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Tumors of the hemopoietic and adenoid tissue

Adenoid tissue - immunocompetent fabric, a basis of complex immune system of an organism. The lymphocytes proliferating in marrow are not committed and are differentiated in primary lymphoid bodies (thymus), circulate in absorbent vessels, settle in secondary lymphoid bodies (lymph nodes, a spleen, almonds, lymphoid formations of a wall of a digestive tract, etc.). Morphologically allocate T lymphocytes and V-lymphocytes. T-cells create cellular, and V-cells — humoral immunity. They occupy various topographical zones of secondary lymphoid bodies including a digestive tract wall. At the same time the T ratio - and V-cells in normal conditions is rather constant.
Malignant lymphoma represent heterogeneous group of the malignant tumors coming from an adenoid tissue. About 2% of all registered malignant tumors fall to their share (Novick A.A., 2000; Jane E. et al., 2001).
Among a set of the classifications considering immunological and histochemical methods of cellular identification of tumors the simplest is REAL-CLASSIFICATION on which allocate three main groups of tumors of an adenoid tissue:

  1. V-cellular,
  2. T-cellular,
  3. Hodzhkin's (lymphogranulomatosis) illness.

Growth of a tumor in lymph nodes is characteristic of Hodzhkin's illness. At the isolated lymphogranulomatosis one group of lymph nodes is surprised (belly, cervical, chest, etc.). As a rule, the digestive tract is involved in pathological process at a generalized lymphogranulomatosis for the second time and extremely seldom, only in 0,25% of cases (Parfyonov A.I., 2002).
In - and T-cellular malignant lymphoma (nekhodzhkinsky lymphoma) initially strike, generally secondary lymphoid bodies (almonds, a digestive tract, skin, bronchial system, etc.), excepting lymph nodes.
In a large intestine primary V-cellular nekhodzhkinsky lymphoma which develops from the adenoid tissue which is a part of an intestinal wall (gut associated lymphoid tissue — GALT system) prevails. The GALT system is provided diffuzno — in the form of intra epithelial lymphocytes and lymphocytes of own plate of a mucous membrane and is organized — in the form of single lymphoid follicles which are located in the thickness of a mucous membrane, and the grouped follicles lying in a submucosa.
Malignant lymphoma of a large intestine — the tumor which is most often localized in the right half of a large intestine (ascending, blind). Less often it meets in a rectum. The endoscopic picture of a nekhodzhkinsky malignant lymphoma practically does not differ from defeat of an adenoid tissue of intestines at a generalized lymphogranulomatosis (Nagasako K., 1982; Jane et al., 2001). Macroscopically in a digestive tract allocate three forms of malignant lymphoma (Aruin L.I. et al., 1998):

  1. limited;
  2. ulcer;
  3. diffusion.

At a kolonoskopiya the limited (polipovidny) form of a malignant lymphoma is the submucosal tumor having an appearance of a node or polipovidny education on the wide basis. As a rule, it the small sizes (to 1-1,5 cm in the diameter), a rounded or oval shape, an elastic consistence, is covered with a smooth brilliant mucous membrane. The surrounding mucous membrane is also visually not changed. In certain cases umbilicate impression is defined on surfaces of a tumor. Defeat has multiple character more often. At the same time polipovidny educations are located in the form of a chain along a gut axis (Breslin N.P. et al., 1999).
Considering tumor arrangement depth, in most cases a shchiptsovy biopsy of a maloinformativn. For verification of the diagnosis it is recommended to use an expanded loopy biopsy.
The limited form of a malignant lymphoma should be differentiated with benign not epithelial tumors and a nodal form of a colon cancer (Ogawa A. et al., 2000).
When progressing process (germination of a tumor in a mucous membrane) at top of nodes erosion and ulcers which have the special carinate form are formed.
Existence of the single, deep ulcer defects extended on gut perimeter, the sizes to 1,5 cm in the diameter with smooth accurate edges and a smooth bottom, pruinose fibrin is characteristic of an ulcer form of a malignant lymphoma. A surrounding mucous membrane without the expressed inflammatory changes.
In some cases the combined defeat of a wall of body (ulcer defects and the isolated single nodes) comes to light. It allows to suggest that the ulcer form of a malignant lymphoma is not independent, and only corresponds to a certain stage of development of process (an ulceration of nodes).
The biopsy is made from edges of ulcer defect, and also from the mucous membrane adjoining an ulcer.
The ulcer form of a malignant lymphoma needs to be differentiated with a saucer-shaped carcinoma and we izjyazvivshitsya by a nodal colon cancer.

