PET/MRI in the Early Diagnosis of Extra-Nodal Primary Colonic Lymphoma: A Rare Case Presentation

PET/MRI in the Early Diagnosis of Extra-Nodal Primary Colonic Lymphoma: A Rare Case Presentation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report PET/MRI in the Early Diagnosis of Extra-Nodal Primary Colonic Lymphoma: A Rare Case Presentation Pawan Gulabrao Shinkar, Somepalli Likhitha, Monal Dayal, Dileep Kumar, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6404631/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Positron emission tomography (PET) integrated with MRI (PET-MRI) offers a superior imaging modality combining functional and metabolic insights with exceptional soft tissue contrast, without ionizing radiation exposure. This case report discusses a rare presentation of extra-nodal primary colonic lymphoma involving the cecum and ascending colon, leading to hollow viscus perforation. A 55-year-old male with a history of diabetes mellitus presented with abdominal distension and weight loss. Initial imaging revealed a right lumbar mass with associated cecal wall dehiscence and peritoneal collections. PET/MRI, preferred over PET/CT due to renal impairment, provided critical diagnostic insights. Histopathological findings confirmed a lymphoproliferative disorder. The patient underwent laparotomy, peritoneal lavage, and loop ileostomy. This case underscores the significance of early diagnosis using advanced imaging techniques like PET/MRI in managing rare gastrointestinal lymphomas, particularly in high-risk populations, to prevent life-threatening complications such as perforation peritonitis. PET-MRI (Positron emission tomography-Magnetic resonance imaging) Lymphoproliferative disorders non-Hodgkin lymphoma diabetes mellitus hollow viscous perforation immunocompromised laparotomy diversion loop ileostomy. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Positron emission tomography (PET) is one of the most accurate imaging modalities that offers a functional report of any organ or tissue at a molecular level. Integrated modalities of PET-CT and PET-MRI have been developed and utilized over the last two decades. PET-MRI is an advanced technique that combines the metabolic and functional properties of tissue from PET with the anatomic properties of tissue from MRI [ 14 ]. The PET-MR imaging technique is superior to PET-CT as it provides better soft tissue contrast and more detailed tissue pathology [ 13 ]. Additionally, it offers the advantage of not exposing patients to ionizing radiation [ 12 ]. Lymphoproliferative disorders are a heterogeneous group of conditions characterized by an unrestrained increase in the production of B-lymphocytes and T-lymphocytes, causing monoclonal lymphocytosis, lymphadenopathy, and bone marrow infiltration. B-cell disorders include B-chronic lymphocytic leukemia, B-prolymphocytic leukemia, non-Hodgkin lymphoma, hairy cell leukemia, and splenic lymphoma. T-cell disorders include Sezary syndrome, T-prolymphocytic leukemia, adult T-cell leukemia-lymphoma, and large granulated lymphocyte leukemia [ 1 ]. Among these, Hodgkin’s and non-Hodgkin’s lymphomas are the most commonly presenting lymphoproliferative disorders. Lymphomas are usually confined to lymph nodes; however, there is considerable evidence of lymphomas affecting extra-nodal organs such as the liver, spleen, gastrointestinal tract, abdominal wall, pancreas, peritoneal cavity, biliary tract, and genitourinary tract [ 2 ]. Extra-nodal involvement of the gastrointestinal tract is not uncommon, but colonic involvement is particularly rare [ 3 ]. Lymphomas are more likely to occur in immunocompromised individuals, with an increased risk among diabetes mellitus patients [ 4 ]. Primary colorectal lymphomas are very rare and most commonly present in the cecum [ 5 ]. Symptoms of colorectal carcinoma include abdominal pain, an abdominal mass, and weight loss [ 7 ]. Neoplasms may cause perforation through direct penetration, necrosis, or obstruction [ 11 ]. Multi-detector computed tomography (MDCT) with contrast has high sensitivity and specificity in detecting the site of perforation and free air [ 15 ]. Renal impairment is a major contraindication for the use of iodinated contrast in CT imaging modalities [ 17 ]. Here, we present a case of extra-nodal primary large intestine lymphoma involving the cecum and ascending colon, which led