A case of early gastric malignant lymphoma diagnosed and completely resected by strip biopsy

A case of early gastric malignant lymphoma definitively diagnosed by strip biopsy is reported. The subsequent operation revealed that the strip biopsy had resulted in radical resection. A 55-year-old woman visited our hospital for detailed examination of a small gastric lesion. Histologic findings of the specimens obtained by conventional forceps biopsy indicated reactive lymphoid hyperplasia, although the possibility of malignant lymphoma was not completely ruled out. Strip biopsy was, therefore, performed to establish a definitive diagnosis. Histopathological examinations of the strip biopsy specimen revealed definitive findings of malignant lymphoma, which was B-cell phenotype immunocytochemically. The margin of the resected specimen was free of invasion by malignant lymphoma and no lymph node involvement was suggested by endoscopic ultrasonography, computed tomography, and gallium scintigram. Subtotal gastrectomy was subsequently performed to rule out the possibility of remaining malignant lymphoma cells. It was proven that the strip biopsy removed the lesion completely and no perigastric lymph nodes were involved. While is still controversial as to whether strip biopsy should be adopted for the radical resection of early gastric lymphoma, this procedure can definitely provide excellent specimens for the accurate diagnosis of gastric malignant lymphoma and probably for group III lesions in the stomach.     

Drug‐induced cutaneous vasculitis in patients with non‐Hodgkin lymphoma treated with the novel proteasome inhibitor bortezomib: a possible surrogate marker of response?

Bortezomib is the first proteasome inhibitor to be approved for use in haematological malignancies. Although a rash has been described as a common adverse event associated with the drug, it has not been well characterised. Based on three phase II studies of bortezomib in patients with non-Hodgkin lymphoma (140 assessable patients), we identified 26 patients who developed a unique erythematous maculopapular rash during treatment, six of whom underwent cutaneous biopsy. Punch biopsy in six patients revealed a perivascular lymphocytic infiltrate without evidence of lymphoma, consistent with a non-necrotising cutaneous vasculitis. The combined overall response rate was 41%. The response in the 26 patients who developed a rash was 73%, compared with 33% in patients who did not. The odds ratio for response given the development of a rash was 4.6 (95% CI, 1.7-12.4, P = 0.001). This is the first report to characterise a vasculitic rash associated with bortezomib, and to show a relationship between development of the rash and response to treatment. Unlike classic hypersensitivity type reactions, this vasculitic rash may not necessarily prompt cessation of drug. In fact, the development of an isolated cutaneous vasculitis may portend a better clinical response to bortezomib in some patients.     

Successful rituximab-CHOP treatment of systemic lupus erythematosus associated with diffuse large B-cell non-Hodgkin lymphoma

The authors discuss the case of a 76-year-old female patient who has been suffering from subacute cutaneous lupus erythematosus since 1983. In 1999 she was diagnosed with systemic lupus erythematosus (SLE) based on her symptoms of malar rash, polyarthritis, leukopenia, autoimmune hemolytic anemia and positive anti-DNA antibody test. For this she received methylprednisolone and cyclophosphamide. After 3 years of remission, symptoms of cutaneous vasculitis appeared in 2004, which transitionally responded to treatment with azathioprin and methylprednisolone. Her cutaneous symptoms, however, progressed quickly along with generalized lymphadenopathy, splenomegaly and thrombocytopenia. Immunohistological evaluation of the lymph node biopsy showed diffuse large B-cell lymphoma. She developed complete remission after treatment with six-cycle R-CHOP (rituximab, and reduced doses of cyclophosphamide, vincristin, adriablastin, methylprednisolone). SLE became inactive and her symptoms of vasculitis resolved. The authors are bringing attention to one of the possible late complications of systemic lupus, and also underscoring that treatment with rituximab (+CHOP) was beneficial not only for the lymphoma but the SLE as well.     

