Korean J Gastroenterol.  2023 Nov;82(5):254-260. 10.4166/kjg.2023.101.

Improvement of Severe Colon Stricture after Rituximab Therapy for Concomitant Mucosa-associated Lymphoid Tissue Lymphoma in a Patient with Ulcerative Colitis

• Park HJ
• Moon W
• Park SJ
• Park MI
• Kim SE
• Kim JH
• Jung K
• Seo KI
• Lee EM
• Jung M

• KMID: 2548496
• DOI: http://doi.org/10.4166/kjg.2023.101

Abstract

Colorectal strictures are uncommon in patients with ulcerative colitis (UC). An extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) lymphoma is rarely involved in the colon but may be associated with inflammatory bowel diseases. A 41-year-old female with a six-year history of UC presented with a severe stricture of the sigmoid colon that prevented the passage of a colonoscope. A histological examination revealed non-specific inflammation and fibrosis without dysplasia or cancer. Despite conventional treatment, including mesalazine and azathioprine for one year after that visit, the stricture persisted. In addition, diffuse, edematous exudative inflammation and multiple shallow ulcers were observed in the distal rectum, revealing a MALT lymphoma testing positive for CD20, CD43, CD5, and Bcl-2, but negative for CD3, CD10, CD23, and cyclin-D1. Four weekly doses of rituximab were administered. Follow-up colonoscopy performed one month after treatment revealed slight improvement in the rectal lesion without remnant histological evidence of a MALT lymphoma. In addition, the stricture showed marked improvement, and the colonoscope could pass easily through the stricture site. This is the first case report on an improvement of a severe sigmoid colon stricture in a patient with UC after rituximab treatment for a concomitant rectal MALT lymphoma.

Keyword

Colitis, ulcerative; Lymphoma, B-cell, marginal zone; Azathioprine; Rituximab; Inflammatory bowel disease

Figure

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  Fig. 1 Findings of colonoscopy performed at the initial visit. (A) Severe stricture in the sigmoid colon, with a lumen diameter of approximately 6 mm, located 17–19 cm from the anal verge. (B) Erythematous mucosa and absence of the vascular pattern with diffuse, continuous-fashion, but no mucosal break was observed from the distal rectum.

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  Fig. 2 Microscopic findings of the mucosa at the stricture site in the sigmoid colon. The mucosa exhibited glandular distortion and fibrous changes in lamina propria (H&E, ×200).

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  Fig. 3 Abdominal CT scan at the initial visit. Stricture in the sigmoid colon (white arrows) and enhanced wall thickening are observed. (A) Axial view. (B) Coronal view.

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  Fig. 4 Findings of colonoscopy conducted after one year since the first visit. (A) No significant changes in severe stricture in the sigmoid colon, with a lumen diameter of approximately 6 mm, located 17–19 cm from the anal verge. (B) Diffuse, edematous exudative inflammation with shallow ulcers was observed in the distal rectum, 5 cm site from the anal verge.

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  Fig. 5 Microscopic findings of rectal mucosa before the rituximab treatment. The rectal mucosa is infiltrated with atypical lymphocytes, revealing small-to-medium-sized nuclei with slightly irregular contours, dispersed chromatin, and inconspicuous nuclei (presented inside the dotted circle) and prominent plasmacytoid differentiation (presented outside the dotted circle) (H&E, ×400).

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  Fig. 6 Findings of colonoscopy performed one month (A, B) and 16 months (C, D) after treatment with rituximab. (A) Stricture of the sigmoid colon markedly improved to a lumen diameter of approximately 20 mm. (B) Edematous inflammation with shallow ulcers in the distal rectum, 5 cm site from the anal verge, showing slightly improved nodularity of the lesion. (C) Stricture of the sigmoid colon appeared to be slightly narrower than its condition one month after treatment. (D) Mucosal scar change in the distal rectum, 5 cm site from the anal verge, showing improved edematous inflammation with shallow ulcers.

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  Fig. 7 Microscopic findings 16 months after the rituximab treatment. (A) The previous stricture site in the sigmoid colon exhibits glandular distortion of ulcerative colitis, such as intracryptal budding (indicated by an open arrowhead) and crypt rings in rows (indicated by closed arrowheads). (B) The previous mucosa-associated lymphoid tissue (MALT) lymphoma site in the rectum exhibits glandular distortion of ulcerative colitis, such as crypt branching (indicated by an arrow). There is no evidence of malignancy, including MALT lymphoma (H&E, ×400).

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