to hollow viscus perforation due to cecal wall dehiscence. This was detected using PET/MRI imaging. A multidisciplinary team involving a radiologist, pathologist, and surgical oncologist managed this case. Clinical Presentation A 55-year-old male patient presented with abdominal distension and significant weight loss. His medical history revealed that he was a known case of diabetes mellitus (DM). Abdominal ultrasound (USG) revealed an intra-abdominal mass in the right lumbar quadrant. PET/CT was contraindicated due to impaired renal function (serum creatinine: 1.6 mg/dL; blood urea: 86 mg/dL; uric acid: 13.8 mg/dL). Therefore, PET/MRI was performed without IV contrast, revealing an FDG-avid mass in the right lumbar region, enclosing the cecum and ascending colon, with cecal wall dehiscence anteromedially and multiple large loculated pockets of peritoneal collection, suggestive of perforation peritonitis (Figures 1 & 2). A USG-guided biopsy of the right lumbar region mass showed fragments with discohesive sheets of medium to small cells. Large areas of hemorrhage were observed. The cells exhibited hyperchromatic round nuclei, inconspicuous nucleoli, and minimal eosinophilic cytoplasm with scattered mitoses. These findings suggested a lymphoproliferative disorder (Figure 5). The patient underwent laparotomy for hollow viscus perforation, followed by peritoneal lavage and a diversion loop ileostomy. IMAGING FINDINGS: DWI image(B) focused on mass revealed restricted diffusion and ADC map(C) revealed low signal intensity (green circle) with ADC mean value of 468*10 -6 mm 2 /s(significantly low value). HISTOPATHOLOGICAL FINDINGS: Discussion Lymphomas presenting as colonic masses are a very rare occurrence. According to the report by Zighelboim et al., 5.8% of all gastrointestinal lymphomas were colonic lymphomas, and colonic lymphomas comprise around 0.16% of colorectal neoplasms [ 6 ]. The most common site is the cecum [ 7 ]. In the above-mentioned case, there is involvement of both the cecum and the ascending colon. A study by Joanna Mitri stated that individuals affected by diabetes mellitus (DM) have an increased risk of non-Hodgkin lymphoma [ 8 ]. This increased risk may be due to impaired neutrophil activity and disrupted cellular and humoral immunity, leading to immune dysfunction in both type 1 and type 2 DM [ 9 ]. According to the report by C. W. Fan et al., the clinical presentations of colon lymphoma-affected patients include abdominal pain (62%), abdominal mass (54%), and weight loss (40%) [ 7 ]. An abdominal mass often remains asymptomatic for a prolonged period, leading to delayed diagnosis. Untreated intestinal masses may lead to perforation, although this is a rare presentation, resulting in peritonitis. Early diagnosis is critical to prevent intestinal perforation [ 10 ]. As mentioned earlier, the MDCT imaging modality is typically preferred for identifying the site of perforation. In a study conducted by Renate M. Hammerstingl et al., it was found that using a higher concentration of iodine contrast improves imaging clarity [ 16 ]. A study by Samuel N. Heyman et al. inferred that administering iodinated radiocontrast to diabetes mellitus (DM) patients adversely affects renal physiology, leading to contrast-induced nephropathy (CIN) [ 18 ]. In the above-mentioned case, the patient presented with abdominal distension and unintentional weight loss. The patient's renal function test (RFT) revealed anomalies, and as a known case of DM, PET/MRI was performed due to the contraindication for contrast administration. Radiological and histological examinations confirmed colonic lymphoma causing perforation peritonitis, which eventually led to hollow viscus perforation—a life-threatening condition. The patient underwent laparotomy, peritoneal lavage, and a diversion loop ileostomy to address the perforation. Declarations Ethics approval and consent to participate The studies involving human participants were reviewed and approved by the Institutional Review Board, Omega hospital, Hyderabad, India. Informed consent was waived due to the retrospective nature of the study by the institutional review board. All procedures performed in studies involving human participants were in accordance with the Helsinki Declaration as revised in 2013 and its later amendments. Consent for publication The authors affirm that IRB had waived informed consent for publication of the images in this manuscript. Availability of data and material The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors have no relevant financial or non-financial interests to disclose. All authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Authors' contributions All authors contributed to the study conception, design, material preparation, data collection and analysis were performed. The first draft of the manuscript was written by Palak Wadhwa and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgements NotApplicable References Justiz Vaillant AA, Stang CM. Lymphoproliferative Disorders. 