S2246 Gastrointestinal Follicular Lymphoma: Cases Series and Management Approach

Abstract

Introduction: Follicular lymphoma (FL) is the second most common subtype of non- Hodgkin lymphoma (NHL). In the gastrointestinal (GI) tract, it accounts for 1-3% of GI malignancies. A clear distinction between primary FL of the GI tract and disseminated FL with GI involvement should be made. The duodenum is the most common site involved, followed by the ileum and the colon. We present three cases of GI follicular lymphoma with unique diagnostic and management approaches. Case Description/Methods: A 54-year-old man presented for a screening colonoscopy. Physical examination and laboratory data were unremarkable. Colonoscopy showed two polyps in the transverse colon. Pathology was consistent with low grade follicular lymphoma. Positron emission tomography (PET) scan was unremarkable. Patient remained asymptomatic on follow-up visits with normal blood work. A 42-year-old female presented with epigastric abdominal pain. Physical exam revealed tenderness to palpation in the epigastrium.Laboratory findings: white blood cell count, 16.8x10(3) mcL. CT showed a mass in the duodenum at the level of the ampulla. EGD showed a 0.8cmx2cm mass in the 2nd portion of duodenum. Pathology was consistent with follicular lymphoma. Patient underwent treatment with chemotherapy for 3 months with remission, and no recurrence. A 73-year-old female presented for a routine screening colonoscopy. Physical examination and laboratory data were unremarkable. Colonoscopy showed hyperplastic, non-bleeding polyps in the terminal ileum. Pathology was consistent with high grade follicular lymphoma. Imaging with CT scan and PET scan were performed with no findings of gross adenopathy or extra nodal involvement. Patient underwent treatment with chemotherapy for 5 months with remission, and no recurrence. Discussion: Tumors originate from germinal center B cells; both centrocytes and centroblasts. Clinical presentation is variable. It is crucial to differentiate whether follicular lymphoma arises primarily from the GI tract, or is a result of disseminated disease. Endoscopy is useful for direct visualization of the GI tract and biopsy. Diagnosis is based on histology, immunophenotyping, bcl-2 protein expression in cells and detection of the t(14;18) translocation by PCR. Management of FL of GI tract is not well established due to rarity of the disease. Monitoring should be conducted via clinic visits, blood work, and cross-sectional imaging CT/PET scan. Treatment should be tailored to each patient’s unique presentation and disease activity.Figure 1.: (A) Abdominal radiograph shows two apposed metallic circular objects projecting over the right hemiabdomen and pan-colonic gaseous dilation without evidence of small bowel obstruction. (B) Colonoscopy images show a penny and shard of glass partially obstructing the opening of the ileocecal valve as well as (C) a dime lodged just proximally to the penny within the ileocecal valve. (D) Rat tooth forceps were used to remove the coins from the ileocecal valve and place them in the cecum for (E) safe and complete removal of the objects from the colon with a Roth net. (F) A penny, dime, and two shards of glass were ultimately retrieved.