Gastrointestinal follicular lymphoma: using primary site as a predictor of survival

Epidemiological features and prognosis for primary gastrointestinal follicular lymphoma

Primary gastrointestinal follicular lymphoma (PGI-FL) is a rare extra-nodal lymphoma. Its epidemiology and prognosis remain unclear. We performed a retrospective analysis of eligible patients with 1648 PGI-FL and 34 892 nodal FL (N-FL) in the Surveillance, Epidemiology and End Results (SEER) database. The age-adjusted average annual incidence of PGI-FL was 0.111/100000. The median overall survival (OS) for PGI-FL and N-FL patients was 207 and 165 months respectively. The 5-year diffuse large B-cell lymphoma (DLBCL) transformation rates were 2.1% and 2.6% respectively. Age, sex, grade, Ann Arbor stage, primary site and radiation were independent prognostic factors (p < 0.05). Nomograms were constructed to predict 1-, 5- and 10-year OS and disease-specific survival (DSS). The receiver operating characteristic curves and calibration plots showed the established nomograms had robust and accurate performance. Patients were classified into three risk groups according to nomogram score. In conclusion, the incidence of PGI-FL has increased over the past 40 years, and PGI-FL has a better prognosis and a lower DLBCL transformation rate than N-FL. The nomograms were developed and validated as an individualized tool to predict survival. Patients were divided into three risk groups to assist clinicians in identifying high-risk patients and choosing the optimal individualized treatments.

Multifocal Follicular Lymphoma Isolated to the Gastrointestinal Tract: A Rare Finding

Follicular lymphoma (FL) is a common form of non-Hodgkin lymphoma. Although extranodal involvement of the gastrointestinal (GI) tract is common in lymphomas, primary GI-FL confined to the GI tract is relatively rare. The disease process is typically indolent in nature and usually incidentally found. Among this subset of patients, the duodenum and terminal ileum tend to be the most common site of origin. Here, we present a rare case of primary multifocal GI-FL that found incidentally during routine colonoscopy with subsequent esophagogastroduodenoscopy and video capsule endoscopy revealing duodenal, jejunal, and sigmoid colon involvement.

Predictive factors for the progression of primary localized stage small-bowel follicular lymphoma

BACKGROUND

Primary small-bowel follicular lymphoma (FL) is mainly diagnosed as a duodenal lesion during esophagogastroduodenoscopy. Recently, with the widespread use of small-bowel endoscopy, FL in the jejunum and ileum has been detected. Most patients with small-bowel FL are diagnosed at the localized stage, and a watch-and-wait policy is used. However, the predictive factors for the progression of small-bowel FL have not been clarified. This study retrospectively examined the predictive factors for the progression of primary localized stage small-bowel FL based on clinicopathological and endoscopic findings.

METHODS

We enrolled 60 consecutive patients with primary small-bowel FL diagnosed at two tertiary hospitals between January 2005 and December 2020, with localized stage, low grade, and low tumor burden with the watch-and-wait policy. We examined the predictive factors for progression according to the clinicopathological and endoscopic findings. Endoscopic findings were focused on the color tone, circumferential location of follicular lesions (circumference ≥ 1/2 or < 1/2), fusion of follicular lesions (fusion [ +] or [ -]), and protruded lesions (≥ 6 mm or < 6 mm).

RESULTS

Progressive disease was observed in 12 (20%) patients (mean observation period, 76.4 ± 55.4 months). In the multivariate analysis, "circumference ≥ 1/2" and "fusion (+)" were significant predictive factors for progression. According to the Kaplan-Meier analysis, progression-free survival was significantly shorter in the "circumference ≥ 1/2" and/or "fusion (+)" group than in the "circumference < 1/2" and "fusion ( -)" group.

CONCLUSIONS

Endoscopic findings of "circumference ≥ 1/2" and "fusion (+)" were significant predictive factors for the progression of primary localized stage small-bowel FL.

Surgical Management of Small Bowel Lymphoma

BACKGROUND

Primary small bowel non-Hodgkin's lymphoma is a rare disease representing 2% of small intestine malignancies. There is limited data delineating the optimal treatment for these heterogeneous tumors. We aim to examine relationships between different treatment modalities and surgical outcomes in patients with small bowel lymphoma.

MATERIALS AND METHODS

Patients diagnosed with stage I-III small bowel lymphoma in 2004-2015 who underwent surgery were identified in the National Cancer Database. Two cohorts were created based on systemic chemotherapy treatment status. The primary outcome was overall survival. An adjusted Cox proportional hazards model was used to evaluate the impact of treatment strategy on survival.

RESULTS

2283 patients met inclusion criteria Of these patients, 826 patients (36%) underwent surgical resection alone, and 1457 patients (64%) underwent resection with systemic chemotherapy. Chemotherapy was associated with improved overall survival in unadjusted (5-year overall survival, 55% versus 70%) and adjusted analysis (HR 0.54, 95% CI 0.47-0.63, p < 0.001).