2023 Aug 14. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 30725847. Lee WK, Lau EW, Duddalwar VA, Stanley AJ, Ho YY. Abdominal manifestations of extranodal lymphoma: spectrum of imaging findings. AJR Am J Roentgenol. 2008;191(1):198–206. doi: 10.2214/AJR.07.3146 . PMID: 18562746. Koch P, del Valle F, Berdel WE, Willich NA, Reers B, Hiddemann W, Grothaus-Pinke B, Reinartz G, Brockmann J, Temmesfeld A, Schmitz R, Rübe C, Probst A, Jaenke G, Bodenstein H, Junker A, Pott C, Schultze J, Heinecke A, Parwaresch R, Tiemann M; German Multicenter Study Group. Primary gastrointestinal non-Hodgkin's lymphoma: I. Anatomic and histologic distribution, clinical features, and survival data of 371 patients registered in the German Multicenter Study GIT NHL 01/92. J Clin Oncol. 2001;19(18):3861-73. doi: 10.1200/JCO.2001.19.18.3861 . PMID: 11559724. Mitri J, Castillo J, Pittas AG. Diabetes and risk of Non-Hodgkin's lymphoma: a meta-analysis of observational studies. Diabetes Care. 2008;31(12):2391–7. doi: 10.2337/dc08-1034 . PMID: 19033419; PMCID: PMC2584201. Wong MT, Eu KW. Primary colorectal lymphomas. Colorectal Dis. 2006;8(7):586 – 91. doi: 10.1111/j.1463-1318.2006.01021.x . PMID: 16919111. Zighelboim J, Larson MV. Primary colonic lymphoma. Clinical presentation, histopathologic features, and outcome with combination chemotherapy. J Clin Gastroenterol. 1994;18(4):291-7. PMID: 8071513. Fan CW, Changchien CR, Wang JY, Chen JS, Hsu KC, Tang R, Chiang JM. Primary colorectal lymphoma. Dis Colon Rectum. 2000;43(9):1277-82. doi: 10.1007/BF02237436 . PMID: 11005497. Mitri J, Castillo J, Pittas AG. Diabetes and risk of Non-Hodgkin's lymphoma: a meta-analysis of observational studies. Diabetes Care. 2008;31(12):2391–7. doi: 10.2337/dc08-1034 . PMID: 19033419; PMCID: PMC2584201. Moutschen MP, Scheen AJ, Lefebvre PJ. Impaired immune responses in diabetes mellitus: analysis of the factors and mechanisms involved. Relevance to the increased susceptibility of diabetic patients to specific infections. Diabete Metab. 1992 May-Jun;18(3):187–201. PMID: 1397473. Tauro LF, Furtado HW, Aithala PS, D'Souza CS, George C, Vishnumoorthy SH. Primary lymphoma of the colon. Saudi J Gastroenterol. 2009 Oct-Dec;15(4):279–82. doi: 10.4103/1319-3767.56095 . PMID: 19794280; PMCID: PMC2981851. Quayle FJ, Lowney JK. Colorectal lymphoma. Clin Colon Rectal Surg. 2006;19(2):49–53. doi: 10.1055/s-2006-942344 . PMID: 20011310; PMCID: PMC2780105. Heesakkers RA, Hövels AM, Jager GJ, van den Bosch HC, Witjes JA, Raat HP, Severens JL, Adang EM, van der Kaa CH, Fütterer JJ, Barentsz J. MRI with a lymph-node-specific contrast agent as an alternative to CT scan and lymph-node dissection in patients with prostate cancer: a prospective multicohort study. Lancet Oncol. 2008;9(9):850-6. doi: 10.1016/S1470-2045(08)70203-1. Epub 2008 Aug 15. PMID: 18708295. Brix G, Lechel U, Glatting G, Ziegler SI, Münzing W, Müller SP, Beyer T. Radiation exposure of patients undergoing whole-body dual-modality 18F-FDG PET/CT examinations. J Nucl Med. 2005;46(4):608–13. PMID: 15809483. Jung JH, Choi Y, Im KC. PET/MRI: Technical Challenges and Recent Advances. Nucl Med Mol Imaging. 2016;50(1):3–12. doi: 10.1007/s13139-016-0393-1. Epub 2016 Jan 26. PMID: 26941854; PMCID: PMC4762872. Del Gaizo AJ, Lall C, Allen BC, Leyendecker JR. From esophagus to rectum: a comprehensive review of alimentary tract perforations at computed tomography. Abdom Imaging. 2014;39(4):802 – 23. doi: 10.1007/s00261-014-0110-4 . PMID: 24584681. Hammerstingl RM, Vogl TJ. Abdominal MDCT: protocols and contrast considerations. Eur Radiol. 2005;15 Suppl 5:E78-90. doi: 10.1007/s10406-005-0169-7 . PMID: 18637234. Iodinated contrast media | Radiology Reference Article | Radiopaedia.org Heyman SN, Rosenberger C, Rosen S, Khamaisi M. Why is diabetes mellitus a risk factor for contrast-induced nephropathy? Biomed Res Int. 2013;2013:123589. doi: 10.1155/2013/123589. Epub 2013 Nov 21. PMID: 24350240; PMCID: PMC3856131. