Synchronous tumors: Hodgkin disease presenting in mesenteric lymph nodes from a right hemicolectomy for colon carcinoma.

Abstract: The authors report the case of a 56-year-old male diagnosed with Hodgkin disease involving the mesenteric lymph nodes recovered from a right hemicolectomy for colonic adenocarcinoma. The liver and bone marrow were also involved by Hodgkin disease. Synchronous colonic carcinoma and lymphoma in the same patient is a rare occurrence, and Hodgkin disease involving the mesenteric lymph nodes is uncommon as well.

Key Words: colonic carcinoma, Hodgkin disease, lymphoma, mesenteric lymph nodes

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Hodgkin disease is a malignancy that rarely affects the mesenteric lymph nodes (<5%). (1) Hodgkin disease characteristically presents as asymptomatic supraclavicular lymph node enlargement in a young adult, but may also be discovered in the mid or high neck or in the axilla. B symptoms may occur in some patients, including fever, night sweats, pruritus, fatigue, and weight loss. We describe a patient diagnosed with Hodgkin disease involving the mesenteric lymph nodes recovered from a right hemicolectomy for colon carcinoma. Coexisting colonic carcinoma and lymphoma in the same patient is an uncommon event.

Case Report

A 56-year-old male presented at the emergency room with complaints of dyspnea, nausea, vomiting, and diarrhea for 14 days. He had been ill for 3 weeks with fever, chills, night sweats, and a 10-pound weight loss. His medical history included peripheral vascular disease, coronary artery disease, hypertension, and type II lipid disorder. He smoked one pack of cigarettes per day for 37 years, but stopped smoking 2 weeks before admission. He did not consume alcohol or abuse alcohol or drugs. He had no melena, rectal bleeding, cough, hemoptysis, or exposure to tuberculosis or enteric illness. His epidemiologic history was unremarkable.

Physical examination showed a confused, dehydrated man in labored breathing. He had a temperature of 102[degrees]F, heart rate of 120 beats per minute, respiratory rate of 28 breaths per minute, and blood pressure of 87/40. Significant findings were right upper and mid abdominal tenderness, palpable liver, and spleen not enlarged.

Laboratory data showed hematocrit of 28.8%, white blood cell count of 6,500 K/CMM and platelet count of 289,000 K/CMM. Prothrombin time was elevated at 15.3 seconds. Alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase were elevated at 363,167, and 88 U/L, respectively. Serum creatinine was elevated at 5.7 mg/dL, and blood urea nitrogen at 59 mg/dL. Cultures from blood, stool, and urine did not grow organisms. Hepatitis profile and Clostridium difficile toxin were negative, as were serologies for Brucella, Leptospira, and Francisella tularensis. Purified protein derivative skin test results did not show induration.

A computed tomographic scan of the chest, abdomen, and pelvis showed mediastinal adenopathy and a suspicious mass-like lesion in the ascending colon.

The patient was started on antibiotics, given fluid resuscitation, and transfused with 2 U of packed red blood cells. Colonoscopy showed a constricting lesion in the right colon, and multiple biopsies were performed which revealed colonic adenocarcinoma. He subsequently underwent a right hemicolectomy and showed a large tumor in the mid-ascending colon with multiple enlarged lymph nodes within the mesentery. A small nodule in the left lobe of the liver was resected and sent for frozen section. Pathology report revealed a 7-cm, moderately differentiated colonic adenocarcinoma invading into but not through the muscularis propria (Duke B). Seven mesenteric lymph nodes were recovered that showed polymorphous infiltrate of lymphoid cells, eosinophils, and plasma cells, with scattered diagnostic Reed-Sternberg cells. Immunohistochemical stains confirmed the diagnosis of classic Hodgkin disease, mixed cellularity type (Figs. 1 and 2). The liver nodule and bone marrow biopsy showed involvement by Hodgkin disease (stage IVB).

After surgery, the patient continued to be febrile, with temperatures ranging from 102 to 105[degrees]F, which was attributed to Hodgkin disease. His postoperative course was otherwise unremarkable, and he was subsequently discharged. He underwent Port-a-Cath placement on another admission for his chemotherapy, and was started on ABVD therapy (Adriamycin, bleomycin, vinblastin, and dimethyltriazenoimidazolecarboxamide [DTIC]).

Discussion

Coexisting primary malignant lymphoma and colon carcinoma in the same patient is a rare event. It has been estimated that the probability of having lymphoma in a patient with existing colonic carcinoma is approximately 2%. (2) There have been studies that proposed possible factors and mechanisms that may play a role in the occurrence of synchronous colonic carcinoma and lymphoma. The implicated factors include environmental agents, immune abnormalities, and genetic constitution of the patient. (2) Barron and Localio (2) suggested that the lymphomatous process may be the initial event that compromises the patient's immune defenses against the development of colon cancer. Oncogenic effects of radiotherapy and chemotherapy have also been implicated, resulting in the development of secondary neoplasms. (3, 4)

Several cases of synchronous lymphoma and colon carcinoma have been reported. Our patient was diagnosed with Hodgkin disease involving the mesenteric lymph nodes recovered from a right hemicolectomy for colonic adenocarcinoma. The liver and bone marrow were also involved by Hodgkin disease. Two cases similar to our patient's have been described by Barron and Localio (2) and Petros and Argy. (5) However, our patient's Hodgkin disease presented with B symptoms.

