D0158 - Screening Colonoscopy Went Wrong: Follicular Lymphoma Presenting as Splenic Flexure Polyp -- A Case Report

Tuesday, October 25, 2022

10:00 AM – 12:00 PM ET

Location: Crown Ballroom

Has Audio

Presenting Author(s)

Ahmed Salem, MD

St. Joseph's University Medical Center
Paterson, NJ

Ahmed Salem, MD¹, Brooke E. Kania, DO², Mina Fransawy Alkomos, MD³, Abdalla Mohamed, MD³, Hardik M. Shah, MD¹, Shoaib Azam, MD¹, Shaker Barham, MD³, Matthew Grossman, MD³
¹St. Joseph's University Medical Center, Paterson, NJ; ²Saint Joseph's University Medical Center, Parsippany-Troy Hills, NJ; ³Saint Joseph's University Medical Center, Paterson, NJ

Introduction: Follicular lymphoma (FL) is a subtype of non-Hodgkin lymphoma (NHL) emerging from germinal focus of B cells. NHL usually arises in lymph nodes and affects liver, spleen, and bone marrow. The three most prevalent subtypes of (FLs) are mucosa-associated lymphoid tissue (MALT) lymphoma, extra-nodal marginal zone lymphoma, and diffuse large B-cell lymphoma, which accounts for approximately 40% of FLs outside lymph nodes. FL of the gastrointestinal tract is rare and accounts for less than 7% of all cases. Colorectal ones account for 1-2% of the cases.

Case Description/Methods: A 75-year-old female underwent first screening colonoscopy. Colonoscopy showed a flat irregular polyp near splenic flexure measuring 20 x 40 mm [Figure 1]. Biopsy showed follicular lymphoma grade I. Other polyps were found in the proximal transverse colon and rectum. Pathology showed sessile serrated adenomas. Subsequently, the patient underwent PET/CT scan in order to estimate further lymphoma involvement. Imaging revealed no evidence of FL, nor increased colonic uptake. Due to the patient’s resected lesion, no further chemotherapy is warranted at this time. Patient had surveillance colonoscopy 6 weeks later and post-polypectomy scars were biopsied and were negative for residual adenomatous changes. Active surveillance with colonoscopy to be performed in 1 year and PET scan every 6 months was recommended. Next generation sequencing cell free DNA (NGS) were negative for clinically significant variants.

Discussion: Pathophysiology of gastrointestinal FL includes clonal B-cell rearrangement as well as mutations in genes that modify chromatin (including CREBBP and KMT2D). In our case, tissue was positive for expression of CD-20, CD-3, CD-10, BCL-2, BCL-6 (faintly positive), CD-21, and CD-35, with negative CD-5 and cyclin D1, consistent with the common histological findings from similar patients with colonic FL. For patients with a low-tumor burden primary follicular lymphoma presenting without symptoms, there is relatively limited data regarding whether patients benefit from rituximab therapy versus observation. In our case, our patient underwent complete resection of distal transverse polyp, with negative extra nodal disease on PET/CT, she will benefit from observation at this time. Surveillance imaging is recommended no more frequently than every 6 months for the first two years following diagnosis, followed by no more frequent than annually after 2 years following diagnosis.

Figure: [Figure 1.1]: Colonoscopy images shows
A-B-D: Sessile polyps found in proximal transverse colon, rectum.
C: Flat irregular polyp near the colonic splenic flexure measuring 20 x 40 mm.

[Figure 1.2]: Distal transverse colon polyp, consistent with grade 1 follicular lymphoma. Immunostaining as evidenced above, demonstrating CD20 (lymphocyte positivity), BCL-2 (bright), CD10 (B cell positivity), CD21 (demonstrates parkedly expanded and disrupted follicular dendritic meshworks), and Ki-67 staining demonstrating low proliferation index (10-20%) in lymphoma cells, with high proliferation index (>90%) in the residual reactive germinal centers.

[Figure 1.3]: (A) and (B) shows Axial PET scan sections with 2.2 uptake in the liver.
There is no abnormal colonic uptake. Specifically, there is no uptake seen in the splenic flexure corresponding to the mass described on prior colonoscopy. (C) Computerized Tomography shows no mediastinal lymphadenopathy, no axillary lymphadenopathy. Liver and spleen not enlarged. Prominent left inguinal lymph node noted without evidence of abnormal FDG activity.

Antibody	Result
CD20	Most of the lymphocytes positive
CD3	Scattered small reactive T-lymphocytes, predominantly at the periphery of B-cell nodules
CD5	B-cells negative
CD10	B-cells positive
BCL-2	Positive
BCL-6	Many cells faintly positive
CD43	Weakly positive to negative.
Cyclin D1	Negative
CD21	FDC and many B-cells positive
CD35	FDC positive
Ki-67	10-20% in lymphoma cells; >90% in residual reactive germinal centers

Table: [Table 1]: Immunohistochemistry Antibodies results table.

Disclosures:

Ahmed Salem indicated no relevant financial relationships.

Brooke Kania indicated no relevant financial relationships.

Mina Fransawy Alkomos indicated no relevant financial relationships.

Abdalla Mohamed indicated no relevant financial relationships.

Hardik M. Shah indicated no relevant financial relationships.

Shoaib Azam indicated no relevant financial relationships.

Shaker Barham indicated no relevant financial relationships.

Matthew Grossman indicated no relevant financial relationships.

Ahmed Salem, MD¹, Brooke E. Kania, DO², Mina Fransawy Alkomos, MD³, Abdalla Mohamed, MD³, Hardik M. Shah, MD¹, Shoaib Azam, MD¹, Shaker Barham, MD³, Matthew Grossman, MD³. D0158 - Screening Colonoscopy Went Wrong: Follicular Lymphoma Presenting as Splenic Flexure Polyp -- A Case Report, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.