Small Bowel Lymphoma
description
Transcript of Small Bowel Lymphoma
![Page 1: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/1.jpg)
Small Bowel LymphomaSeptember 15, 2011
UB Department of SurgeryGrand Rounds
Craig Collins MD
![Page 2: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/2.jpg)
Anatomy/PhysiologyPathogenesisBackgroundIncidenceRisk FactorsDiagnosisManagementPrognosisTake Home PointsFuture
Outline
![Page 3: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/3.jpg)
Anatomy/Physiology
![Page 4: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/4.jpg)
Small Bowel ~3mDuodenum ~20-30cmJejunum ~100-110cmIleum ~ 150cm
Blood supply based upon celiac axis and superior mesenteric artery (SMA). Venous return via superior mesenteric vein (SMV).
Anatomy/Physiology
![Page 5: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/5.jpg)
Layers of Small BowelMucosaSubmucosaMuscularisSerosa
Anatomy/Physiology
![Page 6: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/6.jpg)
Spiral folds of mucosa and submucosa (plicae circularis) are more prominent proximally.
Jejunum is larger in diameter, is generally thicker, and has more prominent mucosal folds.
Peyer’s Patches (lymphoid tissue) found in submucosal layer and become more prominent distally in the Ileum.
Anatomy/Physiology
![Page 7: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/7.jpg)
Primary functions are digestion, absorption, and motility.
Endocrine function (CCK, secretin, other peptides)
Immune function via secretion of IgA from Peyer's patches.
Anatomy/Physiology
![Page 8: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/8.jpg)
Small bowel accounts for 75% of GI tract length and 90% of mucosal surface.
Accounts for 3-6% of GI tract tumors and 1-3% of all malignant GI tumors.
2/3 of symptomatic GI tract tumors are malignant.
Majority of benign lesions are asymptomatic and are discovered at autopsy.
Anatomy/Physiology
![Page 9: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/9.jpg)
Several factors thought to account for rarity of small bowel neoplasms.
Rapid transit timeLiquid contentsNeutral pH and high levels of benzopyrene
hydroxylaseBacterial flora/load Increased lymphoid tissue and IgA-
Immunoprotective role.
Pathogenesis
![Page 10: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/10.jpg)
Hodgkin’s Lymphoma first described in 1832 by Dr. Thomas Hodgkin.
Orderly spread of disease from one lymph node group to another, pathologically characterized by presence of Reed Sternberg cells.
One of the first cancers to be cured by XRT and subsequently by combination chemotherapy. ~93% cure rate.
Background
![Page 11: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/11.jpg)
Classified into 4 pathologic subtypes based upon Reed-Sternberg cell morphology.
Nodular SclerosingMixed CellularityLymphocyte richLymphocyte depleted
Background
![Page 12: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/12.jpg)
Non-Hodgkin’s LymphomaB-Cell*
diffuse large cell*Small cell (Mantle cell and follicular)mixed small and large cellMALT Lymphoma
Burkitt’sEATL (Enteropathy Associated T-Cell Lymphoma) Immunoproliferative small intestinal disease
(IPSID)
Background
* Most common (2/3), 70-80% High grade, 20-30% low grade
![Page 13: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/13.jpg)
Lymphomas can affect any lymph node station and nearly every organ.
Primary GI (extra-nodal) lymphomas represent ~30% of all lymphomas.
Gastric- 75%Small Bowel (including duodenum)- 9%Ileo-cecal region- 7%>1 GI site- 6%Rectum- 2%Colon- 1%
Background
![Page 14: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/14.jpg)
All sub-types of nodal lymphomas may also arise in GI tract but NHL are most common.
Ulcerating or infiltrating.
Background
![Page 15: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/15.jpg)
Colon cancer 50-60x more common than small bowel cancers.
Primary small bowel cancer:Adenocarcinoma (40%) > NET (30%) > Lymphoma
(20%) > Sarcoma/other (~10%)
~ 50% of small bowel neoplasms are secondary (metastasis)*.
Colon, stomach, pancreas, melanoma, breast, & lung.