[FIGURE 1 OMITTED]

Hodgkin disease infrequently presents below the diaphragm, and its occurrence in elderly males is more common in these sites. (6) Approximately 80% of the cases in a combined series presented as peripheral inguinal, femoral, and superficial iliac lymphadenopathy. (6) Patients presenting with central abdominal involvement made up 20% of cases of subdiaphragmatic Hodgkin disease, and were frequently associated with B symptoms. (6) Mesenteric lymph node involvement is uncommon (< 5%). (1) Other initial clinical presentations include fever of unknown origin, epidural mass, splenic pathology, (1) intra-abdominal mass, autoimmune hemolytic anemia, immune thrombocytopenia, (6) and extranodal primary involvement. (7,8) Our patient's Hodgkin disease was of mixed cellularity type, which frequently occurs in subdiaphragmatic Hodgkin disease. An increase in the incidence of lymphocyte-predominant and lymphocyte-depleted subtypes has also been reported. (6)

[FIGURE 2 OMITTED]

Conclusion

Based on the study by Polk et al, (9) multiple primary malignant neoplasms in the same patient is an important consideration in the treatment of patients with carcinoma. (10-14)

While we are postponing, life speeds by.
--Seneca

Accepted June 4, 2004.

References

1. Canellos G, Lister AT, Sular J, in Rosenberg S, Canellos G (eds): Hodgkin's Disease. The Lymphomas. 1st ed. Philadelphia, WB Saunders Company, 1998, pp 305-329.

2. Barron BA, Localio SA. A statistical note on the association of colorectal cancer and lymphoma. Am J Epidemiol 1976; 104:517-522.

3. Aggarwal P, Sharma S, Wali J, et al. Colonic carcinoma after chemotherapy of Hodgkin's disease. J Clin Gastroenterol 1989;11:340-342.

4. Kreiker J, Kattan J. Second colon cancer following Hodgkin's disease: a case report. J Med Libanais 1996;44:107-108.

5. Petros JG, Argy O. Hodgkin's disease in the mesenteric lymph nodes in a patient with colon carcinoma. Mt Sinai J Med 1990;57:368-370.

6. Krikorian JG, Portlock CS, Maunch PM. Hodgkin's disease presenting below the diaphragm: a review. J Clin Oncol 1986;4:1551-1562.

7. Thomas DB, Huston BM, Lamm KR, et al. Primary Hodgkin's disease of the sigmoid colon: a case report and review of the literature. Arch Pathol Lab Med 1997; 121:528-532.

8. Zemsky L, Katz H, Edelman M, et al. Hodgkin's disease involving the large bowel. Clin Colorec Cancer 2001;1:185-186.

9. Polk HC, Spratt JS, Butcher HR. Frequency of multiple primary malignant neoplasms associated with colorectal carcinoma. Am J Surg 1985; 109:71-74.

10. Jaworski RC, Dowton B, Grant A, et al. Colorectal carcinoma and lymphoma. Aust N Z J Surg 1982; 52:37-38.

11. Dinshaw KA, Advani SH, Desai PB, et al. An evaluation of intraabdominal involvement in Hodgkin's disease. J Surg Oncol 1978;10:559-566.

12. Mir-Madjlessi SH, Vafai M, Khadeni J, et al. Coexisting primary malignant lymphoma and adenocarcinoma of the large intestine in an IgA-deficient boy. Dis Colon Rectum 1984; 27:822-824.

13. Sugihara S, Yamaguchi A, Mataumura K, et al. Concurrent malignant lymphomas of the jejunum and multiple synchronous colon cancers. Am J Gastroenterol 1983; 78:341-345.

14. Krikorian JG, Portlock CS, Rosenberg SA, et al. Hodgkin's disease, stages I and II occurring below the diaphragm. Cancer 1979;43:1868-1871.

RELATED ARTICLE: Key Points

* Synchronous occurrence of colonic carcinoma and lymphoma is a rare phenomenon, with an estimated probability of 2%.

* Mesenteric lymph node involvement by Hodgkin disease is also uncommon (< 5%).

* Presence of multiple primary malignant neoplasms in the same patient is an important consideration in the treatment of patients with carcinoma.

Joanne M. Quilon, MD, Scott Day, MD, and James C. Lasker, MD

From the Department of Pathology, Baptist Medical Center-Princeton, Birmingham, AL.

Reprint requests to Joanne M. Quilon, MD, Baptist Medical Center, Department of Pathology, 800 Montclair Road, Birmingham, AL 35213-1984. Email: [e-mail]