378
TIIE INDIANJOUILNALOF PEDIATRICS
Vol. 59, No. 3
Primary Non-Hodgldns Lymphoma of the Rectum A.K. Sharma, Arvind Shukla, Girish Prabhakar, Praveen Mathur, Yogesh Sarin, Sandeep Nijhawan* and R.R Rai Department of Pediatrics Surge~ and *Gastroenterolog),, S.M.S. Medical College & Attached S.P.M. (3ffld Health h~stitj!te, Jaipur Non-Hodgkins Lymphoma is a primary neoplastic process of lymphoreticular system and can be nodal or extranodal. Predominant extranodal sites include small bowel, appendix, Meckel's diverticulum, retropcritoncum etc. Primary gastro-intcstinal lymphomas of colon are infrequent and that of rectum are rare. Herein we report a rare case of primary rectal lymphoma in a 9-year old male child. CASE HISTORY A 9-year old male child was admitted in the department of Pediatric Surgery, SPM Child Health Institute of S.M.S. Medical College, Jaipur with the complaints of bleeding per rectum, altered bowel habits and loss of weight and appetite for a duration of three months. Rectal examination revealed a firm growth occupying about half of the rectal lumen. Sigmoidoscopy revealed an ulcerated irregular growth (Figure 1). There was no peripheral lymphadenopathy. Ultrasonography and CT scan showed only the rectal mass without lymphadenopathy and hepatosplenomcgaly (Figure 2). Routine blood and urinalysis were normal. Biopsy of rectal mass came to be Non-Hodgkins lymphoma (Figure 3) Poor general condition obviated primary resection of the tumour. COMP was started but the child succumbed six days later due to its toxic effects.
Fig. 1. Intraluminal rectal sigmoidoscopically.
growth
seen
Fig. 2. CT scan showingthe rectal mass. DISCUSSION In west, Non-Hodgkins lymphoma in children is 2-4 times more frequcnl than Hodgkins lymphoma, whereas in India
CLINICALBRIEFS : PRIMARY NON-HODGKINSLYMPHOMAOF 'rill,; RECTUM
Fig. 3. Histopathologieal slide showing lamina propria and submucus coat infiltrated diffusely by a monomorphic round cell population. These cells have scanty cytoplasm with round hyperchromatic nuclei showing coarse chromatin. Distinct basophilic nuclei are present in many of the cells. Hodgkins lymphoma is commoner) Gastrointestinal tract is the predominant ex'tranodal site involved in Non-Hodgklns lymphoma comprising alJout 58% of all the cases? 4 Stomach and small bowel are thc most commonly affected organs, followed by ileocecal area and large intestine in decreasing order of frequency. Primary colorectal lymphomas are rare constituting only 10-20% of all gastrointestinal lymphomas in most series, 5,6 but Nirmala et al have rePorted a higher incidence of colorectal lymphomas in India. 7 In most series, colorectal lymphomas have been grouped together and thus the incidence of primary rectal lymphoma is difficult to assess. This is the first case of primary rectal lymphoma diagnosed in our department. It was classified as primary, on the basis of criteria laid down by Dawson ct al. 8 Normally these lesions are single, prescnting as protuberant intraluminal growth. Histologically, most lesions are diffuse with hisliocytic type. Nodular variely is rarely seen. Exact cliol-
379
ogy is obscure. Various predisposing factors implicated include ulcerative colitis and Chron's disease? Usual presenting features of colorectal lymphomas include abdominal pain, weight loss, altered bowel habits and bleeding per rectum. The mass may be palpable per abdomen or per rectum. Some patients may present with complications such as intussusception, perforation or obstruction. 9 Management depends upon the site and extent of the tumour. Surgical excision of the mass, if technically feasible, is the main stay of treatment. Radiotherapy and chemotherapy may also be used. REI,XRENCES
1. Banerjee CK, Srinivas M, Goswami KC et a]. Non-Hodgkin's lymphoma in children-Histopathologic classification in relation to age and sex. h3dian J l:'ediatr 1983; 50 : 511-514. 2. Freeman C, Berg JW, Culter SJ. Occurrcncc and prognosis of extranodal lymphomas. Cattcer 1972; 29 : 252-260. 3. Rosenberg SA, Diamond HD, Jaslowitz B, Craver LF. Lymphosarcoma : A review of 1269 cases. Medicb~e 1961; 40 : 31-34. 4. Jones SE, Fuks Z, BuU M et al. NonHodgkin's lymphomas IV. Clinicopathlogical correlation in 405 cases. Cancer 1973; 31 : 806-823. 5. Contreary K, Nance FC, Becker WF. Primary lymphoma of the gastrointestinal tract. Atm Sta~ 1980; 191 : 593-598. 6. Dragosics B, Bauer P, Radaszkiewicz T. Primary gastro-intcstinal non-Hodgkin's lymphomas. Cancer 1985; 65 : 1060-1073. 7. Nirmala V, Thomas JA, Anthony AJ. Primary malignant lymphoma of colon, btdian J Cancer 1981; 18 : 47-50. 8. Dawson IMP, Cornes JS, Morson BC. Primary malignant lymphoid tumours of the intestinal tract. BrJ Stag 1961; 49 : 80-89. 9. Richards MA. Lymphoma of the colon and rectum, l'ostgmd Med J 1986; 62 : 615620? ........... ~,, ~ .~.;:~;cr, h ~r:~ .:)c~,