Incidence
*Direct extension, intraperitoneal seeding, hematogenous/lymphatic spread
![Page 16: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/16.jpg)
1.6 cases/million/year
Steep rise in the 1980’s in correlation to AIDS
Bimodal age distribution, 20’s-30’s and >50.
Incidence
![Page 17: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/17.jpg)
Celiac diseaseIBDRAChronic infection, poor sanitationHIV/AIDS with low CD4 count Post transplant
Risk factors
Inflammation
Immunosuppression
![Page 18: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/18.jpg)
![Page 19: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/19.jpg)
![Page 20: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/20.jpg)
Data taken as a whole do not support the hypothesis that IBD alone is a risk factor for lymphoma.
Suggests IBD pts. Treated with AZA and 6-MP are at greater risk of lymphoma than general population.
? Regarding risk of severe or prolonged IBD compared with less severe disease.
![Page 21: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/21.jpg)
Small but real increase in the risk of lymphoma in IBD patients receiving anti-TNF-α therapy, but risk yet to be clearly quantified.
![Page 22: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/22.jpg)
Undoubtedly an increased risk of malignancy in celiac disease with regard to small bowel lymphoma and adenocarcinoma.
Risk of NHL may be increased 3-9 fold, but the overall risk to celiac population is < 1 %.
Risk diminishes over time if compliant with gluten free diet and is equal to general population 15 years after diagnosis.
![Page 23: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/23.jpg)
Prospective cohort study of 637 pts with treated celiac disease in the UK from 1978-2001. Malignancy rates recorded.
Risk to general population was estimated from cancer registries.
Median follow up was 6.6 years (2.2-14.5 yrs).
Cancer diagnosis within 2 years of celiac disease excluded.
![Page 24: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/24.jpg)
![Page 25: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/25.jpg)
No increase in overall malignancy rate in diagnosed celiac disease in the post-diagnosis period when compared with the general population.
5x greater rate of NHL and 40x greater rate of small bowel lymphoma compared with general population in the post-diagnosis period.
![Page 26: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/26.jpg)
![Page 27: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/27.jpg)
Abdominal pain, weight loss, nausea, emesis, GIB, chronic anemia.
Median duration of symptoms- 6 months.
Normal PE in 24%, abdominal mass in 46%.
Often present with perforation, bleeding, or obstruction necessitating emergent surgery (~25-50%)
Clinical Presentation
![Page 28: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/28.jpg)
![Page 29: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/29.jpg)
Criteria:Lack of peripheral or mediastinal
lymphadenopathy.Normal WBC count and differential on peripheral
smear.Tumor involvement primarily in GI tract.No involvement of liver or spleen. No history of previously treated nodal lymphoma.
Diagnosis
![Page 30: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/30.jpg)
SBFT/EnteroclysisBarium Enema EGD/ColonoscopyPush Enteroscopy, Double Balloon EndoscopyCapsule endoscopyCTMRIPET/ PET CTExploratory Laparotomy/Laparoscopy*
Diagnosis- Modalities
* Diagnosis in ~50% of patients
![Page 31: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/31.jpg)
Wide variety of radiologic manifestations- ulceration, stricture, polypoid mass, mechanical obstruction, intussusception, fistulas, aneurysmal bowel dilatation, thick mucosal folds, separation of adjacent loops, mesenteric adenopathy and mesenteric thickening.
Clinical and radiographic challenge due to vague symptoms, rarity of disease, and relative inaccessibility of the small bowel.
