肠道非B细胞淋巴瘤与克罗恩病的鉴别诊断
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摘要
目的探讨克罗恩病(Crohn’s disease, CD)和肠道非B细胞淋巴瘤的临床鉴别诊断特点。方法回顾性分析我院2012年1月至2018年8月收治的肠道非B细胞淋巴瘤(n=27)和CD病(n=30)患者的临床资料,寻找具有统计学意义的指标,并进一步分析其在鉴别诊断中的意义。结果腹腔脓肿、瘘管、肛周病变、肠外表现、阑尾切除病史在CD组中更常见,差异有统计学意义(P<0.05);B症状和急性肠穿孔在肠道非B细胞淋巴瘤组中更常见(P<0.05)。血小板在CD组明显升高(P<0.001)。内镜及小肠CT中,节段性病变、回盲部受累、肠腔狭窄、铺路石样改变,以及梳样征、息肉样凸起、系膜血管增生在CD组中更常见(P<0.05),腹腔淋巴结融合增大在肠道非B细胞淋巴瘤组中更为常见(P<0.05)。结论临床需结合小肠CT、检验及内镜寻找CD和肠道非B细胞淋巴瘤的鉴别诊断点,从而提高确诊率。疑诊肠道非B细胞淋巴瘤者需多次内镜并多块深挖活检明确病理诊断。
Objective To investigate the clinical diagnostic characteristics of intestinal non-B cell lymphoma and Crohn's disease(CD). Methods The clinical data of 27 patients with intestinal non-B cell lymphoma and 30 CD patients admitted in our hospital from January 2012 to August 2018 were collected and retrospectively analyzed to search for the indexes with statistical significance and further analyze its significance in differential diagnosis. Results Abdominal abscess, fistula, perianal lesions, and intestinal stenosis were more common in the CD group(P<0.05), while, B symptoms and acute intestinal perforation were more common in lymphoma group(P<0.05). The platelet count was significantly higher in the CD group than the lymphoma group(P<0.001). In the endoscopic and intestinal CT images, segmental changes, ileocecal involvement, intestinal stenosis, cobblestone or paving stone-like changes, comb sign, polypoid bulge and Mesangial angiogenesis were more common in the CD group(P<0.05), while abdominal lymph node fusion was more common in intestinal lymphoma(P<0.05). Conclusion In clinical practice, in order to improve the accuracy of diagnosis, it is necessary to find the differential diagnosis points of CD and intestinal non-B cell lymphoma by combining small intestinal CT scanning and endoscopy. For the patients suspected of lymphoma, multiple endoscopy and multiple deep-dug biopsies are needed to determine the pathological diagnosis.
Objective To investigate the clinical diagnostic characteristics of intestinal non-B cell lymphoma and Crohn's disease(CD). Methods The clinical data of 27 patients with intestinal non-B cell lymphoma and 30 CD patients admitted in our hospital from January 2012 to August 2018 were collected and retrospectively analyzed to search for the indexes with statistical significance and further analyze its significance in differential diagnosis. Results Abdominal abscess, fistula, perianal lesions, and intestinal stenosis were more common in the CD group(P<0.05), while, B symptoms and acute intestinal perforation were more common in lymphoma group(P<0.05). The platelet count was significantly higher in the CD group than the lymphoma group(P<0.001). In the endoscopic and intestinal CT images, segmental changes, ileocecal involvement, intestinal stenosis, cobblestone or paving stone-like changes, comb sign, polypoid bulge and Mesangial angiogenesis were more common in the CD group(P<0.05), while abdominal lymph node fusion was more common in intestinal lymphoma(P<0.05). Conclusion In clinical practice, in order to improve the accuracy of diagnosis, it is necessary to find the differential diagnosis points of CD and intestinal non-B cell lymphoma by combining small intestinal CT scanning and endoscopy. For the patients suspected of lymphoma, multiple endoscopy and multiple deep-dug biopsies are needed to determine the pathological diagnosis.
