The Pillow Sign: Is It Always Benign?

Mucosa-associated lymphoid tissue (MALT) lymphoma is classically found in the stomach; however, in less common, cases can be found in extragastric locations. Colonic MALTomas are exceedingly rare and comprise a small group of extragastric cases. There is no standardized approach for optimal management of this disease. We report a case of a colonic MALT lymphoma found on colonoscopy that demonstrated the pillow sign and appearance of a benign lipoma. Despite antimicrobial and endoscopic therapy, the malignancy reoccurred in a patient with chronic hepatitis B, thereby precluding one of the mainstays of treatment, rituximab, until viral eradication.