Circular and extended defeat of an intestinal wall is characteristic of a diffusion form of a malignant lymphoma. The segment of a large intestine up to 10-15 cm long is involved in process. At the same time the endoscopic picture of a disease depends on extent of involvement of an epithelial layer in pathological process.

Table  

Endoscopic differential diagnostic characters at extended damages of a large intestine


Disease
Signs

Diffusion form of a malignant lymphoma

Diffusion infiltrative cavernous hemangioma

Lipomatoz

Localization

To thicket right-hand (blind + ileal gut)

There is no favourite localization

Right half of a large intestine

Extent

Segment up to 10-15 cm long

Segment up to 10-15 cm long

Diffusion defeat of several anatomic departments

Infiltration of an intestinal wall

Moderately expressed

Expressed

No

Character of a gleam in a defeat zone

The expressed narrowing and deformation

The insignificant / moderately expressed uniform narrowing

Insignificant deformation

Character
circular folds

No

No

Are absent (depends on the number of educations)

Color of a mucous membrane in a defeat zone

Usual hyperemia centers

Cyanochroic / bagrovo-tsianotichny

Usual yellowish shade

Mobility of a mucous membrane in a defeat zone

Sharply is limited/is absent

It is kept

It is kept

Vascular
drawing

Is absent because of a prelum of vessels

No

It is kept

Ulcerations of a mucous membrane

The slit-like ulcers directed on gut perimeter

Seldom superficial erosion

At small educations does not happen

Form of educations

The protrusions in the form of rollers which are randomly directed length prevails over width

The protrusions which are randomly directed are more often along a gut axis, form textures in the form of nodes

Roundish equal contours of close located educations

Amount of educations

Big length at rather not a big thickness (to 1,5 cm) and height (to 1 cm)

Big length with a small width (to 1 cm) and height (to 1 cm)

Formations of rounded/semi-spherical shape with a diameter up to 1,5 cm

Anatomic type of education

-

-

Wide basis

Consistence
educations

Dense, at the expressed infiltration the wall of a gut is rigid

Soft, is easily fallen down at contact with the endoscope

Soft, plastic, there are traces from contact with fortsepty

Morphology

Shchiptsovy biopsy with immunological and histochemical researches of fabric material

Verification of the diagnosis is possible only by means of an angiography, no type of a biopsy is used

The Shchiptsovy, combined, loopy biopsy. The high-differentiated fatty tissue

At an intact cover epithelium circular folds in a zone of damage are absent, are visible sharply reinforced, valikoobrazny, chaotically or longwise the located folds covered with a pale mucous membrane which mobility is sharply limited or is absent. Vascular drawing is grown poor. Elasticity of an intestinal wall is reduced, uniform moderate narrowing of a gleam of a gut in the field of defeat is noted (Doletsky S. Ya. et al., 1984).
Changes of a surface of a diffusion form of a malignant lymphoma are, as a rule, observed at an invasion of tumor cells in tissue of a mucous membrane, destruction of an epithelial layer and accession of a secondary inflammation. In these cases the gleam of the struck segment is deformed and narrowed. The mucous membrane covering sharply reinforced valikoobrazny folds fine-grained, ochagovo is hyperemic, with multiple intra mucous hemorrhages and erosion. The wall of a gut is rigid. When progressing process on a surface of a tumor deep defects of a carinate form are formed.
Considering a relative rarity of a disease, and also a number of similar endoscopic signs, a diffusion form of a malignant lymphoma it is necessary to differentiate with a diffusion infiltrative hemangioma and lipomatozy a large intestine (table) [Doletsky S. Ya. et al., 1984; KudoS., 1996].
Apparently from the table, color, a consistence and extent of deformation of a gleam of a gut — the main differential diagnostic characters allowing to make the correct endoscopic diagnosis and to define a way of its verification.

 
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