Medical College of Georgia Augusta, SC, United States
Mohammad U. Azam, MD1, Haoran Peng, MD, PhD1, Pramila Moideen, MD1, John Erikson Yap, MD2 1Medical College of Georgia, Augusta, GA; 2Medical College of Georgia at Augusta University, Augusta, GA
Introduction: Follicular lymphoma (FL) is one of the most common forms of non-Hodgkin lymphoma (NHL) accounting for 35% of cases. It is relatively rare in the gastrointestinal (GI) tract, and primary GI-FL accounts for 1-3.6% of cases. It is most common in middle aged adults with a 2:1 female predominance. Factors of poor outcome include male sex, presence of abdominal symptoms, and no involvement of the second portion of the duodenum. We present a case of small bowel involvement of FL.
Case Description/Methods: A 67-year-old female with a history of hypertension was referred to the GI clinic for worsening abdominal pain in the epigastric region for the last two years associated with chronic diarrhea. Patient had 2 EGDs previously, which showed endoscopically normal appearing esophagus, stomach, and duodenum. Gastric biopsies were negative for H. pylori, but no small bowel biopsies were performed. Her physical examination showed mild tenderness of the epigastric area on palpation. Laboratory studies revealed normal CBC, CMP, thyroid function, IgA, TTG, as well as negative stools studies (ova & parasite, C. difficile PCR, and GI viral panel). Due to worsening diarrhea, bidirectional endoscopy was performed. A prominent whitish fold at the 3rd portion of the duodenum was seen [FIG1a]. Colonoscopy showed normal terminal ileum (TI) and 6 colon polyps. Microscopic examination of the duodenal and TI biopsies showed a nodular lymphoid infiltrate comprised of CD20 positive B-cells co-expressing CD10 and BCL2. [Fig2] A CT abdomen and PET-CT for staging showed soft tissue density encapsulating the inferior vena cava and abdominal aorta and mildly enlarged abdominal lymph nodes [Fig3] with increased FDG activity within the duodenum and TI. She was referred to oncology and was treated with bendamustine and rituximab. She had an excellent response on CT scan and improvement of her GI symptoms
Discussion: FL of the GI tract is a rare entity, and when isolated disease is noted, a watch and wait approach is usually chosen. Disease course is typically indolent, and it has excellent long-term survivability (median survival of GI-FL is 10 years after diagnosis). Treatment is reserved for those with more advanced stages or in symptomatic patients. In conclusion, we presented a case of a 67-year-old with symptomatic GI-FL who was treated successfully with chemotherapy with resolution of her GI symptoms.
Figure: Figure1: Endoscopic finding of whitish fold at the third portion of the duodenum Figure 2: Pathology findings of the follicular lymphoma. Figure 3: CT scan findings of para-aortic lymph node enlargement, and increased uptake of FDG at the duodenum and terminal ileum on PET-CT
Mohammad Azam indicated no relevant financial relationships.
Haoran Peng indicated no relevant financial relationships.
Pramila Moideen indicated no relevant financial relationships.
John Erikson Yap indicated no relevant financial relationships.
Mohammad U. Azam, MD1, Haoran Peng, MD, PhD1, Pramila Moideen, MD1, John Erikson Yap, MD2. P0961 - Third Time Is the Charm - A Rare Case of Small Bowel Follicular Lymphoma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.