DISCUSSION

Patients with small bowel lymphoma have a low five-year overall survival after surgery. Chemotherapy is associated with improved survival, although one third of patients do not receive this therapy. Several other clinical factors are identified that are also associated with overall survival, including histology subtype, margin status, age, and medical comorbidities. This information can help with prognostication and potentially aid in treatment decision-making.

Common Presentation of an Uncommon Small Intestinal Lymphoma: A Rare Case Entity

Primary gastrointestinal NHL accounts for 30-40% of all extranodal NHL. Primary gastrointestinal lymphomas constitute 5% of total gut neoplasms. Bowel perforation is a severe life-threatening complication and sometimes initial presentation of gastrointestinal lymphoma. A 60-year-old man presented with complaints of abdominal pain, distension, nausea and vomiting. There was clinical suspicion of acute intestinal perforation, which was confirmed by radiology. The patient underwent emergency laparotomy. The resected bowel on histopathological examination and immunohistochemistry was diagnosed as the high-grade transformation of follicular lymphoma (FL). The patient received 6 cycles of chemotherapy and is doing well at 3 years of follow-up. Herein, we report this rare malignancy of the small intestine. FL mostly presents as a nodal disease but also involves the extranodal sites. The most common site of primary gastrointestinal-follicular lymphoma (GI-FL) is the small intestine. The cellular and molecular characteristic of GI-FL is different from that of the nodal FL. Extranodal FL is usually localized, but the prognosis of transformed FL is low, and these are managed by surgery followed by chemotherapy. High clinical suspicion and extensive sampling of perforated bowel are essential to diagnose the high-grade transformation of FL.

Double strangeness: a young male with intestinal obstruction secondary to gastrointestinal follicular lymphoma

Primary follicular lymphomas (FL) of the gastrointestinal (GI) tract are very rare and constitute < 4 % of all non-Hodgkin's lymphomas at this location. We report our experience with primary FL of the GI tract.

Changes in Incidence and Survival by Decade of Patients With Primary Colorectal Lymphoma: A SEER Analysis

Purpose: To reveal changes in the incidence, treatment, and survival of patients with colorectal lymphoma. Methods: Patients diagnosed with primary colorectal lymphoma (PCL) or lymphoma between 1973 and 2014 were identified in the SEER registry. The incidence was estimated by age and join-point analysis. The incidence of different subtypes and the surgical resection rates were compared over different time periods. Results: The PCL incidence increased from 1.4 per 1 000 000 people in 1973 to 3.5 in 2014, with an annual percentage change (APC) of 1.98% (95% confidence interval [CI]: 1.29-2.68%, P < 0.001) from 1985 to 2014. No statistically significant change was found between 1973 and 1984. For people younger than 60 years, there was a slight increase in PCL incidence, from 0.6 to 1.4%, from 1973 to 2014. For people age 60 or older, there was a statistically significant increase in PCL incidence from 5.4 to 14.1% over the same time period. The 5-year cause-specific survival (CSS) for PCL improved markedly from 41.6% in the period 1973-1976 to 80.2% in the period 2009-2012 (P < 0.001). Conversely, the proportion of patients who received surgical therapy decreased gradually from 83.3-100 to 47.7-52.6% throughout the studied time period. Conclusions: The incidence of PLC has increased in recent decades. The 5-year CSS of PCL increased continuously, while the rate of surgical resection decreased steadily. These changes in survival trends and therapy strategies indicate that PCL can be well-managed with newer therapeutic reagents.

Prognosis of Lymphoma in Patients With Known Inflammatory Bowel Disease: A French Multicentre Cohort Study

BACKGROUND AND AIMS

The prognosis of lymphoma that occurs in patients with inflammatory bowel disease [IBD] is poorly known.

METHODS

A multicentre retrospective cohort analysis was done in seven French tertiary centres from 1999 to 2019. Only lymphoma occurring in patients with previous established diagnosis of IBD were analysed. The primary outcome was progression-free survival at 3 years.

RESULTS

A total of 52 patients [male 65%, Crohn's disease 79%, median age 48.3 years, median duration of IBD 10.1 years] were included, of whom 37 had been previously exposed to immunosuppressants and/or biologics for at least 3 months and 20 had primary intestinal lymphomas. The lymphoma histological types were: diffuse large B cell lymphomas [N = 17], Hodgkin lymphomas [N = 17], indolent B cell lymphomas [N = 12], and others including T cell lymphomas, mantle cell lymphomas, and unclassifiable B cell lymphoma [N = 6]. The median follow-up after lymphoma was 5.1 years (interquartile range [IQR] 4-7.8). Progression-free survival at 3 years was 85% in the overall population (95% confidence interval [CI] 75%-96%) with no significant difference between the exposed and unexposed group, 79% for patients exposed to immunosuppressants and/or biologics [95% CI 67%-94%], and 83% for patients diagnosed with primary intestinal lymphoma [95% CI 67%-100%]. No relapse of IBD has been observed during chemotherapy. The IBD relapse rate at the end of the last chemotherapy cycle was 23% at 3 years [95% CI 11%-39%] in the overall population.

