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CASE REPORT  
Year : 2021  |  Volume : 64  |  Issue : 5  |  Page : 92-94
Multifocal colorectal non-Hodgkin's lymphoma in a patient with ulcerative colitis: A case report


1 Institute of Liver, Gastroenterology, and Panceatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Pathology, Sir Ganga Ram Hospital, New Delhi, India

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Date of Submission21-Aug-2019
Date of Decision19-Nov-2019
Date of Acceptance27-Nov-2019
Date of Web Publication7-Jun-2021
 

   Abstract 


A case of multifocal non-Hodgkin's (Diffuse large B cell type) lymphoma of colon in a patient with ulcerative colitis is described. The patient was a 69-year old male treated with azathioprine and methotrexate for ulcerative colitis for 2 years. He was admitted with loose stools and hematochezia. Colonoscopy revealed two deep ulcers in ascending colon and a large ulcer in rectum. Biopsy from both the sites revealed atypical large lymphoid cells, which were CD20 positive. A whole body PET-CT scan showed disease localized to colon with bone marrow examination showing no evidence of lymphoma. The patient was given chemotherapy cycles and recovered well.

Keywords: Cancer, colorectal carcinoma, inflammatory bowel disease, lymphoma

How to cite this article:
Walinjkar S, Kumar A, Sharma P, Gupta P, Bansal N, Singla V, Anikhindi SA, Arora A. Multifocal colorectal non-Hodgkin's lymphoma in a patient with ulcerative colitis: A case report. Indian J Pathol Microbiol 2021;64:92-4

How to cite this URL:
Walinjkar S, Kumar A, Sharma P, Gupta P, Bansal N, Singla V, Anikhindi SA, Arora A. Multifocal colorectal non-Hodgkin's lymphoma in a patient with ulcerative colitis: A case report. Indian J Pathol Microbiol [serial online] 2021 [cited 2021 Jun 13];64:92-4. Available from: https://www.ijpmonline.org/text.asp?2021/64/5/92/317918





   Introduction Top


Primary extra-nodal lymphomas of gastrointestinal tract are a rare entity. Lymphomas account only for 0.2-0.6% of large bowel malignancies.[1] Most patients with non-Hodgkin's lymphoma are associated with immunodeficiency state. Lymphoma can also arise in patients on long-term immunosuppressant agents (e.g., patients receiving organ transplants). In this case report, a rare case of primary colorectal non-Hodgkin's lymphoma developing in a patient with ulcerative colitis is presented.


   Case Presentation Top


A 69-year male, a known case of ulcerative colitis for 2 years, presented with loose stools 10-12 episodes per day along with passage of blood for 45 days. His primary physician diagnosed him as left-sided ulcerative colitis 2 years ago when he had developed bloody diarrhea. He was initially started on corticosteroids that were tapered gradually and were stopped. He was given maintenance therapy with Azathioprine and Methotrexate. With these medications, he had no exacerbations in last 2 years. Recent colonoscopy, done 3 months ago, showed disease under remission. The physical examination of the patient was unremarkable. His routine hematological and biochemical investigations were normal. CRP was negative. Colonoscopy was done which showed 2 deep ulcers in ascending colon and a large deep ulcer with everted and indurated margins in the rectum [Figure 1]. The intervening mucosa was normal. Biopsies were taken from these ulcers and sent for histopathological examination, PCR for tuberculosis (TB) and CMV IHC.
Figure 1: Colonoscopy images showing ulcers in ascending colon (a) and a large rectal ulcer with everted margins (b)

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Colonic ulcer biopsy showed few atypical cells infiltrating lamina propria with scanty cytoplasm with oval nucleus and small nucleoli and lymphoepithelial lesion. Rectosigmoid biopsy [Figure 2] showed mucosal ulceration with moderate dense infiltrate of atypical lymphoid cells. Neoplastic cells infiltration in muscularis mucosa. Immunohistochemistry showed atypical large lymphoid cells in both rectal and colonic ulcer were positive for CD20 and negative for CD3 with Ki-67 proliferation index of 80-90%, compatible with NHL (Diffuse large B cell). The TB-PCR and CMV-IHC were negative.
Figure 2: Histopathology images: (a) Atypical lymphoid cells infiltrating lamina propria; (b) High Resolution view showing atypical cells in lamina propria; (c) Cells with scanty cytoplasm, oval nucleus and small nucleoli and lymphoepithelial lesion; and (d) Lymphoid cells positive for CD20 marker

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Imaging studies were done for systemic involvement of lymphoma. CECT abdomen showed concentric irregular, polyploidal wall thickening in the rectosigmoid colon with peri-colonic stranding and sub centimeter lymphadenopathy. Whole body PET-CT scan [Figure 3] showed FDG avid circumferential mural thickening of maximum 1.4 cm with mass formation in rectosigmoid colon approximately 6 cm from anal verge. It also showed peri-lesional sub-centimeter mildly FDG avid para-rectal lymph nodes. Bone marrow study was done for its involvement which showed cellular marrow with normoblastic erythropoiesis and normal myeloid and lymphoid series with no morphological evidence of lymphoma in bone marrow.
Figure 3: PET scan showing FDG avid lesion in the rectum in axial section (a) and sagittal section (b)

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The patient was given chemotherapy cycles after which the symptoms subsided and had a satisfactory recovery.


