Anaplastic Large Cell Lymphoma of the Colon in a Patient with Colonic Crohn Disease Treated with Infliximab and Methotrexate

Abstract

A 57-year-old woman, with colonic Crohn disease (CD) diagnosed four years previously, presented to the emergency department with a six-week history of severe abdominal pain. She did not have diarrhea. She had inactive perianal fistulas. Laboratory tests at presentation showed an elevated C-reactive protein level of 103 mg/L, and low albumin of 24 g/L. Other bloodwork was unremarkable. Stool testing was negative for Clostridium difficile, and culture and sensitivity. Her medical history was significant for rheumatoid arthritis (RA). She had been receiving infliximab and methotrexate for RA and CD. A computed tomography scan revealed wall thickening in the ascending, transverse and descending colon. No lymphadenopathy was present. Pericolonic inflammatory changes were apparent. No obstruction was present. Colonoscopy at the time of admission, to confirm what appeared to be a CD flare, revealed a benign-appearing ulcerated stricture at 40 cm from the anal verge (Figure 1). The colonoscope could not pass the stricture. There was no active CD in the colon distal to the stricture. The stricture was biopsied. The patient was treated with intravenous solumedrol and, subsequently, prednisone for a presumed CD flare. Steroids led to resolution of her pain. Biopsies of the stricture unexpectedly revealed an anaplastic large cell lymphoma (ALCL) (Figure 2). Infliximab and methotrexate were discontinued. A bone marrow biopsy was negative for lymphoma and computed tomography enterography showed a normal small bowel. The patient successfully completed six cycles of CHOP (cyclophosphamide, hydroxy doxorubicin, vincristine, prednisone) chemotherapy. Repeat biopsies of the stricture postchemotherapy showed no lymphoma, but atypical cells were present (Figure 3). A tattoo was used to mark the location of the stricture. The stricture was balloon-dilated to allow visualization of the proximal colon. There was only a single, discrete patch of ulceration in the ascending colon. Biopsies here were consistent with CD. It was believed that her risk of lymphoma recurrence was high. She was referred for surgical intervention and underwent a left hemicolectomy.

An Unusual Case of BIA-ALCL Associated with Prolonged/Complicated Biocell-Textured Expander, followed by Smooth Round Breast Implant Exposure, and Concurrent Use of Adalimumab

“…The medical oncology literature has extensive descriptions of the increased risk of rare lymphomas associated with immunosuppressants in general, 14 and specifically anti-TNFα medications such as adalimumab and infliximab. 15,16 There is a specific association with primary cutaneous ALCL and adalimumab use, 17 which is notable in that primary cutaneous ALCL is the disease process most similar to BIA-ALCL. This raises an important question: Is active anti-TNFα medication use a relative contraindication to placement of permanent textured breast implants?…”

Synchronous colonic adenoma and intestinal marginal zone B-cell lymphoma associated with Crohn’s disease: a case report and literature review

“…Several subtypes of lymphoma have been described in patients with Crohn’s disease: Hodgkin’s lymphoma, follicular lymphoma, non-Hodgkin’s (low grade lymphoma) [13], anaplastic large cell lymphoma [14], Hepatosplenic T-cell lymphoma [15], EBV-associated plasmablastic lymphoma [16], with only two cases of MALT lymphoma [13, 17].…”

Anaplastic Lymphoma Kinase-Negative Anaplastic Large Cell Lymphoma with Colon Involvement

“…The most frequent extranodal involvement sites are the skin, lungs, liver and gastrointestinal tract, whereas colon involvement is extremely rare (1,2). To our knowledge, only two previous case reports presented endoscopic findings of ALCL with colon involvement; one case showed multiple elevated lesions with ulceration at the apex, and the other showed ulcerated stricture (3,4). If ulcerative colonic lesions are observed on colonoscopy, colon involvement of ALCL should be considered as a rare differential diagnosis.…”