Follicular lymphoma - mesenteric lymphadenopathy
Abdominal pain, previous medical history of Crohn disease.
CT Abdomen and pelvis
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Abnormal appearance of the small bowel mesentery, characterized by lymphadenopathy, with short axis diameter of several of the nodes up to 19mm, as well as hazy opacity of the mesenteric fat. There is also trace volume free fluid lying along the mesenteric border of the small bowel.
There are also short segments of thickened ileum wall with slight mucosal hyperenhancement in keeping with the known Crohn disease. Fecalization of distal small bowel contents, but no distension. Small umbilical hernia contains no obstructed small bowel and fat. Bowel is otherwise unremarkable.
The solid abdominal viscera are unremarkable.
This case illustrates prominent mesenteric lymphadenopathy and infiltrates that, although having a background of Crohn disease, are not related to small bowel active inflammation. The findings are too prominent to be attributed to mesenteric panniculitis as well.
Biopsy of one of the nodes was performed:
Macroscopy: Labeled "Mesenteric lymph node biopsy". 5 pieces of yellow/pale tan tissue in aggregate 30 x 20 x 3 mm.
Microscopy: The sections show lymph node and surrounding fibroadipose connective tissue. The node shows an expanded follicular architecture with an extension of follicular structures into surrounding adipose tissue. Within expanded follicles, there is a dual population of small, hyperchromatic, cleaved cells of centrocytic appearance, accompanied by large cells with prominent nucleoli and pale staining chromatin in keeping with centroblasts, the latter numbering fewer than 15 per high-power field.
Immunoreactivity with antibodies against CD20, CD10, Bcl-6 and Bcl-2 is present within the neoplastic follicles. Ki67 proliferative index within the follicles measures < 10%. CD21 immunohistochemistry highlights expanded follicular dendritic cell networks. CD3 and CD5 immunohistochemistry highlight an interfollicular T lymphocyte population. Immunohistochemistry with the following markers is negative: MUM-1, CD15, CD30, Cyclin D1, TdT, c-myc, CD138.
Conclusion: Mesenteric lymph node biopsy: Follicular lymphoma, low-grade.
Although its mechanisms are not completely understood, patients with inflammatory bowel disease are speculated to have an increased risk of malignant lymphomas, particularly the non-Hodgkin form 1.