A Case of Diffuse Large B-cell Lymphoma of Colon in a Patient with Ulcerative Colitis

Abstract

INTRODUCTION: Adalimumab is an anti-TNF agent approved for the treatment of severe active Ulcerative Colitis (UC). Use of anti-TNF agents along with thiopurines increases the risk of lymphoma compared to thiopurines alone. Limited data is available regarding the risk of lymphoma in UC patients treated with anti-TNF agents alone. CASE: A 66 y/o old male with Left sided UC maintained on azathioprine (5 years) and adalimumab (3 years), presented with increasing abdominal cramping and bloody diarrhea with mucus for 3 weeks. Hemodynamically stable and physical exam significant for diffuse abdominal tenderness. Labs: Hgb 12.2 g/dL, normal WBC, negative Stool studies and C. difficile toxin. CT Abdomen showed distal sigmoid and rectal wall thickening with pericolonic fat stranding consistent with active inflammation and lymphadenopathy. Flexible sigmoidoscopy showed near complete obstruction due to rectal stricture with inability to pass scope beyond 10 cm. Biopsy revealed Diffuse large B-cell lymphoma. Azathioprine and Adalimumab were stopped and the patient received chemotherapy (with R-CHOP), followed by radiation and subsequent colectomy. DISCUSSION: Patients with Inflammatory Bowel Disease (IBD) have a slightly increased risk of lymphoma compared to the general population. The absolute risk is nearly twice as high in Crohn's Disease (CD) compared to UC. Incidence of lymphoma is approximately 4 times higher in IBD patients treated with thiopurines compared to patients not on these drugs. Among patients treated with anti-TNF agents (with and without thiopurines), the SIRR was 5.5 for past use (95% CI: 4.5-6.6) and 4.4 for current use (95% CI: 3.4-5.4). However studying the association between lymphoma and anti-TNF drugs is complicated because most patients treated with anti-TNF agents have been previously treated with Thiopurines or are receiving both medications concurrently. Reactivation of latent EBV infection is the best-studied mechanism for development of lymphoma in IBD patients on immunosuppressant therapy. When the patient develops lymphoma, therapy should be discontinued until the lymphoma has been treated and is in remission. If the patient has UC, surgical therapy is a better option when there is concern for lymphoma. Anti-TNF agents are effective in the treatment of IBD and can significantly improve quality of life. Decision to start these agents should be made by considering the potential risk of lymphoma against benefits.Figure 1Figure 2Figure 3