Oklahoma University Health Sciences Center Oklahoma City, OK
Erin Tsambikos, MD, Muhammad Hanafi, MD, Mohammad Madhoun, MD, Robert Todd; Oklahoma University Health Sciences Center, Oklahoma City, OK
Introduction: Colorectal lymphomas comprise only 10-20% of gastrointestinal lymphomas and 1% of large bowel malignancies. The most common histologic subtype of gastrointestinal lymphoma is diffuse large B-cell. Given the rarity of disease, a high index of suspicion is required for diagnosis.
Methods: An 84-year-old male with history of coronary artery disease presented with six weeks of diplopia and left eye pain. Computed tomography showed a pre- and post-septal and peri-bulbar enhancing mass-like abnormality of the left orbit. Eye examination was significant for left-sided erythema, periorbital edema, increased intraocular pressure, and decreased acuity. Right eye examination was normal.
Magnetic resonance imaging of the orbits revealed a trans-spatial infiltrative orbit lesion concerning for lymphoma. Anterior orbitotomy with biopsy of the left eye was performed along with positron emission tomography-computed tomography, which revealed an FDG-avid mass at the cecum. Subsequent colonoscopy revealed a tumor in the proximal ascending colon. Histopathology of both the colon and left orbit was consistent with diffuse large B-cell lymphoma, germinal center B-cell subtype.
The diagnosis of diffuse large B-cell lymphoma of the colon with orbital metastasis was made. Chemotherapy with rituximab and reduced dose cyclophosphamide, doxorubicin, vincristine, and prednisone was started. Bone marrow biopsy showed no evidence of marrow involvement. Filgrastim was started after chemotherapy, and lumbar puncture with intra-thecal methotrexate was performed. Diplopia, orbital pain, and erythema drastically improved. Discussion: The criteria for diagnosing primary gastrointestinal lymphoma includes: (1) absence of palpable lymphadenopathy, (2) absence of enlarged mediastinal lymph nodes, (3) normal hematologic laboratory values, (4) predominance of bowel lesion with lymph node involvement confined to the drainage area of the involved segment of gut, and (5) no lymphomatous involvement of the liver or spleen. Typical presenting symptoms include abdominal pain, weight loss, change in bowel habits, and a palpable mass. The patient described in this case report presented symptoms stemming from the metastasis, complicating the diagnostic process. Orbital metastases have never been described in colonic diffuse large B-cell lymphoma creating initial suspicion of two separate processes taking place. Imaging and biopsy of both the colonic and orbital lesion were pivotal in diagnosis, staging, and treatment.
Computed tomography of the orbit showing a pre- and post-septal and peri-bulbar dense or enhancing mass-like abnormality of the left orbit
Computed tomography of the abdomen and pelvis showing a locally advanced right lower quadrant abdominal mass centered over the cecum
Colonoscopy showing fungating, ulcerated, and circumferential mass in the proximal ascending colon
Disclosures: Erin Tsambikos indicated no relevant financial relationships. Muhammad Hanafi indicated no relevant financial relationships. Mohammad Madhoun indicated no relevant financial relationships. Robert Todd indicated no relevant financial relationships.