A 25-year-old man was suspected of having advanced rectal cancer by his previous physician and was referred to our hospital for surgery. Colonoscopy was repeated in our hospital before surgery. White-light imaging revealed a semi-circumferential ulcerative lesion in the rectum (Fig. 1a). The lesion was stained with 1% methylene blue and 0.05% crystal violet solution and evaluated using endocytoscopy. Proliferation of swollen, irregular-shaped nuclei with the formation of glandular duct structures was observed (Fig. 1b). Tissue biopsies were taken for flow cytometry and histological assessment. Histopathological examination after hematoxylin and eosin staining revealed infiltration and proliferation of enlarged dysplastic cells, without formation of glandular ducts (Fig. 1c). Immunohistochemistry was performed in response to the flow cytometry results, and was positive for CD20, CD79a, bcl2, and bcl6, but negative for CD3, CD10, multiple myeloma oncogene 1, and Epstein–Barr-virus-encoded small RNA in situ hybridization. Ki-67 index was 90%. The lesion was diagnosed as diffuse large B-cell lymphoma (DLBCL), germinal center B-cell-like type. Malignant lymphomas of the colon account for 0.1%–0.7% of all colorectal malignancies. In the colon, DLBCL is the second most common tumor after mucosa-associated lymphoid tissue lymphoma. DLBCL is often ulcerated and resembles ulcerated colorectal cancer by white-light endoscopic imaging (Fig. 2a). However, differentiation is required for treatment decision-making. Tissue sampling for flow cytometry can be used to quantify expression of proteins associated with prognosis and to detect multidrug resistance, which makes it useful for measuring prognostic indicators in lymphoid neoplasia. Hence, it is important to make a diagnosis of lymphoma on-site to prevent multiple repeat colonoscopies. Endocytoscopy allows real-time, in vivo visualization of atypical cells on the tumor surface and tissue details, including nuclei and glandular lumens, resulting in high diagnostic accuracy for adenocarcinoma or adenomatous lesions. However, there are few reports of the endocytoscopic findings of lymphomas in the gastrointestinal tract. In this case, endocytoscopy (520×, H290ECI; Olympus, Tokyo, Japan) showed a significant difference between DLBCL and adenocarcinoma, with irregular and rough lumens and agglomeration of distorted nuclei strongly stained with methylene blue (Fig. 2b,c).
Read full abstract