Sujay Alvencar, MD1, Erik Holzwanger, MD2, Rohit Dhingra, MD2, Raffi Karagozian, MD1, Lori Olans, MD, MPH2, Nikola Natov, MD2; 1Tufts Medical Center, Boston, MA; 2Tufts University Medical Center, Boston, MA
Introduction: Low grade B cell lymphoma of mucosa associated lymphoid tissue (MALT lymphoma), is an indolent form of non-Hodgkin’s lymphoma (NHL) that comprises approximately 5-10% of all NHL. MALT lymphomas classically originate in the stomach, with less common occurrences in extra-gastric locations. As a result, there is no standardized approach for the treatment of colonic MALT lymphomas when compared with their gastric counterparts. We report a case of a colonic MALT lymphoma incidentally found on colonoscopy to exhibit the pillow sign and the complexity of treatment in the setting of a patient with chronic hepatitis B (HBV) infection.
Methods: A 56 year-old man from China with untreated chronic HBV presented to his primary care physician with one month of unintentional 10 pound weight loss and worsening fatigue. Laboratory data, chest x-ray and physical exam were unremarkable. Colonoscopic evaluation revealed a 6 mm subepithelial lesion at the hepatic flexure with a positive pillow sign. Biopsies of the lesion were diagnostic for extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue. Upper endoscopic biopsies of the antrum and body returned positive for Helicobacter pylori (H. Pylori) gastritis subsequently treated with quadruple therapy. CT of the chest, abdomen and pelvis for staging did not demonstrate metastatic lesions. PET scan showed reactive cervical lymph nodes but no metastatic disease. After a multidisciplinary discussion, the decision was made to proceed with endoscopic mucosal resection given the lack of metastatic disease and the desire to avoid rituximab in the setting of chronic HBV. The patient underwent a repeat colonoscopy following mucosal resection of the lesion with biopsies of the mucosectomy scar positive for persistent MALT lymphoma. As a result, he is currently undergoing further evaluation of treatment for his chronic HBV for possible initiation of Rituximab. Discussion: This case describes an unusual presentation of colonic MALT lymphoma and highlights the complexities of treating this disease. While colonic MALT lymphoma has had many endoscopic descriptions, none to date have reported an associated pillow sign. The differential diagnosis for lesions exhibiting the pillow sign should not be limited to benign etiologies alone. Colonic MALT lymphoma should now be considered as well. In our case, despite H. pylori eradication and endoscopic mucosal resection, disease recurrence occurred with chronic HBV limiting the use of rituximab.
Figure 1. The 6mm subepithelial lesion exhibiting the pillow sign at the hepatic flexure. Image A demonstrates original lesion at hepatic flexure prior to intervention. Image B demonstrates a closed forceps induced indentation. Image C demonstrates reversion of the indentation with the lesion returning to its original shape.
Figure 2. Image A demonstrates hepatic flexure lesion under low power. Image B demonstrates hepatic flexure lesion under high power. The pathology report was diagnostic for MALT lymphoma.
Disclosures: Sujay Alvencar indicated no relevant financial relationships. Erik Holzwanger indicated no relevant financial relationships. Rohit Dhingra indicated no relevant financial relationships. Raffi Karagozian indicated no relevant financial relationships. Lori Olans indicated no relevant financial relationships. Nikola Natov indicated no relevant financial relationships.