引文
[1] AOKI R, KARUBE K, SUGITA Y, et al. Distribution of malignant lymphoma in Japan: Analysis of 2260 cases, 2001-2006[J]. Pathol Int, 2008, 58(3): 174-182. DOI: 10.1111/j.1440-1827.2007.02207.x.
[2] YANG Q P, ZHANG W Y, YU J B, et al. Subtype distribution of lymphomas in Southwest China: analysis of 6, 382 cases using WHO classification in a single institution[J]. Diagn Pathol, 2011, 6: 77. DOI: 10.1186/1746-1596-6-77.
[3] YOON S O, SUH C, LEE D H, et al. Distribution of lymphoid neoplasms in the Republic of Korea: analysis of 5318 cases according to the World Health Organization classification[J]. Am J Hematol, 2010, 85(10): 760-764. DOI: 10.1002/ajh.21824.
[4] CHEN W L, TSAI W C, CHAO T Y, et al. The clinicopathological analysis of 303 cases with malignant lymphoma classified according to the World Health Organization classification system in a single institute of Taiwan[J]. Ann Hematol, 2010, 89(6): 553-562. DOI: 10.1007/s00277-009-0870-z.
[5] KIM S J, CHOI C W, MUN Y C, et al. Multicenter retrospective analysis of 581 patients with primary intestinal non-hodgkin lymphoma from the Consortium for Improving Survival of Lymphoma (CISL)[J]. BMC Cancer, 2011, 11: 321. DOI: 10.1186/1471-2407-11-321.
[6] 郑梅英, 王承党. 原发性肠道淋巴瘤的临床特点分析[J]. 胃肠病学和肝病学杂志, 2015, 24(5): 582-585. DOI: 10.3969/j.issn.1006-5709.2015.05.028. ZHENG M Y, WANG C D. The clinical characteristics of primary intestinal lymphoma[J]. Chin J Gastroenterol Hepatol, 2015, 24(5): 582-585. DOI: 10.3969/j.issn.1006-5709.2015.05.028.
[7] ZHENG S M, OUYANG Q, LI G D, et al. Primary intestinal NK/T cell lymphoma: A clinicopathologic study of 25 Chinese cases[J]. Arch Iran Med, 2012, 15(1): 36-42. DOI: 012151/AIM.0011.
[8] YANG L, TANG X F, PENG X, et al. Clinical characteristics of primary intestinal NK/T cell lymphoma, nasal type: Case series and review of the literature[J]. Pathol Res Pract, 2018, 214(8): 1081-1086. DOI: 10.1016/j.prp.2018.05.013.
[9] OOI C J, MAKHARIA G K, HILMI I, et al. Asia pacific consensus statements on crohn’s disease. part 1: definition, diagnosis, and epidemiology[J]. J Gastroenterol Hepatol, 2016, 31(1): 45-55. DOI: 10.1111/jgh.12956.
[10] Apdw Chinese Ibd Working Group. Retrospective analysis of 515 cases of Crohn’s disease hospitalization in China: nationwide study from 1990 to 2003[J]. J Gastroenterol Hepatol, 2006, 21(6): 1009-1015. DOI: 10.1111/j.1440-1746.2006.04140.x.
[11] ZHENG J J, ZHU X S, HUANGFU Z, et al. Crohn’s disease in mainland China: A systematic analysis of 50 years of research[J]. Chin J Dig Dis, 2005, 6(4): 175-181. DOI: 10.1111/j.1443-9573.2005.00227.x.
[12] MAASER C, STURM A, VAVRICKA S R, et al. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detections of complications[J]. J Crohn’s Colitis, 2018,13(2): 1-32. DOI: 10.1093/ecco-jcc/jjy113.
