Intussusception following treatment for glioblastoma multiforme: A rare association.

Sir,

Non-Hodgkins Lymphoma (NHL) as a lead point causing intussusception is very rare, though reported.[1] Our patient was a 6-year-old boy who was symptomatic for three months with a vague, ill-defined pain in the right lower abdomen with recurrent episodes of bilious vomiting. Two years ago, he had been diagnosed with Glioblastoma Multiforme grade IV, for which he had undergone craniotomy and tumor excision, followed by radiotherapy and chemotherapy with temozolomide (TMZ). Abdominal examination revealed a solitary globular, soft, nontender ill-defined fixed mass measuring about 5 × 5 cm in the right iliac fossa. Ultrasound revealed hypoechoic thick-walled concentric ring-like lesion in the right hypochondrium with vascularity in the region. Barium meal follow through was suggestive of chronic ileocolic intussusception [Figure 1]. The patient underwent laparotomy and, intraoperatively, a 2 × 2–cm intraluminal mass was noticed in the cecum with edematous terminal ileum and multiple mesenteric lymph nodes. A limited right hemicolectomy with ileo ascending end-to-end anastomosis was performed. Postoperative recovery was unremarkable. The histopathology of the resected cecal polyp revealed NHL, B cell immunophenotype with CD 20 positivity. The dissected lymph nodes also showed the features of NHL. The patient has been started on a chemotherapy regime for NHL.

Figure 1

Barium meal follow through showing a coiled spring sign in the right subhepatic location with a mild dilatation and abrupt narrowing of the terminal ileum and non-visualization of cecum along with the part of the ascending colon

Temozolomide (TMZ) is a DNA-alkylating drug registered for the treatment of patients with newly diagnosed glioblastoma and recurrent gliomas.[2] It is an orally administered analog of dacarbazine whose activity is mediated primarily via DNA methylation at the O6 position of guanine.[3] It is relatively well tolerated and is increasingly administered in clinical studies over prolonged periods to patients with gliomas and several other malignancies. Secondary malignancy in the form of therapy-related leukemia and myelodysplastic syndrome (MDS) after treatment with TMZ has been reported in literature. Sharma et al. reported a 20-year-old woman with high-grade primary glioblastoma who received concurrent TMZ with radiation, and developed disseminated Burkitt's lymphoma within 60 days of starting on TMZ.[4] Temozolomide has mutagenic potential for bone marrow cells in vivo in the mouse model system, which may point toward the reported therapy-related leukemia and MDS after TMZ treatment.[5] As the survival of brain tumor increases with better treatment modalities and longer follow-up, there is a possibility of increased incidents of a second malignancy or other unusual side effects after therapy with TMZ.