LETTERS TO THE EDITOR

 

Primary intestinal lymphoma associated with Crohn's disease

Linfoma intestinal primario asociado a enfermedad de Crohn

 

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Key words: Intestinal lymphoma. Crohn's disease.

Palabras clave: Linfoma intestinal. Enfermedad de Crohn.

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Dear Editor,

Patients with Crohn's disease (CD) have a greater risk of suffering cancer, primarily colon cancer (adenocarcinoma) and hemopoietic cancers. While treatment with 5 aminosalicylates is considered to provide certain protection from colorectal cancer, immunosuppressant medications like methotrexate and azathioprine increase cancer risk. At the present time the use of thiopurines and tumor necrosis factor antagonists has favored the incidence of lymphomas (1). We present the case of a patient with this complication.

 

Case Report

A 65 year old man diagnosed with Crohn's disease 11 years previously and currently under treatment with mesalazine, sought treatment for abdominal pain in the right lower quadrant radiating to the hypogastrium from 2 months prior to consultation. It was associated with sporadic vomiting and weight loss of 5 Kg although there was no loss of appetite. Physical examination revealed a hard abdominal mass in the right lower quadrant which on exploration was a painless stony mass with slight mobility although adhering to deeper levels. Blood tests detected leucocytosis (16,79x10e9/L) with neutrophiles and hemoglobin of 122.0 g/L. Both globular sedimentation velocity (89.0 mm/h) and reactive C protein levels (38,6 mg/l) were higher than normal. Tumor indicators (carcinoembryonic antigen, Beta-2-microglobulin, C.A. antigen 15.3, 19.9 and 125) were within normal limits.

Abdominal computed tomography (Fig. 1) shows a solid mass surrounding the sigmoid colon (blank arrow), terminal ileum (white arrow) and cecum (black arrow) associated with multiple adenopathies forming conglomerates in some cases (asterisks). Biopsy of the sigmoid colon showed diffuse B-cell lymphoma with centrogerminal immunophenotype. The patient was admitted for chemotherapy according to the GELTAMO protocol but died 4 days later.

 

Discussion

Lymphomas are not normally suspected in patients with CD as their symptoms can be similar to those caused by inflammatory activity. It is only when a palpable mass or intestinal obstruction is found that the possibility of lymphoma is considered and the published cases are usually reported as non-Hodgkin's lymphomas (2). Most of these patients have long-term CD (more than 9 years) and the tumor appears in a site with previous CD involvement. Houlobar et al. (3) carried out a revision of primary intestinal lymphomas and found that the most frequent symptoms were diarrhea and stomach pain followed by weight loss. The most frequent site of the lymphoma was the terminal ileum (26%), where the CD was also located, while for those patients presenting pancolitis as the CD the area affected by the lymphoma was the rectosygmoid union. Although the influence of inflammatory intestinal disease on the development of colon cancer has been widely recognized (4), the mechanism behind this association still remains unclear (5).

 

María A. Iribarren-Marín, Raquel González-Martín, Jesús Aguilar-García,
Cristina Martínez-Polanco and Herminia Pérez-Vega
Department of Radiodiagnosis. Hospitales Universitarios
Virgen del Rocío. Sevilla, Spain

 

References

1. Hemminki K, Li X, Sundquist J, Sundquist K. Canceer risk in Crohn disease patients. Ann Oncol 2009;20:574-80.         [ Links ]

2. Siegel CA, Marden SM, Persing SM, Larson RJ, Sands BE. Risk of lymphoma associated with combination anti-tumor necrosis factor and immunomodulador therapy for the treatment of Crohn's disease: a meta-analysis. Clin Gastroenterol Hepatol 2009;7:874-81.         [ Links ]

3. Houlobar SD, Dozois EJ, Loftus EV, The SH, Benavente LA, Harmsen WS, et al. Primary intestinal lymphoma in patients with inflammatory bowel disease: a descriptive series from the prebiologic therapy era. Imflamm Bowel Dis 2010; Nov 4. [Epub ahead of print]         [ Links ].

4. Rutter M, Saunders B, Wilkinson K, et al. Severity of inflammation is a risk factor for colorectal neoplasia in ulcerative colitis. Gastroenterology 2004;126:451-9.         [ Links ]

5. Hall CH, Shamman M. Primary intestinal lymphoma complicating        [ Links ]