[13] 吴开春, 梁洁, 冉志华, 等. 炎症性肠病诊断与治疗的共识意见(2018年·北京)[J]. 中国实用内科杂志, 2018, 38(9): 796-813. DOI: 10.19538/j.nk2018090106. WU K C, LIANG J, RAN Z H, et al. Chinese consensus on diagnosis and treatment of inflammatory bowel disease(Beijing, 2018)[J]. Chin J Pract Intern Med, 2018, 38(9): 796-813. DOI: 10.19538/j.nk2018090106.
[14] WEIR A B, POON M C, GROARKE J F, et al. Lymphoma simulating Crohn’s colitis[J]. Dig Dis Sci, 1980, 25(1): 69-72.
[15] BERKELHAMMER C, MOHAMMED A, ZALZALEH G, et al. Spontaneous multiperforation in lymphomatous colitis masquerading as Crohn’s disease: 2 cases[J]. Inflamm Bowel Dis, 2008, 14(8): 1172-1173. DOI: 10.1002/ibd.20436.
[16] GUALCO G, DOMENY-DUARTE P, CHIOATO L, et al. Clinicopathologic and molecular features of 122 Brazilian cases of nodal and extranodal NK/T-cell lymphoma, nasal type, with EBV subtyping analysis[J]. Am J Surg Pathol, 2011, 35(8): 1195-1203. DOI: 10.1097/PAS.0b013e31821ec4b5.
[17] LAURINI J A, PERRY A M, BOILESEN E, et al. Classification of non-Hodgkin lymphoma in Central and South America: A review of 1028 cases[J]. Blood, 2012, 120(24): 4795-4801. DOI: 10.1182/blood-2012-07-440073.
[18] BARRIONUEVO C, ZAHARIA M, MARTINEZ M T, et al. Extranodal NK/T-cell lymphoma, nasal type: study of clinicopathologic and prognosis factors in a series of 78 cases from Peru[J]. Appl Immunohistochem Mol Morphol, 2007, 15(1): 38-44.
[19] AVILé S A, DíAZ N R, NERI N, et al. Angiocentric nasal T/natural killer cell lymphoma: A single centre study of prognostic factors in 108 patients[J]. Clin Lab Haematol, 2000, 22(4): 215-220.
[20] SUN Z H, ZHOU H M, SONG G X, et al. Intestinal T-cell lymphomas: A retrospective analysis of 68 cases in China[J]. World J Gastroenterol, 2014, 20(1): 296-302. DOI: 10.3748/wjg.v20.i1.296.
[21] GOU H F, ZANG J, JIANG M, et al. Clinical prognostic analysis of 116 patients with primary intestinal non-Hodgkin lymphoma[J]. Med Oncol, 2012, 29(1): 227-234. DOI: 10.1007/s12032-010-9783-x.
[22] 尹文娟, 吴梅娟, 杨海燕, 等. 216例原发胃肠道非霍奇金淋巴瘤患者病理特征与预后关系分析[J]. 中华血液学杂志, 2013, 34(5): 377-382. DOI: 10.3760/cma.j.issn.0253-2727.2013.05.001. YIN W J, WU M J, YANG H Y, et al. Clinicopathological features and prognostic factors of 216 cases with primary gastrointestinal tract non-Hodgkin’s lymphoma[J]. Chin J Hematol, 2013, 34(5): 377-382. DOI: 10.3760/cma.j.issn.0253-2727.2013.05.001.
[23] YU H S, WANG Y D, PENG L, et al. Endoscopic manifestations of primary colorectal lymphoma[J]. Hepatogastroenterol, 2014, 61(129): 76-78.
[24] 冉文斌, 欧阳钦. 肠道原发性非霍奇金淋巴瘤85例分析[J]. 南方医科大学学报, 2012, 32(4): 534-538. DOI: 10.3969/j.issn.1673-4254.2012.04.021. RAN W B, OUYANG Q. Primary intestinal non-Hodgkin’s lymphoma: A retrospective study of 85 cases[J]. J Southern Med Univ, 2012, 32(4): 534-538. DOI: 10.3969/j.issn.1673-4254.2012.04.021.