Cutaneous vasculitis as an initiating paraneoplastic symptom in Hodgkin lymphoma

Skin vasculitis may be associated with infections and autoimmune diseases. Furthermore, vasculitis may appear as a paraneoplastic symptom. A 19-year-old male patient was examined with swollen joints and papules presented on lower extremitis. Laboratory results showed high erythrocyte sedimentation ratio, positive C reactive protein, increased number of leukocytes and high circulating immune complex level. Histopatology of skin biopsy specimen proved vasculitis. ANCA was not present. No other changes could be observed besides skin involvement. Symptoms disappeared on 0.5-mg/bwkg methylprednisolon therapy. Few weeks later, enlarged cervical lymph nodes developed besides fever and weight loss. Biopsy indicated the presence of mixed cell type Hodgkin lymphoma. Appropriate examinations revealed clinical stage III/B with favorable prognosis (IPS = 2). After eight cycles of ABVD therapy complete remission was achieved as confirmed by FDG-PET. As a consequence of the treatment of Hodgkin lymphoma, vasculitis also disappeared. The present case report calls to attention the importance of careful examinations to exclude other diseases, especially malignancies that may remain at the background of cutaneous vasculitis. Treatment of the primary disease also results in the improvement of secondary skin vasculitis.     

Rituximab induces remission in refractory HCV associated cryoglobulinaemic vasculitis

OBJECTIVES: To report the successful induction of remission with the monoclonal anti-CD20 antibody rituximab in a patient with hepatitis C virus (HCV) associated cryoglobulinaemic vasculitis and a non-Hodgkin's lymphoma (NHL) resistant to previously advocated conventional treatments. Case report: The patient was a 45 year old woman with HCV associated cryoglobulinaemic vasculitis, with purpura, arthralgia, constitutional symptoms, and a polyneuropathy. A malignant NHL was found as underlying lymphoproliferative disease. At this stage the disease was refractory to interferon alpha2b and ribavirin and to subsequent immunosuppressive treatment with cyclophosphamide. Six rituximab infusions targeting the CD20 antigen on cells of the B cell lineage induced remission of the vasculitis. Bone marrow biopsy disclosed absence of the NHL. Remission has subsequently been maintained and HCV eliminated with the new pegylated interferon alpha2b and ribavirin for nearly one year. CONCLUSIONS: Transition of the underlying "benign" lymphoproliferative disease to a malignant lymphoma may result in difficult to treat HCV associated cryoglobulinaemic vasculitis. Rituximab offers a new possibility for inducing remission in refractory HCV associated cryoglobulinaemic vasculitis and the lymphoproliferative disorder. After remission, HCV may subsequently be eliminated with pegylated interferon alpha2b and ribavirin.     

The effect of isotretinoin in six patients with cutaneous T-cell lymphoma

Oral retinoids are effective in the treatment of patients with a variety of malignant and nonmalignant skin disorders, including mycosis fungoides. We treated six patients with cutaneous T-cell lymphomas with isotretinoin 1 to 2 mg/kg/d. All patients experienced symptomatic relief (fading of skin lesions and disappearance of pruritus) within two to eight weeks of starting the drug therapy; pretreatment and posttreatment biopsy specimens were unchanged. Adverse effects were minor and primarily consisted of drying of the mucous membranes. We conclude that isotretinoin is a well-tolerated, easily administered drug that provides good palliation of symptoms and signs associated with cutaneous T-cell lymphoma in patients who are unable or unwilling to comply with standard therapy.     

Pulmonary lymphoma of large B-cell type mimicking Wegener's granulomatosis

A 27-year-old man with a primary pulmonary lymphoma of large B-cell type is described. Symptoms involved both the upper and lower respiratory tract. A chest roentgenogram showed a dense mass with cavitation. Transbronchial biopsy specimens revealed no atypical cells, rather they demonstrated granulomatous infiltration and vasculitis consistent with but not conclusively diagnostic of Wegener's granulomatosis. The pulmonary mass became smaller after sulfamethoxazole-trimethoprim therapy. These features suggested Wegener's granulomatosis. However, an open biopsy specimen was diagnostic for diffuse lymphoma of large B-cell type. High-grade pulmonary lymphoma should be considered in the differential diagnosis of patients with clinical and pathologic features suggesting Wegener's granulomatosis.     