Diagnosis
![Page 32: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/32.jpg)
Physical Exam with performance statusCBC with differential, plateletsLDHHep B testing if Rituximab contemplatedCT Chest/Abdomen/Pelvis for stagingPregnancy testing in women of childbearing age if
chemo planned.Select cases- Bone marrow biopsy with aspirate for
multifocal disease. PET-CT, MRI, Hep C testing
Diagnosis/Work up- NCCN
![Page 33: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/33.jpg)
Diagnosis- CT Enteroclysis
![Page 34: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/34.jpg)
Diagnosis- CT Enteroclysis
![Page 35: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/35.jpg)
Diagnosis- CT
![Page 36: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/36.jpg)
Diagnosis- CT
![Page 37: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/37.jpg)
Diagnosis- CT
![Page 38: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/38.jpg)
Diagnosis- CT
![Page 39: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/39.jpg)
Diagnosis- CT
![Page 40: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/40.jpg)
Diagnosis- MRI
![Page 41: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/41.jpg)
Endoscope introduced, balloon inflated, scope advanced. Performed via oral and anal routes. Depth range from 1-8.8m.
Allows for visualization and tissue diagnosis.
Diagnosis- Double Balloon Endoscopy
![Page 42: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/42.jpg)
Retrospective review of 29 pts with GI lymphoma, further examined by double balloon endoscopy.
Sought to determine prevalence of additional GI lymphomas.
![Page 43: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/43.jpg)
![Page 44: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/44.jpg)
50% of their pts had additional GI lymphomas.
Recommends complete evaluation of the small bowel in any patient with GI lymphoma.
![Page 45: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/45.jpg)
Double Balloon Endoscopy
![Page 46: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/46.jpg)
Diagnosis- Capsule Endoscopy
![Page 47: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/47.jpg)
![Page 48: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/48.jpg)
Low yield but superior test for small bowel
Diagnostic impact in 57%, exclusive therapeutic decisions in 12%
Overall diagnostic yield for obscure GIB 58-80%
6% were SB tumors
![Page 49: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/49.jpg)
PET-CT
![Page 50: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/50.jpg)
Staging- Ann ArborStage I- limited to intestine
Stage II- Extension into regional nodes or infiltration of surrounding organ
Stage III- Involvement of lymph nodes on both sides of diaphragm
Stage IV- Involvement of distant organs or extra abdominal lymph nodes
![Page 51: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/51.jpg)
Optimal treatment remains poorly defined but remains surgical as a primary therapy followed by adjuvant chemotherapy.
Rarity of tumors, paucity of data on mgmt and prognosis…info usually from small case series and extrapolated from nodal lymphomas.
Two most important factors regarding management
HistologyStaging
Management
![Page 52: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/52.jpg)
For localized, early stage disease, surgical resection with wide margins including node bearing mesentery is the standard.
For advanced, disseminated tumors which are not resectable, surgical treatment is limited to obtaining tissue for diagnosis and palliating complications.
Radiation and chemotherapy.
Management
![Page 53: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/53.jpg)
Stage I/II- Resection +/- chemotherapy Negative margins- clinical f/u Q3-6mos for 5 years then
annually thereafter Positive margins- chemotherapy, possible reoperation Multiple lymphomatous polyposis- chemo only
Stage III/IV- Resection + Chemotherapy Observation Close clinical follow up Re-staging- which imaging to use? Neoadjuvant therapy?
Management-NCCN
![Page 54: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/54.jpg)
The best chemotherapy regimen depends on the histology of the tumor. diffuse large B-cell lymphoma-CHOP is still the
gold standard. +/- Rituximab- primary therapy, combination,
maintenence
Low-grade lymphomas- indolent course- Fludarabine alone or in combination with cyclophosphamide. Rituximab as monotherapy.
Management-NCCN
![Page 55: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/55.jpg)
First Line- R+CHOP, RCVP x 6 cycles
First line for elderly or Infirm- Rituximab + single agent alkylator (cyclophosphamide, chlorambucil)
Extended therapy- Rituximab maintenance x 2 years
Fludarabine, cyclo, mitoxantrone
Chemotherapy regimens
![Page 56: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/56.jpg)
Extent of therapy based upon age, performance status, previous therapies, and extent of relapse.
No role for radiation of the small bowel.