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6404631","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":453935714,"identity":"db67accc-3508-4b31-be25-a588cbb48daf","order_by":0,"name":"Pawan Gulabrao Shinkar","email":"","orcid":"","institution":"Omega Hospitals","correspondingAuthor":false,"prefix":"","firstName":"Pawan","middleName":"Gulabrao","lastName":"Shinkar","suffix":""},{"id":453935715,"identity":"383d2c6f-6b40-46f8-bcf7-cdeb16f97ed6","order_by":1,"name":"Somepalli Likhitha","email":"","orcid":"","institution":"Omega Hospitals","correspondingAuthor":false,"prefix":"","firstName":"Somepalli","middleName":"","lastName":"Likhitha","suffix":""},{"id":453935716,"identity":"da77d31c-4cce-4620-8579-4c549f03f0bb","order_by":2,"name":"Monal Dayal","email":"","orcid":"","institution":"Omega Hospitals","correspondingAuthor":false,"prefix":"","firstName":"Monal","middleName":"","lastName":"Dayal","suffix":""},{"id":453935717,"identity":"82855d6e-af5b-4dec-890e-deaaf1303e2f","order_by":3,"name":"Dileep Kumar","email":"","orcid":"","institution":"United Imaging Healthcare","correspondingAuthor":false,"prefix":"","firstName":"Dileep","middleName":"","lastName":"Kumar","suffix":""},{"id":453935718,"identity":"2d005285-486e-49ad-9f29-417288af56e1","order_by":4,"name":"Chaitanya Kumari Damerla","email":"","orcid":"","institution":"Omega Hospitals","correspondingAuthor":false,"prefix":"","firstName":"Chaitanya","middleName":"Kumari","lastName":"Damerla","suffix":""},{"id":453935719,"identity":"c8effda0-af92-4d0a-aa93-21736628f292","order_by":5,"name":"Mohana Vamsy","email":"","orcid":"","institution":"Omega Hospitals","correspondingAuthor":false,"prefix":"","firstName":"Mohana","middleName":"","lastName":"Vamsy","suffix":""},{"id":453935720,"identity":"d64dd01e-ab43-4946-bd00-215416ce72e2","order_by":6,"name":"Palak Wadhwa","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYJACaSC2s29mPgCkJWSI1pJswM6WANLCQ7QWxg38PAYgDmEt5hLJD28XttkxmzPzfH51o8aCh4H98NEN+LRYzkgztp7Zlsxn2cy7zTrnGNBhPGlpN/BpMbidYCbNu42ZmeEw7zbjHDagFgkeMwJa0r8BtdQzNhzmeWac848oLTkgWw4zbjjMw/w4t40ILZbz3xRb8/47nizZzGbGnNsnwcNGyC/mPMc33uY5U23Hz3/48eecb3Vy/OyHj+F3GBKbTQJM4lOOroX5AyHVo2AUjIJRMDIBAM5RQhy5aJjoAAAAAElFTkSuQmCC","orcid":"","institution":"United Imaging Healthcare","correspondingAuthor":true,"prefix":"","firstName":"Palak","middleName":"","lastName":"Wadhwa","suffix":""}],"badges":[],"createdAt":"2025-04-08 15:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6404631/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6404631/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82604249,"identity":"c192cc87-f37c-40dd-aa57-fec33b89c982","added_by":"auto","created_at":"2025-05-13 09:56:02","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":586355,"visible":true,"origin":"","legend":"\u003cp\u003e(A, C) AXIAL T2W HASTE images showing large lumbar mass encasing caecum and ascending colon with caecal wall dehiscence anteromedially. Fused PET/MRI (B, D) and FDG PET(E, F) images reveal intense FDG uptake in right lumbar region mass.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6404631/v1/81d5a32c037837d70c3e0577.jpeg"},{"id":82604245,"identity":"654335ef-ded0-427c-bb07-76d57f1f0349","added_by":"auto","created_at":"2025-05-13 09:56:02","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":208768,"visible":true,"origin":"","legend":"\u003cp\u003eCoronal T2W HASTE FS image (A) showing right lumbar mass causing caecal wall dehiscence with multiple large loculated pockets of peritoneal collection s/o perforation peritonitis.