Sabato 27 ottobre 2012 - Pacini Editore

PoStER
MALT lymphoma of the rectum: a case report
R. Giannatiempo1 , M. Postiglione1 , L. Nugnes1 , R. Franco2 ,
A. Russo1 , A. Nicastro1 , D. Oppressore1 1 UOS Anatomia ed Istologia Patologica /Ospedale Evangelico Fondazione
Betania, Napoli, Italia; 2 AF Anatomia Patologica/ INT Fondazione G. Pascale,
Napoli, Italia
Case presentation. A 64-year-old man had suffered from rectal
bleeding during defecation for a few weeks, admitted to our
department. He denied other symptoms or signs including pain,
weight loss, fatigue or enlargement of lymph nodes. Laboratory
findings were normal except a slight elevation in the level of
alkaline phosphatase.
There was a palpable mass on rectal examination; the mass was
smooth, firm to hard, and fixed to the rectal wall.
As further evaluation of the rectal bleeding, colonoscopic examination
was performed and multiple polypoid lesions were
observed. However, the appearance of the lesions was not similar
to the adenomatous polyps that were seen in patients who had
polyposis syndromes. Instead, lesions were in different sizes from
millimeters to a few centimeters, connected to each other without
any normal mucosa in-between, and occupied the lower rectum.
Multiple biopsies were taken and the histological and immunochemical
evaluation showed atypical lymphoid cell proliferation
and lymphoepithelial lesions on the colonic mucosa.
Histopathological examination of the biopsy specimens from
the rectal lesion demonstrated a low-grade B cell lymphoma of
MALT type (Extranodal marginal zone lymphoma) diffuse lymphocytic
infiltratimg lamina propria, with uniform membranous
staining of the cells with the B-cell marker CD20). CD5, CD10,
CD23 and bcl-6 markers were found negative. IgM and bcl-2
were found positive. Use of polymerase chain reaction (PCR) to
amplify the immunoglobulin heavy chain (IgH) gene indicated a
monoclonal pattern. The proliferation index (Ki-67) was high.
After the diagnosis had been confirmed as low grade MALT lymphoma,
further evaluation was indicated for stage assessment.
As additional investigations did not show any evidence of infiltration
to other organs, the disease was staged as clinical stage I
rectal lymphoma.
However, the lesion was enlarged enormously during an observation
period.This could suggest that the lesion had a tendency to
advance into a more aggressive clinical course.
The mass was excised transanally (in pieces, because of friability);
the tumor measured 5 × 7 cm, localized 1-2 cm proximal to the al
verge. After surgery, the patient received adjuvant chemotherapy.
Three months after the completion of therapy, a follow-up
colonoscopy revealed normal mucosal view.
In addition, the mucosa was biopsied and the pathological examination
revealed the complete response of the disease to the therapy.
During the follow-up, colonoscopic examination and blind biopsies
were repeated in every 6 months, revealed endoscopically
and pathologically normal mucosa each time. The patient is still
alive without any recurrence of the disease 15 months after the
diagnosis.
Methacrhonous leiomiosarcoma of small bowel
with ductal adenocarcinoma of pancreas arising
with a short interval: a case report
R. Giannatiempo1 , M. Postiglione1 , L. Nugnes1 , R. Franco2 ,
A. Russo1 , A. Nicastro1 , D. Oppressore1 1 UOS Anatomia ed Istologia Patologica /Ospedale Evangelico Fondazione
Betania, Napoli, Italia; 2 AF Anatomia Patologica/ INT Fondazione
G.Pascale, Napoli, Italia
Case presentation. A 71 years old man was admitted in the surgical
emergency with 2 days history of diffuse abdominal pain,
chest pain, flatulence.
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He denied any associated gastrointestinal symptoms such as nausea,
weight loss, diarrhea, melena and hematemesis. He also had
compliant of constipation lasting for the previous 2 days.
A duodenal ulcer, surgery for an umbilical hernia and chronic
anemia were mentioned in his medical history.
The patient has as comorbidities essential hypertension, ischemic
heart disease, stable angina pectoris and benigne prostate hypertrophy.
On physical examination he had tachycardia, hypotension but
body temperature was normal. The abdomen was distended with
visible peristalsis. There was generalized tenderness on deep
palpation. Non palpable mass was identified. Bowel sounds
were exaggerated.. Digital rectal examination was unremarkable.
Laboratory investigations showed leukocytosis and raised blood
urea but serum creatinin was within normal range.
Plain abdominal X-ray in the upright position showed multiple
air fluid levels below the hemidiaphragms with dilated transverse
colon and prominent loops of small bowel.
From the computed tomography (CT) scan of the abdomen a low
density area was detected and abdominal ultrasonography (US)
revealed a low echoid mass in the abdominal cavity.
99m Tc Scintigraphy showed an accumulation in the small intestine
and a hypervascular mass was supplied from the branch of
the superior mesenteric artery was demonstrated angiographically.
With all these findings suggestive of acute intestinal
obstruction, patient was planned for exploratory laparotomy
revealing diffuse peritonitis caused by a perforated small intestine
tumor. Infact intra operatively ileoileal intussusception was
present 5 cm about to ileo-ceacal junction. The bowel proximal
to this area was dilataded. There was an intramural mass arising
from the wall of ileum making the lead point of intussusception.
So the tumor together about 15 cm of the ileum were extirped
and enteoenteroanastomosis were performed. Mesenteric lymph
nodes were enlarged.
A search of the entire gastrointestinal tract and the peritoneal cavity
didn’t reaveal other abnormalities.
Resected specimen of the tumor measured 11x7. Cut surface of
the specimen revealed a nodular firm tumor which originated
from the intrinsic muscle layer was observed macroscopically.
The cut surface was graysh-white and soft with partial lightyellowish
necrosis.
Microscopically, the tumor consisted of spindle-shape cells in an
interlacing or fascicular pattern Mitotic features were occasionally
encountered at counts of 6 per each 10 high power field.
The malignant cells were positive for vimentin and smooth muscle
actin and desmin immunostains. Other immunostains were
negative (cytocheratin, CD34,CD117, S100).
The tumor involved the serosal layer with vascular invasion present.
The proximal and distal margins were free.
Mesenteric lymph node biopsy showed chronic non specific
inflammation. The diagnosis of malignant leiomiosarcoma was
made.
The patient was referred to Oncology for adjuvant therapy and
was subjected to regular follow-up without any signs of recurrence
of disease 12 months after surgery.
One year later he was referred to surgical emergency for multiple
episodes of bilous vomiting. Laboratory tests on admission
showed evidence of anemia, HB 10g/dk, PCR 1,5 mg/dl and
abnormal tumor markers levels: CEA 9,68 ng/ml, CA 125 41,70
IU/ml, TPA 109 U/L.
Computed tomography scan showed an intense homogenously
enhancing tumor with 3.5 cm in diameter with vanishing limits
and necrotic areas in the pancreatic head region. The tumor was
well-demarcated and strongly enhanced on contrastenhanced CT
images.
Abdominal ultrasonography revealed 3.5 cm sized, oval-shaped
hypoechoic solid nodule around the uncinate process of the
pancreas.