Mantle Cell Lymphoma of the Gastrointestinal Tract Detected by Endoscopy

Abstract

Mantle cell lymphoma (MCL) of the gastrointestinal tract is a rare extra-nodal manifestation of malignant lymphomas. The endoscopic findings usually range from ulcers to infiltrative thickening to polyps. Extensive polyps, known as multiple lymphomatous polyposis (MLP), is seen in 0.5-2% of all cases of lymphoma, and should always be considered when there is a high clinical index of suspicion. Here, we present a rare case of MCL initially diagnosed with endoscopy. A 51 year old male, previously healthy without routine medical care, presented with abdominal bloating and constipation for 1 month. He had noted changes in the caliber of his stool, poor appetite, and 10 lb unintentional weight loss. He was prescribed a 2 week course of antibiotics due to concern for bacterial gastroenteritis which did not improve his symptoms. Examination was significant for generalized enlargement of cervical, axillary and inguinal lymph nodes, and mild abdominal distention. Blood work significant for ESR 42 CRP 82.2 Hb 7.9 MCV 77. CT scan of the abdomen had stomach wall thickening with diffuse extensive lymphadenopathy. Upper and lower endoscopy showed extensive involvement of the gastrointestinal tract with small to large polypoid lesions without any ulceration or surrounding erythema (Image 1,2). Tissue biopsy showed dense lymphoid infiltrate throughout lamina propria consistent with MCL (Image 3). Patient was started on the first cycle of R-CHOP therapy during this hospitalization. MCL involving the gastrointestinal tract must be differentiated from other causes of MLP, which include lymphoid nodular hyperplasia, adenomatous hereditary polyposis, lipomatosis, adenomas, carcinomas, and other lymphomas. Diagnosis is confirmed by tissue biopsy. Current guidelines for treatment of MCL is R-CHOP therapy and maintenance Rituximab. More intensive therapy involves aggressive chemotherapy followed by autologous stem-cell transplantation. MLP does not require separate treatment, other than symptom control with laxatives and high fiber diet. Monitoring for response after therapy will usually include repeat endoscopy to evaluate for disease regression. This case was unusual, as the gastrointestinal symptoms preceded the B symptoms typically associated with lymphomas. This prompted endoscopic evaluation, where the preliminary diagnosis of lymphoma was made by the finding of extensive polyps in the clinical context of diffuse lymphadenopathy.1880_A Figure 1. Esophagogastroduodenoscopy showing nodularity and cobblestone appearance throughout the stomach into the duodenal bulb.1880_B Figure 2. Colonoscopy showing cobblestone appearance and nodularity throughout the colon, with large ileocecal mass.1880_C Figure 3. H&E staining demonstrates colonic mucosa with a dense lymphoid infiltrate within the lamina propria.