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6404631/v1/63c623ed5a526e993b76db58.jpeg"},{"id":82607104,"identity":"f0022a29-08f6-477f-8d8d-dc929aa81a2f","added_by":"auto","created_at":"2025-05-13 10:12:02","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":389146,"visible":true,"origin":"","legend":"\u003cp\u003eAxial HASTE (A), Fused PET MRI (B) and FDG PET (C) images of primary mass showing Metabolic tumor volume (MTV) of 432548.8 mm2\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6404631/v1/f4dedcd4d61e40728c4fb419.jpeg"},{"id":82605871,"identity":"cb954078-d8c8-420d-a445-07d3fe9deb74","added_by":"auto","created_at":"2025-05-13 10:04:02","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":427278,"visible":true,"origin":"","legend":"\u003cp\u003eAxial HASTE (A), Fused PET MRI (B) and FDG PET (C) images of anterior para renal deposit showing metabolic tumor volume (MTV) of 58843.5 mm2\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6404631/v1/d38f034ec6a5c9b8c7251f7c.jpeg"},{"id":82604248,"identity":"233b201c-b68e-4f16-8ce5-539851090d90","added_by":"auto","created_at":"2025-05-13 09:56:02","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1286266,"visible":true,"origin":"","legend":"\u003cp\u003eUltrasound guided biopsy of intra-abdominal right lumbar mass showed discohesive sheets of medium to small cells. These cells have vesicular to hyperchromatic round nucleus, inconspicuous nucleoli with scattered mitosis s/o Lymphoproliferative disorder\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6404631/v1/b0440dd7a1ca15985ebdea82.jpeg"},{"id":89606212,"identity":"63533b8c-7982-4c95-8663-b659c37c40e0","added_by":"auto","created_at":"2025-08-21 20:01:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3199312,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6404631/v1/f673e41e-361b-4ccf-aa29-f432f08c7342.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"PET/MRI in the Early Diagnosis of Extra-Nodal Primary Colonic Lymphoma: A Rare Case Presentation","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePositron emission tomography (PET) is one of the most accurate imaging modalities that offers a functional report of any organ or tissue at a molecular level. Integrated modalities of PET-CT and PET-MRI have been developed and utilized over the last two decades. PET-MRI is an advanced technique that combines the metabolic and functional properties of tissue from PET with the anatomic properties of tissue from MRI [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The PET-MR imaging technique is superior to PET-CT as it provides better soft tissue contrast and more detailed tissue pathology [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Additionally, it offers the advantage of not exposing patients to ionizing radiation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLymphoproliferative disorders are a heterogeneous group of conditions characterized by an unrestrained increase in the production of B-lymphocytes and T-lymphocytes, causing monoclonal lymphocytosis, lymphadenopathy, and bone marrow infiltration. B-cell disorders include B-chronic lymphocytic leukemia, B-prolymphocytic leukemia, non-Hodgkin lymphoma, hairy cell leukemia, and splenic lymphoma. T-cell disorders include Sezary syndrome, T-prolymphocytic leukemia, adult T-cell leukemia-lymphoma, and large granulated lymphocyte leukemia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Among these, Hodgkin’s and non-Hodgkin’s lymphomas are the most commonly presenting lymphoproliferative disorders.\u003c/p\u003e \u003cp\u003eLymphomas are usually confined to lymph nodes; however, there is considerable evidence of lymphomas affecting extra-nodal organs such as the liver, spleen, gastrointestinal tract, abdominal wall, pancreas, peritoneal cavity, biliary tract, and genitourinary tract [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Extra-nodal involvement of the gastrointestinal tract is not uncommon, but colonic involvement is particularly rare [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Lymphomas are more likely to occur in immunocompromised individuals, with an increased risk among diabetes mellitus patients [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Primary colorectal lymphomas are very rare and most commonly present in the cecum [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Symptoms of colorectal carcinoma include abdominal pain, an abdominal mass, and weight loss [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNeoplasms may cause perforation through direct penetration, necrosis, or obstruction [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Multi-detector computed tomography (MDCT) with contrast has high sensitivity and specificity in detecting the site of perforation and free air [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Renal impairment is a major contraindication for the use of iodinated contrast in CT imaging modalities [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHere, we present a case of extra-nodal primary large intestine lymphoma involving the cecum and ascending colon, which led to hollow viscus perforation due to cecal wall dehiscence. This was detected using PET/MRI imaging. A multidisciplinary team involving a radiologist, pathologist, and surgical oncologist managed this case.