[25] DING W S, ZHAO S, WANG J C, et al. Gastrointestinal lymphoma in southwest China: subtype distribution of 1, 010 cases using the WHO (2008) classification in a single institution[J]. Acta Haematol, 2016, 135(1): 21-28. DOI: 10.1159/000437130.
[26] SUN J, YANG Q P, LU Z H, et al. Distribution of lymphoid neoplasms in China: analysis of 4, 638 cases according to the World Health Organization classification[J]. Am J Clin Pathol, 2012, 138(3): 429-434. DOI: 10.1309/AJCP7YLTQPUSDQ5C.
[27] KIM Y H, LEE J H, YANG S K, et al. Primary colon lymphoma in korea: A KASID (korean association for the study of intestinal diseases) study[J]. Dig Dis Sci, 2005, 50(12): 2243-2247. DOI: 10.1007/s10620-005-3041-7.
[28] ZHANG T Y, LIN Y, FAN R, et al. Potential model for differential diagnosis between Crohn’s disease and primary intestinal lymphoma[J]. World J Gastroenterol, 2016, 22(42): 9411-9418. DOI: 10.3748/wjg.v22.i42.9411.
[29] CHEN M K, CAO Z, LIU S Z, et al. Differential diagnosis of intestinal tuberculosis from Crohn’s disease and primary intestinal lymphoma in China[J]. Saudi J Gastroenterol, 2014, 20(4): 241. DOI: 10.4103/1319-3767.136979.
[30] CAKAL B, AKOZ A G, USTUNDAG Y, et al. Red cell distribution width for assessment of activity of inflammatory bowel disease[J]. Dig Dis Sci, 2009, 54(4): 842-847. DOI: 10.1007/s10620-008-0436-2.
[31] KAPSORITAKIS A N, KOUKOURAKIS M I, SFIRIDAKI A, et al. Mean platelet volume: A useful marker of inflammatory bowel disease activity[J]. Am J Gastroenterology, 2001, 96(3): 776-781. DOI: 10.1111/j.1572-0241.2001.03621.x.
[2] YANG Q P, ZHANG W Y, YU J B, et al. Subtype distribution of lymphomas in Southwest China: analysis of 6, 382 cases using WHO classification in a single institution[J]. Diagn Pathol, 2011, 6: 77. DOI: 10.1186/1746-1596-6-77.
[3] YOON S O, SUH C, LEE D H, et al. Distribution of lymphoid neoplasms in the Republic of Korea: analysis of 5318 cases according to the World Health Organization classification[J]. Am J Hematol, 2010, 85(10): 760-764. DOI: 10.1002/ajh.21824.
[4] CHEN W L, TSAI W C, CHAO T Y, et al. The clinicopathological analysis of 303 cases with malignant lymphoma classified according to the World Health Organization classification system in a single institute of Taiwan[J]. Ann Hematol, 2010, 89(6): 553-562. DOI: 10.1007/s00277-009-0870-z.
[5] KIM S J, CHOI C W, MUN Y C, et al. Multicenter retrospective analysis of 581 patients with primary intestinal non-hodgkin lymphoma from the Consortium for Improving Survival of Lymphoma (CISL)[J]. BMC Cancer, 2011, 11: 321. DOI: 10.1186/1471-2407-11-321.
[6] 郑梅英, 王承党. 原发性肠道淋巴瘤的临床特点分析[J]. 胃肠病学和肝病学杂志, 2015, 24(5): 582-585. DOI: 10.3969/j.issn.1006-5709.2015.05.028. ZHENG M Y, WANG C D. The clinical characteristics of primary intestinal lymphoma[J]. Chin J Gastroenterol Hepatol, 2015, 24(5): 582-585. DOI: 10.3969/j.issn.1006-5709.2015.05.028.
