Presentation
Per rectal bleed
Patient Data
Abdomen/pelvis: The liver has a 6 mm hypodense lesion in the segment 5/6, too small to characterize on CT; Otherwise, normal liver enhancement. The gallbladder, pancreas, adrenal glands, spleen, and kidneys are normal. Note is made to two small simple renal cortical cysts on the left.
The rectum is abnormal with bulky thickened walls. Also, there is extensive mesorectal, bilateral pelvic sidewall, retroperitoneal, and mesenteric lymphadenopathy. Small amount of free fluid in the peritoneal cavity, but no free gas. Features in keeping right hemicolectomy, end-ileostomy, and mucous fistula. Bilateral iliac fossa region ileostomies, on the right with a small parastomal hernia but no incarceration.
No suspicious osseous lesions.
Conclusion:
- Extensive abdominal/pelvic lymphadenopathy is highly suggestive of lymphoma recurrence.
- The bulkiness of the rectal wall in a mass-like appearance is favored lymphoma involvement rather than primary colorectal malignancy.
- The non-specific small liver lesion in seg V/VI is indeterminate (cyst? other?) - targeted ultrasound or correlation with old scans recommended.
- Small right-sided pleural effusion, no nodal disease above the diaphragm.
Case Discussion
This patient has a previous history of mantle cell lymphoma and had large bowel intussusception that has been managed with right hemicolectomy, end ileostomy, and mucous fistula formation. He was submitted to an autograft transplant.
The current presentation, which is documented on this scan, is best explained by lymphoma recurrence with distal large bowel involvement.
Rectosigmoidscopy with biopsies was performed:
Macroscopy:
Labeled "Sigmoid colon biopsy". Seven tissue fragments 2mm to 5mm.
Labeled "Rectum". Three tissue fragments 2mm to 8mm.
Microscopy: Both the specimens show similar features. The sections show colonic mucosa with the expansion of lamina propria by a population of atypical medium-sized lymphocytes. These lymphocytes show moderate nuclear pleomorphism, irregular nuclear membranes, nuclear hyperchromasia and scattered small nucleoli. There are foci of necrosis and apoptoses. These lymphoid cells are diffusely positive for CD20, BCL2, CD5 and cyclin D1, negative for CD10, CD23, CD5 and BCL6.
Conclusion: Sigmoid colonic and rectal biopsy: Mantle cell lymphoma. Ki67 immunostain shows a proliferative index of 70-80%.
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