\u003c/p\u003e\n"},{"header":"Clinical Presentation","content":"\u003cp\u003eA 55-year-old male patient presented with abdominal distension and significant weight loss. His medical history revealed that he was a known case of diabetes mellitus (DM). Abdominal ultrasound (USG) revealed an intra-abdominal mass in the right lumbar quadrant. PET/CT was contraindicated due to impaired renal function (serum creatinine: 1.6 mg/dL; blood urea: 86 mg/dL; uric acid: 13.8 mg/dL). Therefore, PET/MRI was performed without IV contrast, revealing an FDG-avid mass in the right lumbar region, enclosing the cecum and ascending colon, with cecal wall dehiscence anteromedially and multiple large loculated pockets of peritoneal collection, suggestive of perforation peritonitis (Figures 1 \u0026amp; 2).\u003c/p\u003e\n\u003cp\u003eA USG-guided biopsy of the right lumbar region mass showed fragments with discohesive sheets of medium to small cells. Large areas of hemorrhage were observed. The cells exhibited hyperchromatic round nuclei, inconspicuous nucleoli, and minimal eosinophilic cytoplasm with scattered mitoses. These findings suggested a lymphoproliferative disorder (Figure 5). The patient underwent laparotomy for hollow viscus perforation, followed by peritoneal lavage and a diversion loop ileostomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIMAGING FINDINGS:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDWI image(B) focused on mass revealed restricted diffusion and ADC map(C) revealed low signal intensity (green circle) with ADC mean value of 468*10\u003csup\u003e-6\u003c/sup\u003emm\u003csup\u003e2\u003c/sup\u003e/s(significantly low value).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHISTOPATHOLOGICAL FINDINGS:\u003c/strong\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLymphomas presenting as colonic masses are a very rare occurrence. According to the report by Zighelboim et al., 5.8% of all gastrointestinal lymphomas were colonic lymphomas, and colonic lymphomas comprise around 0.16% of colorectal neoplasms [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The most common site is the cecum [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In the above-mentioned case, there is involvement of both the cecum and the ascending colon.\u003c/p\u003e \u003cp\u003eA study by Joanna Mitri stated that individuals affected by diabetes mellitus (DM) have an increased risk of non-Hodgkin lymphoma [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This increased risk may be due to impaired neutrophil activity and disrupted cellular and humoral immunity, leading to immune dysfunction in both type 1 and type 2 DM [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. According to the report by C. W. Fan et al., the clinical presentations of colon lymphoma-affected patients include abdominal pain (62%), abdominal mass (54%), and weight loss (40%) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAn abdominal mass often remains asymptomatic for a prolonged period, leading to delayed diagnosis. Untreated intestinal masses may lead to perforation, although this is a rare presentation, resulting in peritonitis. Early diagnosis is critical to prevent intestinal perforation [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. As mentioned earlier, the MDCT imaging modality is typically preferred for identifying the site of perforation. In a study conducted by Renate M. Hammerstingl et al., it was found that using a higher concentration of iodine contrast improves imaging clarity [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA study by Samuel N. Heyman et al. inferred that administering iodinated radiocontrast to diabetes mellitus (DM) patients adversely affects renal physiology, leading to contrast-induced nephropathy (CIN) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the above-mentioned case, the patient presented with abdominal distension and unintentional weight loss. The patient's renal function test (RFT) revealed anomalies, and as a known case of DM, PET/MRI was performed due to the contraindication for contrast