[7] ZHENG S M, OUYANG Q, LI G D, et al. Primary intestinal NK/T cell lymphoma: A clinicopathologic study of 25 Chinese cases[J]. Arch Iran Med, 2012, 15(1): 36-42. DOI: 012151/AIM.0011.
[8] YANG L, TANG X F, PENG X, et al. Clinical characteristics of primary intestinal NK/T cell lymphoma, nasal type: Case series and review of the literature[J]. Pathol Res Pract, 2018, 214(8): 1081-1086. DOI: 10.1016/j.prp.2018.05.013.
[9] OOI C J, MAKHARIA G K, HILMI I, et al. Asia pacific consensus statements on crohn’s disease. part 1: definition, diagnosis, and epidemiology[J]. J Gastroenterol Hepatol, 2016, 31(1): 45-55. DOI: 10.1111/jgh.12956.
[10] Apdw Chinese Ibd Working Group. Retrospective analysis of 515 cases of Crohn’s disease hospitalization in China: nationwide study from 1990 to 2003[J]. J Gastroenterol Hepatol, 2006, 21(6): 1009-1015. DOI: 10.1111/j.1440-1746.2006.04140.x.
[11] ZHENG J J, ZHU X S, HUANGFU Z, et al. Crohn’s disease in mainland China: A systematic analysis of 50 years of research[J]. Chin J Dig Dis, 2005, 6(4): 175-181. DOI: 10.1111/j.1443-9573.2005.00227.x.
[12] MAASER C, STURM A, VAVRICKA S R, et al. ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detections of complications[J]. J Crohn’s Colitis, 2018,13(2): 1-32. DOI: 10.1093/ecco-jcc/jjy113.
[13] 吴开春, 梁洁, 冉志华, 等. 炎症性肠病诊断与治疗的共识意见(2018年·北京)[J]. 中国实用内科杂志, 2018, 38(9): 796-813. DOI: 10.19538/j.nk2018090106. WU K C, LIANG J, RAN Z H, et al. Chinese consensus on diagnosis and treatment of inflammatory bowel disease(Beijing, 2018)[J]. Chin J Pract Intern Med, 2018, 38(9): 796-813. DOI: 10.19538/j.nk2018090106.
[14] WEIR A B, POON M C, GROARKE J F, et al. Lymphoma simulating Crohn’s colitis[J]. Dig Dis Sci, 1980, 25(1): 69-72.
[15] BERKELHAMMER C, MOHAMMED A, ZALZALEH G, et al. Spontaneous multiperforation in lymphomatous colitis masquerading as Crohn’s disease: 2 cases[J]. Inflamm Bowel Dis, 2008, 14(8): 1172-1173. DOI: 10.1002/ibd.20436.
[16] GUALCO G, DOMENY-DUARTE P, CHIOATO L, et al. Clinicopathologic and molecular features of 122 Brazilian cases of nodal and extranodal NK/T-cell lymphoma, nasal type, with EBV subtyping analysis[J]. Am J Surg Pathol, 2011, 35(8): 1195-1203. DOI: 10.1097/PAS.0b013e31821ec4b5.
[17] LAURINI J A, PERRY A M, BOILESEN E, et al. Classification of non-Hodgkin lymphoma in Central and South America: A review of 1028 cases[J]. Blood, 2012, 120(24): 4795-4801. DOI: 10.1182/blood-2012-07-440073.
[18] BARRIONUEVO C, ZAHARIA M, MARTINEZ M T, et al. Extranodal NK/T-cell lymphoma, nasal type: study of clinicopathologic and prognosis factors in a series of 78 cases from Peru[J]. Appl Immunohistochem Mol Morphol, 2007, 15(1): 38-44.
[19] AVILé S A, DíAZ N R, NERI N, et al. Angiocentric nasal T/natural killer cell lymphoma: A single centre study of prognostic factors in 108 patients[J]. Clin Lab Haematol, 2000, 22(4): 215-220.
