The patient was a non-smoker, tobacco chewer, alcohol or betel nut chewer.

On examination, the mass of 3x4 cm was palpated at the right iliac fossa.

Initial blood works were normal, a CT scan revealed growth in ascending colon & caecum, and colonoscopic biopsies showed chronic active colitis.

Table 1: Blood investigation reports.

Tumor marker: CEA 2.55 (normal)

CECT Abdomen suggested:

-Abnormal Circumferential wall thickening and luminal narrowing in the caecum, ic junction and terminal ileum.

-Multiple Lymphonodes in right ileocolic mesentery max dia 2x1 cm and aortocaval 1.7x1.4cm.

OGD- proliferative nodular growth at the cecum and edematous ileocecal valve noted, the biopsy was taken correspondingly.

Biopsy 1: chronic active colitis, no evidence of dysplasia or malignancy

Because of persistent symptoms proceeded with Right hemicolectomy

Fig 1: Right hemicolectomy specimen Final biopsy report.

is 55 years. Men are affected twice as often as women. The most common symptoms of colonic lymphoma are Abdominal pain, Nausea, Vomiting, Weight loss, Abdominal mass, Change in bowel habits, Hematochezia, Obstruction, Intussusceptions, Acute peritonitis due to intestinal perforation. Lymphoma can often present with B symptoms (fever, night sweats and weight loss)

The infrequency of these complaints suggests that, despite the large size of the lymphoma, mucosal ulceration does not usually occur

The cecum is the most frequent location for primary colorectal lymphoma, probably due to the larger amount of lymphoid tissue in this region. In different series, the data on the frequency in the rectum varies from 8.3% to 35%.

The lack of specific complaints makes the diagnosis hard to establish. Unfortunately, for some patients, a surgical procedure is the only diagnostic tool. As a rare lesion, it requires a high index of suspicion. Due to a delay in diagnosis in 33%-65% of patients, the operative procedure is either urgent or emergent.

Dawson et al established criteria for the diagnosis of primary colorectal lymphomas in 1961(3)

These are:

(1) no enlarged superficial lymph nodes when the patient is first seen;

(2) chest radiographs without obvious enlargement of the mediastinal nodes;

(3) the white blood cell counts, both total and differential, are within normal range and bone marrow biopsy is also normal.

(4) at laparotomy only regional nodes are affected by the disease.

(5) the liver and spleen are free of tumors.

Table 2 : Published Studies in Large Bowel Lymphoma. Kindly refer Annexure 1

Anderson et al have shown that the distribution of NHL subtypes differs in various geographical areas and suggested that this could be a reflection of differences in etiological factors or the host response to these factors [4]. Unlike western countries, the frequency of T cell lymphoma in the East is reported to be 17.9%-42%.

In 2005, Bilsel et al (16) reported a case of primary lymphoma of the rectum with a complete clinical response after a combination of radiation and chemotherapy. Similar results were published by other authors.

In case series published in 2002, Pricolo et al [17] treated patients with surgical resection and adjuvant chemo and radiotherapy.

Shimono et al (18) from Japan suggested preoperative radiotherapy.

Some authors proposed the so-called preventive chemotherapy in patients with stage IE, reaching five-year survival of 80%.

In cases of indolent lymphomas (mantle cell, follicular cell and T cell lymphomas), complete surgical resection and radiation are recommended because of decreased chemoresponsiveness.

Factors affecting survival differ among authors. The stage at the diagnosis has an impact on survival. According to Fan et al, only histological grade seems to be an adverse factor for prognosis. The urgency of the surgical procedure is also found to be an important factor affecting survival.