   Discussion Top


Patients with ulcerative colitis are prone to increased risk of developing colorectal adenocarcinoma, annual incidence rates being elevated by around 30% as compared to patients without inflammatory bowel disease.[2] Gastrointestinal (GI) tract is the most common extra-nodal site of non-Hodgkin's lymphoma,[3] stomach being most common site followed by small intestine. Colorectal lymphomas comprise only 10%-20% of primary GI lymphomas.[4],[5] Cornes et al. suggested a significant relationship between repeated episodes of lymphoid hyperplasia seen in healing phases of ulcerative colitis and eventual development of NHL.[6] The autoimmune nature of IBD has been implicated in development of lymphoma as a result of prolonged stimulation of mucosa associated lymphoid tissue.[7] The incidence of non-Hodgkin's lymphoma (NHL) in transplant patients requiring immunosuppressive therapy is 40-100 times greater than in general population.[8] Thus, the increasing use of immunosuppressive agents in patients with ulcerative colitis have raised similar worries. Although the association of colorectal cancer and IBD, particularly ulcerative colitis is well established, the association between IBD and NHL is not clearly known as there are very few studies to clarify this association. However, it is generally accepted that there is an increased risk of NHL in IBD patients receiving immunosuppressive agents.[9],[10] A study done by RJ Farrell et al. showed increased incidence and risk of NHL in inflammatory bowel disease patients on immunosuppressive therapy.[11] In a study done by Kinlen that included 1634 patients, 634 patients with rheumatoid arthritis and 321 with IBD. Out of these, 1109 patients receiving azathioprine had 11-fold increased risk of NHL.[12] The diagnosis of colonic non-Hodgkin's lymphoma should be suspected in patients with ulcerative colitis on long term immunosuppressant therapy having deep ulcerations in colon, presenting with acute exacerbation like presentation. Our patient was on azathioprine and methotrexate for around 2 years and presented to us with similar picture and was initially suspected to have CMV colitis due to large colonic ulcerations, however was subsequently diagnosed with colonic non-Hodgkin's lymphoma of diffuse large B cell type.

In conclusion, patients with inflammatory bowel disease on imuunosuppresive agents such as azathioprine and methotrexate for many years are prone to develop lymphoid malignancies. Special attention is warranted in such patient when they present after long period of clinical remission, as there is an increased risk of lymphoproliferative disorder. Although the period of immunosuppressant therapy was relatively less in our patient for development of lymphoma, it can develop in any patient with ulcerative colitis due to disease activity per se. Vigilance is hence required in such patients as lymphoma is a potentially treatable malignancy. Also, methotrexate is not efficacious in ulcerative colitis, and hence should be avoided.

Abbreviations

NHL: non-Hodgkin lymphoma; PET-CT: positron emission tomography-computed tomography; IBD: inflammatory bowel disease; FDG: fluorodeoxy glucose.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Wong MT, Eu KW. Primary colorectal lymphomas. Colorectal Dis 2006;8:586-91.  Back to cited text no. 1
    
2.
Herrinton LJ, Liu L, Levin TR, Allison JE, Lewis JD, Velayos F. Incidence and mortality of colorectal adenocarcinoma in persons with inflammatory bowel disease from 1998 to 2010. Gastroenterology 2012;143:382-9.  Back to cited text no. 2
    
3.
Freeman C, Berg JW, Cutler SJ. Occurrence and prognosis of extranodal lymphomas. Cancer 1972;29:252-60.  Back to cited text no. 3
    
4.
Loehr WJ, Mujahed Z, Zahn FD, Gray GF, Thorbjarnarson B. Primary lymphoma of the gastrointestinal tract: A review of 100 cases. Ann Surg 1969;170:232-8.  Back to cited text no. 4
    
5.
Dragosics B, Bauer P, Radaszkiewicz T. Primary gastrointestinal non-Hodgkin's lymphomas. A retrospective clinicopathologic study of 150 cases. Cancer 1985;55:1060-73.  Back to cited text no. 5
    
6.
Cornes JS, Smith JC, Southwood WF. Lymphosarcoma in chronic ulcerative colitis with report of two cases. Br J Surg 1961;49:50-3.  Back to cited text no. 6
    
7.
Sataline LR, Mobley EM, Kirkham W. Ulcerative colitis complicated by colonic lymphoma. Gastroenterology 1963;44:342-7.  Back to cited text no. 7
    
8.
Hoover R, Fraumeni JF Jr. Risk of cancer in renal-transplant recipients. Lancet 1973;2:55-7.  Back to cited text no. 8
    
9.
Lémann M, Bonhomme P, Bitoun A, Messing B, Modigliani R, Rambaud JC. Treatment of Crohn's disease with azathioprine or 6-mercaptopurine. Retrospective study of 126 cases. Gastroenterol Clin Biol 1990;14:548-54.  Back to cited text no. 9
    
10.
Present DH, Meltzer SJ, Krumholz MP, Wolke A, Korelitz BI. 6-Mercaptopurine in the management of inflammatory bowel disease: Short- and long-term toxicity. Ann Intern Med 1989;111:641-9.  Back to cited text no. 10
    
11.
Farrell RJ, Ang Y, Kileen P, O'Briain DS, Kelleher D, Keeling PW, et al. Increased incidence of non-Hodgkin's lymphoma in inflammatory bowel disease patients on immunosuppressive therapy but overall risk is low. Gut 2000;47:514-9.  Back to cited text no. 11
    
12.
Kinlen LJ. Incidence of cancer in rheumatoid arthritis and other disorders after immunosuppressive treatment. Am J Med 1985;78:44-9.  Back to cited text no. 12
    

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Correspondence Address:
Ashish Kumar
Institute of Liver, Gastroenterology, and Panceatico-Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi - 110 060
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_654_19

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