A 59-year-old man with rectal bleeding was referred to our department for endoscopic resection of left-sided colonic polyps detected by previous colonoscopy. The patient had been diagnosed with stage III mantle cell lymphoma (MCL) and was treated with homologous hematopoietic stem cell transplantation 35 months earlier. Complete response was achieved and the patient was considered to be disease-free. His laboratory tests and physical examination were remarkable only for hemorrhoids.
Initial colonoscopy had revealed four polyps in proximal sigmoid colon up to 25 mm in diameter. Multiple forceps biopsies taken during the referral endoscopy were negative for neoplasia. In our examination, all polyps appeared macroscopically to be covered with normal mucosa (pit pattern I, Fig. 1A). We decided to lift the larger one with submucosal injection of adrenaline solution and indigo carmine. There was no apparent difficulty in lifting the polyp, so we proceeded with piecemeal endoscopic mucosal resection (p-EMR). The first cut revealed a creamy white internal surface (Fig. 1B). We then suspected possible recurrence of the MCL and decided to discontinue p-EMR. Histology findings were consistent with MCL relapse (Fig. 2). The patient was referred to the Oncology Unit for further care.
Figure 1
(A) Polyp of the proximal sigmoid colon with pit pattern I mucosa. (B) piecemeal endoscopic mucosal resection of the polyp and precautionary placement of endoscopic clip. The appearance of the cut surface raises the suspicion of mantle cell lymphoma recurrence
Figure 2
(A) Submucosal invasion of uniform small to medium-sized lymphocytes (Hematoxylin and eosin stain, original magnification 40x). (B) Cyclin D1 positivity (original magnification 100x). The immunophenotype of the lymphocytes was CD20+, Pax-5+, CD3-, CD5+, IgD+, IgM+, cyclinD1+, SOX11+, Ki67 labeling index: 50%, confirming the diagnosis of mantle cell lymphoma relapse
Gastrointestinal (GI) involvement of MCL is common in patients who present with GI symptoms [1]. Nevertheless, very few cases have been reported in the literature where MCL relapse is diagnosed by colonoscopy. Current guidelines do not include endoscopy in the regular follow up of such patients [2]. EMR is an advanced endoscopy technique usually performed with a therapeutic intent. This case may underscore the diagnostic value of EMR, because it can provide an adequate biopsy specimen for definitive pathology diagnosis.