Follicular Lymphoma With Small Intestinal Involvement Detected by Double-Balloon Enteroscopy

Abstract

1 57-year-old woman was referred for further examination of a duodenal lesion. She was asymptomatic and physical ndings were normal. Laboratory data revealed no abnormal ndings. Upper gastrointestinal endoscopy revealed multiple ranules with a white color in the second portion of the duoenum. Biopsy specimens showed lymphoid follicles with a onotonous population of small-cleaved cells in the mucosa nd the immunohistochemical staining was positive for CD20, D10, and bcl-2 (Figure A) and negative for CD5. Thus, a iagnosis was made of follicular lymphoma (FL), grade 1, by a ematopathologist. Colonoscopic examination revealed no abormal findings. To investigate the initial spread and pattern of he small intestinal involvement, double-balloon enteroscopy DBE) was performed. DBE findings revealed multiple small ranules at the jejunum (Figure B). Biopsy specimens, which ere taken under DBE, also revealed FL, grade 1. Computerized omography of the chest and abdomen, gallium scintigraphy, nd bone marrow aspirate were normal. Based on these findngs, FL had arisen not only in the duodenum but also the ejunum. The lymphoma was evaluated as stage IE (involvement f a single lymph node region/lymphoid structure and involveent of a single extranodal site). Systemic chemotherapy was erformed because her lymphoma was not localized. The paient was treated with a combination of cyclophosphamide, oxorubicin, vincristine, prednisone, and rituximab. Sixteen onths after this chemotherapy, DBE revealed the disappearnce of lymphoma. FLs in the duodenum, which we encountered, have been eported with increasing frequency.1 However, it has been difcult to investigate whether FLs are involved extensively in the mall intestine or not. As we report here, DBE enables us to mprove the diagnostic yield in identifying small intestinal nvolvement of FL and to decide the optimal therapy.