Follicular Lymphoma Of Gastrointestinal Tract Research Articles

S2246 Gastrointestinal Follicular Lymphoma: Cases Series and Management Approach

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.

Richter Syndrome With Follicular Colonization of Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma Cells Mimicking Follicular Lymphoma

Follicular colonization is occasionally observed in marginal zone lymphoma. In rare cases, it has also been associated with mantle cell lymphoma. Chronic lymphocytic leukemia typically involves nodal or extranodal tissues as diffuse proliferation by complete effacement of the normal architecture. The involvement of chronic lymphocytic leukemia may be less frequently limited to the interfollicular areas. Here, we report a case of Richter syndrome of the small intestine that was initially diagnosed as follicular lymphoma of the gastrointestinal tract because of a partial follicular growth pattern in addition to a mainly diffuse proliferation pattern. The follicular pattern mimicking follicular lymphoma was shown to be composed of reactive follicles with follicular colonization of the original chronic lymphocytic leukemia cells. As the prognoses of Richter syndrome and follicular lymphoma of gastrointestinal tract are quite different, clinicians must carefully diagnose these conditions to avoid a misdiagnosis.

A duodenal follicular lymphoma associated with the lesion mimicking MALT lymphoma in terminal ileum and Bauhin valve

This is a case report of a 66-year-old woman who consulted us with a 1-week history of postprandial epigastric discomfort and dyspepsia. Upper and lower gastrointestinal endoscopy and double-balloon enteroscopy revealed lesions in three parts: a swelling with a shallow depression in the ampulla of Vater, flat and rough nodules in the jejunum, and a mixture of lymphoid polyposis and rough surface of follicular lymphoma of the terminal ileum and Bauhin valve. The histological, immunophenotypic, and molecular findings of the duodenal lesion confirmed the diagnosis of follicular lymphoma. We initially diagnosed the ileal lesion as MALT lymphoma immunohistochemically. However, Southern blot hybridization analysis for immunoglobulin heavy chain gene rearrangement showed identical monoclonal bands in both the duodenal and ileal lesions. The molecular cytogenetic studies were also positive for the 14;18 translocation in both lesions. Therefore, the true diagnosis of this ileal lesion should be a follicular lymphoma with marginal zone differentiation. Primary follicular lymphomas of gastrointestinal tract were suggested to have intermediate features between nodal follicular lymphoma and MALT lymphoma. This case is an important clue to prove the similarity of follicular lymphoma of gastrointestinal tract to MALT lymphoma and will be crucial in considering the therapeutic strategy.