also reflect improving diagnostic technology.2 In that study, more than half MALT lymphomas were found in the stomach, whereas only 10%-20% of cases were found in the small bowel or colon. In a review of several case studies of MALT lymphoma, Akasaka et al1 noted that, when found endoscopically, these lesions are typically polypoid lesions that can occur solitarily or in groups, and can be associated with nearby vascular abnormalities. However, they can also occur as flat lesions,3 in which case chromoendoscopy may be helpful in identifying the lesions. Immunohistochemical analysis will generally show centrocyte-like cells expressing positivity for CD19, CD20, CD70, but not CD5, CD10, CD23, or cyclin D1.1 Several comorbidities have been suggested as potential etiologies for MALT lymphomas, most notably H pylori infection. However, although this may be true of gastric MALT lymphomas, this may not be true of lymphomas found in the colon.1,2 Other bacteria with which these lymphomas may be associated include Borrelia afzelii, Campylobacter jejuni, Chlamydia psittaci, and various Mycobacteria.3 Additionally, MALT lymphomas may be associated with genetic aberrancies including multiple translocations and trisomy 3, or several autoimmune conditions including rheumatoid arthritis, Hashimoto thyroiditis, systemic lupus erythematosis, and others.3 The workup typically involves endoscopic ultrasonography to assess tumor depth, and positron emission or computed tomography scanning to complete staging. No clear treatment has been identified for extranodal marginal cell lymphomas of the colon. Treatments used in case studies have included surgical resection, radiation, and chemotherapy with rituximab or chlorambucil.2
References 1. 2. 3.
e12
Akasaka R, Chiba T, Dutta AK, et al. Colonic mucosa-associated lymphoid tissue lymphoma. Case Rep Gastroenterol 2012;6:569–575. Ramavaram S, Velchala N, Levy R, et al. Malt lymphoma of the colon: a rare occurrence. J Gastrointest Cancer 2014;45 Suppl 1:29–32. Seo SW, Lee SH, Lee DJ, et al. Colonic mucosa-associated lymphoid tissue lymphoma identified by chromoendoscopy. World J Gastroenterol 2014;20:18487–18494.
Question: A 71year-old man presented to the emergency department with episodic bright red blood per rectum. He reported that these episodes occur for 15-20 minutes per day for 1- to 2week periods and usually resolve spontaneously, but that when he bleeds, he has to wear pads or toilet paper to avoid soiling his clothing with blood. These episodes have been occurring for months. He denies any alleviating or exacerbating factors, and denies any pain associated with his bleeding. His past medical history includes diagnoses of rheumatoid arthritis, external hemorrhoids, tubular adenomatous polyps, permanent atrial fibrillation on Coumadin, diabetes mellitus type 2, hypertension, and coronary artery disease. The gastroenterology service was consulted in light of his hematochezia. A colonoscopy was performed that demonstrated nonbleeding internal hemorrhoids and multiple diverticula in the sigmoid, transverse, and ascending colon that were thought to be the source of the patient’s bleeding. Incidentally, a cecal sessile polyp measuring 4 mm was found and retrieved, 4 sessile polyps measuring 3-4 mm were identified and retrieved within the descending colon, and one 5-mm polyp in the sigmoid colon was resected. One polyp from the descending colon and the (Figure A) sigmoid colon polyp were investigated microscopically and immunohistochemically by pathology. Microscopic examination demonstrated predominately small to (Figure B) medium monocytoid lymphocytes that (Figure C) stained positive for CD20 (Figure D) and bcl-2, but were negative for CD10, bcl-6, cyclin D-1, CD3, and CD43. The patient was tested for Helicobacter pylori infection with a stool assay, which was negative. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2016 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2016.04.012
Gastroenterology 2016;151:e11–e12
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to: Image 4: Extranodal Marginal Zone Lymphoma of Mucosa-associated Lymphoid Tissue Mucosa-associated lymphoid tissue (MALT) lymphomas are a type of extranodal non-Hodgkin lymphomas that rarely arise in the gastrointestinal tract,2 and are usually diffuse large B-cell lymphomas. When they do occur in this organ system, however, they are usually found within the stomach or the small bowel. Rarely do they present in the colon, although case studies have suggested that, when they do occur, they typically arise in the rectosigmoid segment as opposed to the transverse or ascending colon. They are usually found incidentally while investigating other gastrointestinal complaints. At least 1 study has suggested that the incidence rate of primary gastrointestinal non-Hodgkin lymphoma may be rising in North America, from 0.25 to 0.45 per 100,000 people between 2000 and 2008, although these changes may also reflect improving diagnostic technology.2 In that study, more than half MALT lymphomas were found in the stomach, whereas only 10%-20% of cases were found in the small bowel or colon. In a review of several case studies of MALT lymphoma, Akasaka et al1 noted that, when found endoscopically, these lesions are typically polypoid lesions that can occur solitarily or in groups, and can be associated with nearby vascular abnormalities. However, they can also occur as flat lesions,3 in which case chromoendoscopy may be helpful in identifying the lesions. Immunohistochemical analysis will generally show centrocyte-like cells expressing positivity for CD19, CD20, CD70, but not CD5, CD10, CD23, or cyclin D1.1 Several comorbidities have been suggested as potential etiologies for MALT lymphomas, most notably H pylori infection. However, although this may be true of gastric MALT lymphomas, this may not be true of lymphomas found in the colon.1,2 Other bacteria with which these lymphomas may be associated include Borrelia afzelii, Campylobacter jejuni, Chlamydia psittaci, and various Mycobacteria.3 Additionally, MALT lymphomas may be associated with genetic aberrancies including multiple translocations and trisomy 3, or several autoimmune conditions including rheumatoid arthritis, Hashimoto thyroiditis, systemic lupus erythematosis, and others.3 The workup typically involves endoscopic ultrasonography to assess tumor depth, and positron emission or computed tomography scanning to complete staging. No clear treatment has been identified for extranodal marginal cell lymphomas of the colon. Treatments used in case studies have included surgical resection, radiation, and chemotherapy with rituximab or chlorambucil.2
References 1. 2. 3.
e12
Akasaka R, Chiba T, Dutta AK, et al. Colonic mucosa-associated lymphoid tissue lymphoma. Case Rep Gastroenterol 2012;6:569–575. Ramavaram S, Velchala N, Levy R, et al. Malt lymphoma of the colon: a rare occurrence. J Gastrointest Cancer 2014;45 Suppl 1:29–32. Seo SW, Lee SH, Lee DJ, et al. Colonic mucosa-associated lymphoid tissue lymphoma identified by chromoendoscopy. World J Gastroenterol 2014;20:18487–18494.