Alternaria infection in a patient receiving chemotherapy for lymphoma

A 60-year-old man receiving chemotherapy for an intermediate-grade non-Hodgkin's lymphoma developed multiple papuloerythematous cutaneous lesions. Alternaria alternata was cultured from the lesions, and hyphae were seen in biopsy specimens. This is an unusual infection, without a well-established treatment, in patients with lymphoma. The use of amphotericin B resulted in cure.     

Fulminant vasculitis: a rare fatal complication of lymphoma

Vasculitis is rarely associated with lymphoma; however, most cases associated with lymphoma are cutaneous. Systemic vasculitis in association with lymphoma is usually an indolent and non-fatal complication. Two patients presented to our department with fulminant vasculitis with a fatal course and were later diagnosed with lymphoma. A search of the literature for systemic fulminant vasculitis in association with lymphoma disclosed eight case reports. We suggest that lymphoma should be considered as a possible etiology in patients with fulminant systemic vasculitis. The therapeutic implications of such an association are discussed.     

Endoscopic and histologic findings in malignant non-Hodgkin lymphomas of the stomach

The authors have carried out a retrospective analysis of primary malignant Non-Hodgkin-lymphomas of the stomach verified histologically by surgical specimens, with the patients being submitted preoperatively to a gastroscopy with biopsy. The endoscopic and histological findings are outlined. Endoscopically the diagnosis of a malignant lymphoma was established only once, while an ulcerated carcinoma was diagnosed in almost two-thirds of the cases. The histological diagnosis of a malignant lymphoma was established in 10 cases, and a malignant lymphoma suspected in 6 cases. A carcinoma was diagnosed in 4 patients. The results are compared with the literature data and diagnostic problems discussed.     

A case of primary malignant lymphoma of the liver

Primary lymphoma of the liver is extremely rare, and its preoperative or premortem diagnosis is still difficult. The author report here a case of primary malignant lymphoma of the liver diagnosed on a basis of ultrasonically guided biopsy of the tumor. A 51-year-old man was found to have a relatively large tumor in the right lobe of the liver as well as elevated serum LDH with abnormal isoenzyme pattern. Immunohistological studies of both biopsy and postmortem specimens of the tumor indicated T cell malignant lymphoma of the liver. The present case appears to be the second case of T cell origin of the disease.     

Malignant lymphoma in the ileum diagnosed by double-balloon enteroscopy

A 73-year old man presented with abdominal pain. A tumor with central ulceration was observed in the ileum using double-balloon enteroscopy. Histological findings of the biopsy specimens were consistent with malignant lymphoma. Double-balloon enteroscopy confirmed the diagnosis of a malignant lymphoma tumor which was surgically resected. The patient is still in complete remission now.     

Small cell pleomorphic T-cell lymphoma presenting with cutaneous vasculitis

Summary The association between cutaneous vasculitis and lymphoproliferative disease has been increasingly recognized. We report a female patient who presented with cutaneous vasculitis which was due to a small cell pleomorphic T-cell lymphoma. In spite of aggressive therapy, she died two years after onset of disease. The clinical picture of vasculitis associated with lympho-proliferative disease is addressed with particular emphasis on symptoms and signs suggesting malignancy rather than vasculitis appearing in concert with well-defined connective tissue disorders.     

Ileocolic intussusception in adult due to malignant lymphoma in the cecum with intramural metatasis

A rare adult case of intussusception caused by malignant lymphoma of the cecum with intramural metastasis is reported. The patient was a 24-year-old man. Ileocolic intussusception was diagnosed by characteristic findings on abdominal computed tomography. Endoscopic examination revealed a massive protuberant tumor, 3 cm in diameter, and a semipedunculated polyp, 1 cm in diameter, in the cecum, which had caused the ileocolic intussusception. Endoscopic biopsy specimens failed to yield a definitive diagnosis histologically, but right hemicolectomy with lymph node dissection was performed. On histologic examination of the surgical specimens, both the tumor and the polyp were diagnosed as diffuse lymphoma of medium-sized cell type, and no lymph node involvement was found. The patient responded well to surgical and chemotherapeutic treatment, and has had no recurrence of malignant lymphoma in the 2 years since the surgical treatment. This was a very rare case of an intussusception in an adult patient due to malignant lymphoma in the cecum with intramural metastasis and without lymph node involvement.     

