The Turkish Journal of Gastroenterology

To the Editor,
Immunoproliferative small intestinal disease (IPSID) is a subtype of mucosa-associated lymphoid tissue (MALT) lymphoma. Campylobacter jejuni is suspected in the etiology. The most frequently affected sites are the duodenum and upper jejunum. To date, long-term antibiotic therapy has been the first-line treatment for early and late stage 0 in a staging system proposed by Salem and Estephan, and then chemotherapy is the next choice. In contrast, surgery is reserved for staging and uncommon abdominal disasters (1,2).

A 53-year-old woman had stage IA endometrial adenocarcinoma, FIGO grade 1, and underwent a staging operation. One year after the initial diagnosis of endometrial cancer, pelvic sonography showed ascites. At that time, this patient complained of mild intermittent abdominal distention and lower abdominal discomfort. Apart from these symptoms, she denied having weight loss, chronic diarrhea, nausea, or fever, etc. Computed tomography (CT) showed a 3.7-centimeter conglomerate mass as well as multiple nodules nearby and focal fat stranding in the mesentery of the right lower quadrant, close to the terminal ileum (Figure 1). Aside from these abnormalities, there were no other significant findings in any other region. Another CT six weeks later displayed that the above-mentioned lesions had grown slightly. There was no important abnormality in the basic laboratory data.

Metastasis of endometrial cancer was originally considered as the primary cause of these lesions, but a few differential diagnoses such as lymphoma or inflammatory diseases were also contemplated. In order to reach a definite diagnosis, exploratory laparotomy was performed, and multiple nodules in the mesocolon of the ascending colon were found. The frozen section report showed lymphoid tissue proliferation but lymphoma could not be ruled out. Since the possibility of malignancy could still not be excluded, right hemicolectomy was carried out. The pathology report confirmed the final diagnosis as IPSID, late stage 0.

The history of malignancy initially lured us into attributing these lesions to metastasis. However, for lesions near the terminal ileum, there are various differential diagnoses, ranging from malignant to benign entities (3). Primary small intestinal lymphoma was the second impression in this patient because of the patient’s age and the affected location of the lymphadenopathy. However, focal clustered enlarged lymph nodes are not typical for metastasis or primary small intestinal lymphoma (1,4). Therefore, retrieving more problematic tissue by surgical biopsy might have been a better choice for this patient because this would have given the patient the opportunity to receive antibiotic treatment or chemotherapy instead of right hemicolectomy.