Capsule Endoscopy and Follicular Lymphoma of Small Bowel

Abstract

Purpose: We present a case report of primary small bowel follicular lymphoma from Northern America in which capsule endoscopy played an important role in diagnosis and determining the extent of disease. Methods: Case report Results: 61 year old male with diabetes, complained of dysphagia to solids over several years and occasional bleeding per rectum for few months. No weight loss and altered bowel habits. No h/o celiac disease or IBD. He underwent EGD which showed mild antral erythema and slightly nodular duodenal mucosa. Gastric mucosa biopsy revealed reactive gastropathy, negative for Helicobacter Pylori. Duodenal mucosa biopsy showed normal villous architecture with prominent lymphoid aggregates with focal extension into the epithelium. 2 mm descending colon tubular adenoma found on colonoscopy. On capsule endoscopy multiple nodules and polypoidal lesions seen extending from 45 minutes to 70 minutes into the examination of the small bowel. Repeat EGD again showed nodular mucosa in distal duodenum. The biopsies showed atypical lymphoproliferation. The neoplastic follicles were positive for pan B cell markers CD20 and PAX-5. They co-expressed CD10 and BCL-2, indicative of follicle center cell origin. CT abdomen and pelvis was negative for lymph node involvement. Bone marrow biopsy negative for lymphoma. No hypermetabolic isotopic localization on PET scan in the chest or abdomen. Diagnosis of primary follicular lymphoma of the small bowel was made. Conclusion: Main differential diagnosis of lymphoproliferative disorder with extensive small bowel involvement includes low-grade B-cell lymphoma of the MALT type, follicular lymphoma, and mantle lymphoma. Follicular lymphomas occur rarely in the gastrointestinal tract, representing only 1–3% of all GI B-cell Non-Hodgkin's Lymphomas. It is generally considered to be a low grade malignancy, with indolent course, with 5-year survival rate of 70–82%. Most patients present with disseminated disease. However, our patient had follicular lymphoma primarily involving the small bowel. Capsule endoscopy was useful in the diagnosis and evaluation of extent of small bowel involvement in our patient.Figure: Capsule endoscopy: Polypoidal lesion in small bowel