The value of small bowel magnetic resonance imaging in the management of enteropathy associated T‐cell lymphoma

Abstract

A 50-year-old female with a 9-year history of coeliac disease, presented with an acute jejunal perforation. Resection of the distal jejunem and primary anastomosis was carried out. Histology showed a high grade T-cell lymphoma on a background of coeliac disease [Enteropathy associated T-cell lymphoma (EATCL)]. A computed tomography (CT) scan carried out postoperatively showed no lymphadenopathy or evidence of residual lymphoma mass in the abdomen or pelvis. The patient then received three cycles of CHOP (cyclophosphamide, adriamycin, oncovin and prednisolone), but remained symptomatic with abdominal pain, anorexia and diarrhoea. A CT scan of the abdomen was normal. A magnetic resonance imaging (MRI) small bowel study was then carried out, which clearly demonstrated a residual mass in the small bowel consistent with lymphoma (Fig 1A). Her treatment was escalated and she received three cycles of ESHAP (cisplatin, cytarabine, etoposide, methylprednisolone) with stem cell harvesting on recovery from the first cycle. A repeat MRI after two cycles showed resolution of the mass. Treatment was completed with a BEAM [BCNU (carmustine), etoposide, cytarabine, melphalan] conditioned autologous stem cell transplant, as has been advocated in responding patients who are able to tolerate the procedure (Lennard et al, 2002; Bishton & Haynes, 2006). A further MRI small bowel study, carried out 2 months post-transplant, was normal (Fig 1B) and she remains well after 9 months of follow up. The EATCL is an aggressive lymphoma with a poor prognosis. Traditional radiological imaging techniques, such as CT, can be insensitive at detecting this lymphoma, particularly when disease may be confined to the epithelial layer of the bowel wall and be multi-focal. Positron emission tomography techniques can be of value in imaging EATCL, but false positives do occur (Hoffmann et al, 2003; Bernstein et al, 2005). MRI offers several advantages over these techniques without exposure to radiation. It can provide cross-sectional images in multiple planes with high soft tissue contrast resolution, thus giving functional as well as anatomic information. We believe this case demonstrates an important role for MRI small bowel studies in assessing response to treatment in EATCL.