TIIE INDIANJOUILNALOF PEDIATRICS
Vol. 59, No. 3
Primary Non-Hodgldns Lymphoma of the Rectum A.K. Sharma, Arvind Shukla, Girish Prabhakar, Praveen Mathur, Yogesh Sarin, Sandeep Nijhawan* and R.R Rai Department of Pediatrics Surge~ and *Gastroenterolog),, S.M.S. Medical College & Attached S.P.M. (3ffld Health h~stitj!te, Jaipur Non-Hodgkins Lymphoma is a primary neoplastic process of lymphoreticular system and can be nodal or extranodal. Predominant extranodal sites include small bowel, appendix, Meckel's diverticulum, retropcritoncum etc. Primary gastro-intcstinal lymphomas of colon are infrequent and that of rectum are rare. Herein we report a rare case of primary rectal lymphoma in a 9-year old male child. CASE HISTORY A 9-year old male child was admitted in the department of Pediatric Surgery, SPM Child Health Institute of S.M.S. Medical College, Jaipur with the complaints of bleeding per rectum, altered bowel habits and loss of weight and appetite for a duration of three months. Rectal examination revealed a firm growth occupying about half of the rectal lumen. Sigmoidoscopy revealed an ulcerated irregular growth (Figure 1). There was no peripheral lymphadenopathy. Ultrasonography and CT scan showed only the rectal mass without lymphadenopathy and hepatosplenomcgaly (Figure 2). Routine blood and urinalysis were normal. Biopsy of rectal mass came to be Non-Hodgkins lymphoma (Figure 3) Poor general condition obviated primary resection of the tumour. COMP was started but the child succumbed six days later due to its toxic effects.
Fig. 1. Intraluminal rectal sigmoidoscopically.
growth
seen
Fig. 2. CT scan showingthe rectal mass. DISCUSSION In west, Non-Hodgkins lymphoma in children is 2-4 times more frequcnl than Hodgkins lymphoma, whereas in India
CLINICALBRIEFS : PRIMARY NON-HODGKINSLYMPHOMAOF 'rill,; RECTUM
Fig. 3. Histopathologieal slide showing lamina propria and submucus coat infiltrated diffusely by a monomorphic round cell population. These cells have scanty cytoplasm with round hyperchromatic nuclei showing coarse chromatin. Distinct basophilic nuclei are present in many of the cells. Hodgkins lymphoma is commoner) Gastrointestinal tract is the predominant ex'tranodal site involved in Non-Hodgklns lymphoma comprising alJout 58% of all the cases? 4 Stomach and small bowel are thc most commonly affected organs, followed by ileocecal area and large intestine in decreasing order of frequency. Primary colorectal lymphomas are rare constituting only 10-20% of all gastrointestinal lymphomas in most series, 5,6 but Nirmala et al have rePorted a higher incidence of colorectal lymphomas in India. 7 In most series, colorectal lymphomas have been grouped together and thus the incidence of primary rectal lymphoma is difficult to assess. This is the first case of primary rectal lymphoma diagnosed in our department. It was classified as primary, on the basis of criteria laid down by Dawson ct al. 8 Normally these lesions are single, prescnting as protuberant intraluminal growth. Histologically, most lesions are diffuse with hisliocytic type. Nodular variely is rarely seen. Exact cliol-
379
ogy is obscure. Various predisposing factors implicated include ulcerative colitis and Chron's disease? Usual presenting features of colorectal lymphomas include abdominal pain, weight loss, altered bowel habits and bleeding per rectum. The mass may be palpable per abdomen or per rectum. Some patients may present with complications such as intussusception, perforation or obstruction. 9 Management depends upon the site and extent of the tumour. Surgical excision of the mass, if technically feasible, is the main stay of treatment. Radiotherapy and chemotherapy may also be used. REI,XRENCES
1. Banerjee CK, Srinivas M, Goswami KC et a]. Non-Hodgkin's lymphoma in children-Histopathologic classification in relation to age and sex. h3dian J l:'ediatr 1983; 50 : 511-514. 2. Freeman C, Berg JW, Culter SJ. Occurrcncc and prognosis of extranodal lymphomas. Cattcer 1972; 29 : 252-260. 3. Rosenberg SA, Diamond HD, Jaslowitz B, Craver LF. Lymphosarcoma : A review of 1269 cases. Medicb~e 1961; 40 : 31-34. 4. Jones SE, Fuks Z, BuU M et al. NonHodgkin's lymphomas IV. Clinicopathlogical correlation in 405 cases. Cancer 1973; 31 : 806-823. 5. Contreary K, Nance FC, Becker WF. Primary lymphoma of the gastrointestinal tract. Atm Sta~ 1980; 191 : 593-598. 6. Dragosics B, Bauer P, Radaszkiewicz T. Primary gastro-intcstinal non-Hodgkin's lymphomas. Cancer 1985; 65 : 1060-1073. 7. Nirmala V, Thomas JA, Anthony AJ. Primary malignant lymphoma of colon, btdian J Cancer 1981; 18 : 47-50. 8. Dawson IMP, Cornes JS, Morson BC. Primary malignant lymphoid tumours of the intestinal tract. BrJ Stag 1961; 49 : 80-89. 9. Richards MA. Lymphoma of the colon and rectum, l'ostgmd Med J 1986; 62 : 615620? ........... ~,, ~ .~.;:~;cr, h ~r:~ .:)c~,
