Recurrent Mantle Cell Lymphoma Presenting as Colonic Mass

Abstract

Mantle cell lymphoma (MCL) is a rare and aggressive subtype of B cell Non-Hodgkin's Lymphoma. MCL frequently involves extranodal sites and gastrointestinal tract is involved in 80% of cases. MCL is usually resistant to standard chemotherapy regimens and associated with high recurrence rate. Recurrent disease is very aggressive and resistant to treatment. We present a case of recurrent MCL involving the colon despite intensive chemotherapy. A 58 year old woman presented to our hospital with complaints of left sided abdominal pain and hematochezia since one day. Abdominal pain was described as severe and continuous with no radiation. She was diagnosed with MCL two years ago when she had axillary lymph node biopsy. She was treated with standard chemotherapy regimen and stem cell transplantation at that time. She had a relapse one year after initial treatment for which she was again treated with chemotherapy. On examination, no lymphadenopathy was noted. Abdominal examination was significant for left lower quadrant tenderness without guarding, rigidity or hepatosplenomegaly. Laboratory tests were normal. Computed tomography scan of abdomen showed ascending colon wall thickening. Colonoscopy showed mass like lesion in the ascending colon and polyps in the ascending colon as well as splenic flexure. The biopsy of all the three lesions showed atypical lymphocytes infiltrating the lamina propria. The tumor cells were positive for cyclin-D1, CD 5, CD 20, CD 43 and CD 79A consistent with the diagnosis of MCL. Patients with MCL and gastrointestinal involvement could be asymptomatic or may present with abdominal pain, obstruction, diarrhea, or hematochezia. The most common site of involvement in the GI tract is ileocecal region, but any other area may be involved from the stomach to the rectum. Involvement of the gastrointestinal tract may occur with or without the appearance of polyps. Even though there are no standard guidelines for endoscopic screening of gastrointestinal tract in asymptomatic patients, one should be aware of involvement of gastrointestinal tract in the early course of disease or recurrent disease. Although mantle cell lymphoma is initially responsive to chemotherapy, it eventually becomes refractory with median survival of 3 to 5 years. Patients with obstructive tumor masses require surgical therapy, but the mainstay of treatment is chemotherapy.Figure: A polypoid non-obstructing medium-sized mass. Polyp with normal looking mucosa was found at the splenic flexure.Figure: A frond-like/villous, fungating, infiltrative, polypoid and ulcerated nonobstructing large mass was found in the ascending colon.