Management
![Page 57: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/57.jpg)
Bovine and shark cartilageEchinaceaGarlicGinsengGinger
Alternative/Complementary Therapy
![Page 58: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/58.jpg)
Perforation- median survival of 8 months
AIDS related lymphomasMedian survival 5-11 months
B cellstage I/II- ~60-75% 5 year survivalStage III/IV- ~ 20-40% 5 year survival
EATL5 year survival 10-20%
Prognosis
![Page 59: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/59.jpg)
![Page 60: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/60.jpg)
![Page 61: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/61.jpg)
![Page 62: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/62.jpg)
Small bowel lymphoma is a rare disease with vague symptoms initially, making timely diagnosis difficult.
Risk factors include RA, CD, ?IBD, & immunosuppression.
Imaging plays an integral role in diagnosis but studies remain difficult to obtain/interpret.
Majority of cases diagnosed at laparotomy, many present emergently
Take Home Points
![Page 63: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/63.jpg)
>50% of patients have nodal/distant mets at presentation.
Primary therapy is surgery followed by adjuvant chemotherapy depending on the stage and histology.
Minimal progress in overall survival over the last 2 decades.
Take Home Points
![Page 64: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/64.jpg)
Significant improvement in diagnostic modalities and surgical care over the past 20 years but no significant change in survival.
Need better medical therapyImmunotherapyGene therapyChemotherapyNeoadjuvant therapy?
Future
![Page 65: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/65.jpg)
References1. Balthazar EJ, et al. "CT of small-bowel lymphoma in immunocompetent patients and patients with AIDS: comparison of findings." AJR. American Journal of Roentgenology 168.3 (1997): 675-80. 2. Berkelhammer C, et al. "Ileocecal intussusception of small-bowel lymphoma: diagnosis by colonoscopy." Journal of Clinical Gastroenterology 25.1 (1997): 358-61.
3. Boudiaf M, et al. "Small-bowel diseases: prospective evaluation of multi-detector row helical CT enteroclysis in 107 consecutive patients." Radiology 233.2 (2004): 338-44. 4. Chao TC, et al. "Perforation through small bowel malignant tumors." Journal of Gastrointestinal Surgery 9.3 (2005): 430-5. 5. Freeman HJ. "Free perforation due to intestinal lymphoma in biopsy-defined or suspected celiac disease." Journal of Clinical Gastroenterology 37.4 (2003): 299-302. 6. Johnston SD and Watson RG. "Small bowel lymphoma in unrecognized coeliac disease: a cause for concern?." European Journal of Gastroenterology & Hepatology 12.6 (2000): 7. Loberant N, et al. "Enteropathy-associated T-cell lymphoma: a case report with radiographic and computed tomography appearance." Journal of Surgical Oncology 65.1 (1997): 8. Matsumoto T, et al. "Double-balloon endoscopy depicts diminutive small bowel lesions in gastrointestinal lymphoma." Digestive Diseases & Sciences 55.1 (2010): 158-65. 9. Neugut AI, et al. "The epidemiology of cancer of the small bowel." Cancer Epidemiology, Biomarkers & Prevention 7.3 (1998): 243-51 10. Nguyen AT, et al. "A new subtype of Hodgkin's lymphoma, syncytial nodular sclerosing: first case report of primary small bowel lymphoma." Journal of Gastrointestinal Cancer 40.1-2 (2009): 38-40. 11. O'Boyle CJ, et al. "Primary small intestinal tumours: increased incidence of lymphoma and improved survival." Annals of the Royal College of Surgeons of England 80.5 (1998): 12. Pandey M, et al. "Malignant lymphoma of the gastrointestinal tract." European Journal of Surgical Oncology 25.2 (1999): 164-713.Pasta V, et al. "[Small bowel lymphomas: a case report]." [in Italian] Giornale di
Chirurgia 25.3 (2004): 89-94.
![Page 66: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/66.jpg)
References14. Ullerich H, et al. "18F-Fluorodeoxyglucose PET in a patient with primary small bowel
lymphoma: the only sensitive method of imaging." American Journal of Gastroenterology 96.8 (2001): 2497-9
15. Washington K, et al. "Gastrointestinal pathology in patients with common variable immunodeficiency and X-linked agammaglobulinemia." American Journal of Surgical Pathology 20.10 (1996): 1240-52.