Lymphome non hodgkinien Ki-1 positif révélé par des ulcérations cutanéomuqueuses et une glomérulonéphrite

Malignant lymphoma particularly of T phenotype can be associated with specific or non specific cutaneous lesions. These cutaneous manifestations can occur at the onset of the disease being sometimes the revealing sign or they can appear during the course of the lymphoreticular malignancies. Glomerulonephritis was also described in lymphoma. Ki- positive large cell lymphoma was recently identified. A new case is reported with lymphadenopathy and intestinal localisation revealed by cutaneous and mucosal ulcerations principally in the mouth and a focal segmental glomerulonephritis with endo- and extracapillary proliferation. The absence of lymphoma in cutaneous and renal lesions and the clinical presentation support the hypothesis of paraneoplastic manifestations, may be related to a vasculitis.     

Complete resolution of dermatomyositis with refractory cutaneous vasculitis by intravenous cyclophosphamide pulse therapy

Cutaneous ulcers associated with vasculitis are rarely reported in adult-onset dermatomyositis (DM), and are often resistant to treatment, resulting in a poor prognosis. There is no general treatment strategy and the effects of various treatments have never been confirmed histopathologically. A 43-year old man with DM developed refractory multiple cutaneous ulcers which were revealed as vasculitis by skin biopsy. Repeated intravenous cyclophosphamide pulse therapy (IV-CY) without high-dose corticosteroid therapy resulted in complete resolution of the ulcers without adverse effects or severe complications. A repeat biopsy confirmed complete remission of vasculitis. Repeated IV-CY is a useful treatment for induction of clinical remission of DM with cutaneous vasculitis.     

Systemic hypersensitivity vasculitis associated with bronchiectasis.

Systemic hypersensitivity vasculitis developed in a 53-year-old man during acute exacerbation of bronchiectasis infected with Pseudomonas aeruginosa. High grade fever, mononeuropathy multiplex, cutaneous vasculitis, and biopsy specimen-proved mesangioproliferative glomerulonephritis with crescent formation and leukocytoclastic vasculitis associated with circulating immune complex occurred. Corticosteroid and cyclophosphamide therapy was effective for vasculitis and bronchiectasis.     

Calciphylaxis: a rare differential diagnosis of systemic vasculitis

INTRODUCTION: Calciphylaxis is a rare phenomenon of medium- and small-vessel calcifications leading to cutaneous necrosis mimicking vasculitis. CASE REPORT: A 75 year-old-woman with chronic renal insufficiency was admitted for extensive cutaneous necrosis of the limb. Diagnosis of vasculitis was made, but inspite of corticosteroid therapy, the condition of the patient was worsening. After cutaneous biopsy, the diagnosis of calciphylaxis was established. CONCLUSION: Calciphylaxis must be suspected in cases of cutaneous necrosis occurring in a patient with chronic renal failure. Treatment requires rapid normalization of phosphocalcic balance. It is a condition with high mortality.     

Cutaneous vasculitis induced by TNF inhibitors: a report of three cases

We describe 3 rheumatoid arthritis (RA) patients with anti-tumor necrosis factor (TNF) therapy-induced cutaneous vasculitis. Two cases were induced by infliximab and the other, in whom cutaneous vasculitis was found early at the start of therapy, was induced by etanercept. Skin biopsy was obtained in 2 patients, with histology-proven leukocytoclastic vasculitis. One patient spontaneously improved after cessation of the TNF inhibitor. Two patients required oral corticosteroid, the efficacy of which was observed to be excellent and rapid.     

A case of primary malignant lymphoma of the liver.

Primary lymphoma of the liver is extremely rare, and its preoperative or premortem diagnosis is still difficult. The author report here a case of primary malignant lymphoma of the liver diagnosed on a basis of ultrasonically guided biopsy of the tumor. A 51-year-old man was found to have a relatively large tumor in the right lobe of the liver as well as elevated serum LDH with abnormal isoenzyme pattern. Immunohistological studies of both biopsy and postmortem specimens of the tumor indicated T cell malignant lymphoma of the liver. The present case appears to be the second case of T cell origin of the disease.