[20] SUN Z H, ZHOU H M, SONG G X, et al. Intestinal T-cell lymphomas: A retrospective analysis of 68 cases in China[J]. World J Gastroenterol, 2014, 20(1): 296-302. DOI: 10.3748/wjg.v20.i1.296.
[21] GOU H F, ZANG J, JIANG M, et al. Clinical prognostic analysis of 116 patients with primary intestinal non-Hodgkin lymphoma[J]. Med Oncol, 2012, 29(1): 227-234. DOI: 10.1007/s12032-010-9783-x.
[22] 尹文娟, 吴梅娟, 杨海燕, 等. 216例原发胃肠道非霍奇金淋巴瘤患者病理特征与预后关系分析[J]. 中华血液学杂志, 2013, 34(5): 377-382. DOI: 10.3760/cma.j.issn.0253-2727.2013.05.001. YIN W J, WU M J, YANG H Y, et al. Clinicopathological features and prognostic factors of 216 cases with primary gastrointestinal tract non-Hodgkin’s lymphoma[J]. Chin J Hematol, 2013, 34(5): 377-382. DOI: 10.3760/cma.j.issn.0253-2727.2013.05.001.
[23] YU H S, WANG Y D, PENG L, et al. Endoscopic manifestations of primary colorectal lymphoma[J]. Hepatogastroenterol, 2014, 61(129): 76-78.
[24] 冉文斌, 欧阳钦. 肠道原发性非霍奇金淋巴瘤85例分析[J]. 南方医科大学学报, 2012, 32(4): 534-538. DOI: 10.3969/j.issn.1673-4254.2012.04.021. RAN W B, OUYANG Q. Primary intestinal non-Hodgkin’s lymphoma: A retrospective study of 85 cases[J]. J Southern Med Univ, 2012, 32(4): 534-538. DOI: 10.3969/j.issn.1673-4254.2012.04.021.
[25] DING W S, ZHAO S, WANG J C, et al. Gastrointestinal lymphoma in southwest China: subtype distribution of 1, 010 cases using the WHO (2008) classification in a single institution[J]. Acta Haematol, 2016, 135(1): 21-28. DOI: 10.1159/000437130.
[26] SUN J, YANG Q P, LU Z H, et al. Distribution of lymphoid neoplasms in China: analysis of 4, 638 cases according to the World Health Organization classification[J]. Am J Clin Pathol, 2012, 138(3): 429-434. DOI: 10.1309/AJCP7YLTQPUSDQ5C.
[27] KIM Y H, LEE J H, YANG S K, et al. Primary colon lymphoma in korea: A KASID (korean association for the study of intestinal diseases) study[J]. Dig Dis Sci, 2005, 50(12): 2243-2247. DOI: 10.1007/s10620-005-3041-7.
[28] ZHANG T Y, LIN Y, FAN R, et al. Potential model for differential diagnosis between Crohn’s disease and primary intestinal lymphoma[J]. World J Gastroenterol, 2016, 22(42): 9411-9418. DOI: 10.3748/wjg.v22.i42.9411.
[29] CHEN M K, CAO Z, LIU S Z, et al. Differential diagnosis of intestinal tuberculosis from Crohn’s disease and primary intestinal lymphoma in China[J]. Saudi J Gastroenterol, 2014, 20(4): 241. DOI: 10.4103/1319-3767.136979.
[30] CAKAL B, AKOZ A G, USTUNDAG Y, et al. Red cell distribution width for assessment of activity of inflammatory bowel disease[J]. Dig Dis Sci, 2009, 54(4): 842-847. DOI: 10.1007/s10620-008-0436-2.
[31] KAPSORITAKIS A N, KOUKOURAKIS M I, SFIRIDAKI A, et al. Mean platelet volume: A useful marker of inflammatory bowel disease activity[J]. Am J Gastroenterology, 2001, 96(3): 776-781. DOI: 10.1111/j.1572-0241.2001.03621.x.