16. Woodley HE, Spencer JA and MacLennan KA. "Small-bowel lymphoma complicating long-standing Crohn's disease." AJR. American Journal of Roentgenology 9.5 (1997):
17. Liu PP, et al. "Lymphoproliferative disorder after liver transplantation." Journal of the Formosan Medical Association 97.1 (1998): 59-62..
18. Lohan DG, et al. "MR enterography of small-bowel lymphoma: potential for suggestion of histologic subtype and the presence of underlying celiac disease." AJR. American Journal of Roentgenology 190.2 (2008): 287-93.
19. McGough N and Cummings JH. "Coeliac disease: a diverse clinical syndrome caused by intolerance of wheat, barley and rye." Proceedings of the Nutrition Society 64.4 (2005):
20. Ang YS and Farrell RJ. "Risk of lymphoma: inflammatory bowel disease and immunomodulators." Gut 55.4 (2006): 580-1.
21. Barrington SF and O'Doherty MJ. "Limitations of PET for imaging lymphoma." European Journal of Nuclear Medicine & Molecular Imaging 30 Suppl 1.(2003): S117-27.
22. Buckley JA and Fishman EK. "CT evaluation of small bowel neoplasms: spectrum of disease." Radiographics 18.2 (1998): 379-92.
23. Card TR, West J and Holmes GK. "Risk of malignancy in diagnosed coeliac disease: a 24-year prospective, population- based, cohort study." Alimentary Pharmacology & Therapeutics 20.7 (2004): 769-75.
24. Catena F, et al. "Small bowel tumours in emergency surgery: specificity of clinical presentation." ANZ Journal of Surgery 75.11 (2005): 997-9.
25. Cheung DY, et al. "Capsule endoscopy in small bowel tumors: a multicenter Korean study." Journal of Gastroenterology & Hepatology 25.6 (2010): 1079-86.
26. Gore RM, et al. "Diagnosis and staging of small bowel tumours." Cancer Imaging 6.(2006): 209-12.
![Page 67: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/67.jpg)
References27. Jones JL and Loftus EV Jr. "Lymphoma risk in inflammatory bowel disease: is it the
disease or its treatment?." Inflammatory Bowel Diseases 13.10 (2007): 1299-307.28 Kam MH, et al. "Small bowel malignancies: a review of 29 patients at a single centre." 29. .Lepage C, et al. "Incidence and management of primary malignant small bowel cancers:
a well-defined French population study." American Journal of Gastroenterology 101.12 (2006): 2826-32.
30. Lewis JD, et al. "Inflammatory bowel disease is not associated with an increased risk of lymphoma." Gastroenterology 121.5 (2001): 1080-7.
31. Loftus EV Jr and Sandborn WJ. "Lymphoma risk in inflammatory bowel disease: influences of referral bias and therapy." Gastroenterology 121.5 (2001): 1239-42.
32. O'Riordan BG, Vilor M and Herrera L. "Small bowel tumors: an overview." Digestive Diseases 14.4 (1996): 245-57.
33. Psyrri A, Papageorgiou S and Economopoulos T. "Primary extranodal lymphomas of stomach: clinical presentation, diagnostic pitfalls and management." Annals of Oncology 19.12 (2008): 1992-9.
34. Rawis RA, Vega KJ, Trotman BW. “Small Bowel Lymphoma.” Curr treat Options Gastroenterol. 2003. Feb; (1):27-34.
35. Daum S, Ullrich R, Heise W, et al. Intestinal non-Hodgkin’s lymphoma: a multicenter prospective clinical study from the German Study Group on Intestinal non-Hodgkin’s Lymphoma. J Clin Oncol 2003; 21:2740.
36. Sabiston. “Textbook of Surgery.” 17th Edition.2004.37. Cameron. “Current Surgical Management. 10th Edition. 2011.
![Page 68: Small Bowel Lymphoma](https://reader035.fdocuments.us/reader035/viewer/2022062501/5681650d550346895dd78670/html5/thumbnails/68.jpg)
Thank You