administration. Radiological and histological examinations confirmed colonic lymphoma causing perforation peritonitis, which eventually led to hollow viscus perforation\u0026mdash;a life-threatening condition. The patient underwent laparotomy, peritoneal lavage, and a diversion loop ileostomy to address the perforation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe studies involving human participants were reviewed and approved by the Institutional Review Board, Omega hospital, Hyderabad, India. Informed consent was waived due to the retrospective nature of the study by the institutional review board. All procedures performed in studies involving human participants were in accordance with the Helsinki Declaration as revised in 2013 and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConsent for publication\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors affirm that IRB had waived informed consent for publication of the images in this manuscript.\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cu\u003eAvailability of data and material\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.\u003cbr\u003e\u0026nbsp;\u003cu\u003eCompeting interests\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003eAll authors declare that they have no competing interests.\u003cbr\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors' contributions\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception, design, material preparation, data collection and analysis were performed. The first draft of the manuscript was written by Palak Wadhwa and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAcknowledgements\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNotApplicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJustiz Vaillant AA, Stang CM. Lymphoproliferative Disorders. 2023 Aug 14. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan\u0026ndash;. PMID: 30725847.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee WK, Lau EW, Duddalwar VA, Stanley AJ, Ho YY. Abdominal manifestations of extranodal lymphoma: spectrum of imaging findings. 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PMID: 24350240; PMCID: PMC3856131.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"PET-MRI (Positron emission tomography-Magnetic resonance imaging), Lymphoproliferative disorders, non-Hodgkin lymphoma, diabetes mellitus, hollow viscous perforation, immunocompromised, laparotomy, diversion loop ileostomy.","lastPublishedDoi":"10.21203/rs.3.rs-6404631/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6404631/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePositron emission tomography (PET) integrated with MRI (PET-MRI) offers a superior imaging modality combining functional and metabolic insights with exceptional soft tissue contrast, without ionizing radiation exposure. This case report discusses a rare presentation of extra-nodal primary colonic lymphoma involving the cecum and ascending colon, leading to hollow viscus perforation. A 55-year-old male with a history of diabetes mellitus presented with abdominal distension and weight loss. Initial imaging revealed a right lumbar mass with associated cecal wall dehiscence and peritoneal collections. PET/MRI, preferred over PET/CT due to renal impairment, provided critical diagnostic insights. Histopathological findings confirmed a lymphoproliferative disorder. The patient underwent laparotomy, peritoneal lavage, and loop ileostomy. This case underscores the significance of early diagnosis using advanced imaging techniques like PET/MRI in managing rare gastrointestinal lymphomas, particularly in high-risk populations, to prevent life-threatening complications such as perforation peritonitis.\u003c/p\u003e","manuscriptTitle":"PET/MRI in the Early Diagnosis of Extra-Nodal Primary Colonic Lymphoma: A Rare Case Presentation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-13 09:55:58","doi":"10.21203/rs.3.rs-6404631/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8dd8321d-61f6-4cbc-8dfe-1ad2233133c6","owner":[],"postedDate":"May 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-21T19:53:49+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-13 09:55:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6404631","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6404631","identity":"rs-6404631","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}