CONCLUSIONS

In this large cohort, the prognosis for lymphomas occurring in IBD appears to be good and similar to what is expected, irrespective of the exposure to biologics and/or immunosuppressants.

Early Stage Extranodal Follicular Lymphoma: Characteristics, Management, and Outcomes

INTRODUCTION

Extranodal follicular lymphoma (E-FL) is a rare entity that has distinct characteristics and outcomes compared with nodal follicular lymphoma.

PATIENTS AND METHODS

This cohort comprised 37 patients with stages I/II E-FL, diagnosed from 2003 to 2013. Outcomes included progression-free survival (PFS), and overall survival (OS). Survival outcomes were calculated using Kaplan-Meier methods.

RESULTS

Median age was 60 years (range, 37-84 years). Disease was stage I in 29 (78.4%). The Follicular Lymphoma International Prognostic Index score was 0 to 1 in 31 (83.8%), 2 in 2 (5.4%), 3 in 1 (2.7%), and missing in 3 (8.1%). Sites of involvement included the gastrointestinal (GI) tract in 22 (59.5%), and non-GI sites in 15 (40.5%). Initial management consisted of chemotherapy (CHT) alone in 21 (56.8%), radiation therapy (RT) alone in 2 patients (5.4%), RT and rituximab in 1 (2.7%), CHT and RT in 7 (18.9%), and observation in 6 (16.2%). RT was to a median dose of 30.6 Gy (range, 23.4-44.0 Gy). At a median follow-up of 69 months (range, 8-157 months), 5-year PFS and OS were 70.4% and 94.4%, respectively. Although the 5-year PFS of those observed was worse than for those who received therapy (33.3% vs. 77.6%; P = .011), that did not translate into an OS difference. Patients who received RT as part of upfront management had a 100% local control (LC) rate and a trend toward improved 5-year PFS (90% vs. 62.2%; P = .067).

CONCLUSION

Early stage E-FL is an indolent disease and is associated with excellent OS. Treatment strategies should be individualized with RT prioritized when LC is a significant goal.

Primary duodenal follicular lymphoma with late disseminated nodal relapse responsive to rituximab monotherapy: A case report

Gastrointestinal follicular lymphoma is a rare malignancy accounting for only 1-3.6% of primary non-Hodgkin lymphomas of the gastrointestinal tract and it is a relatively new clinical entity that was recently classified as a distinct variant of systemic follicular lymphoma. Therefore, data regarding long-term outcome are currently lacking. In addition, a consensus on the management of this disease has not been established and treatment strategies are derived from systemic follicular lymphoma. We herein report the case of a 51-year-old female patient diagnosed with duodenal follicular lymphoma who had nodal relapse nearly 5 years after complete remission. The patient was successfully treated with a 4-week course of rituximab during the initial diagnosis and relapse. To the best of our knowledge, this is the first case report to demonstrate the efficacy of a 4-week course of rituximab during both the initial diagnosis and nodal relapse. The aim of this report was to add to the limited available data on the treatment of gastrointestinal follicular lymphoma.

Gastrointestinal follicular lymphoma: using primary site as a predictor of survival

Gastrointestinal follicular lymphoma (GI‐FL) is a rare extranodal variant of follicular lymphoma (FL) that has been increasingly reported in the literature. An especially indolent course is linked to the disease after a lack of observed patient death in past studies. However, overall survival (OS) and associated prognostic factors remain unclear. A large population‐based database was utilized to identify demographic and clinicopathologic characteristics of GI‐FL, along with survival differences among primary sites. The Surveillance, Epidemiology, and End Results Registry was used to identify GI‐FL cases between the years of 1973 and 2012. Kaplan–Meier curves compared OS differences and Cox proportional hazard models analyzed prognostic factors. Final analysis included 1109 cases. Small intestinal cases, which included those with single‐site and multi‐segment involvement, were most common (63.6%) followed by gastric (18.2%) and colorectal cases (18.2%). Small intestinal GI‐FL presented more frequently with grade I histology, and less often with grade III histology (P < 0.001 and P < 0.001, respectively). Small intestinal cases had better outcomes (5‐year OS = 80.9%, P < 0.001) compared to cases involving the stomach (5‐year OS = 52.7%) and colorectum (5‐year OS = 71.5%). On multivariate analysis for predictors of mortality, small intestinal involvement predicted for better survival; hazard ratio (HR) 0.66 (95% CI: 0.51–0.85). Advanced age (≥66), grade (grade III), and stage (Ann Arbor Stage III/IV) predicted for mortality with HR 5.46 (95% CI: 3.80–7.84), 1.42 (95% CI: 1.10–1.83), 1.57 (95% CI: 1.15–2.16), respectively. GI‐FL has poorer outcomes than previously suggested. Small intestinal involvement has a better prognosis. A possible biological basis for this will require further investigations in the future.