Capsule endoscopy findings in intestinal follicular lymphoma

Characteristic endoscopic findings of gastrointestinal malignant lymphomas other than mucosa-associated lymphoid tissue lymphoma

Background and study aims: The gastrointestinal (GI) tract is the most common site of extra-nodal involvement for non-Hodgkin’s lymphoma (NHL). The features of GI NHLs remain unclear. The aim of this study was to clarify endoscopic characteristics of GI NHLs. Patients and methods: We retrospectively analyzed the morphological characteristics of 63 GI malignant lymphomas other than mucosa-associated lymphoid tissue lymphoma. Lesions were diagnosed between 2005 and 2020. Macroscopic findings were classified into five subtypes: superficial (S); protruding without ulcer (P); protruding with ulcer (PU); fungating (F); and multiple nodules (MN). Results: Thirty-one lesions in the stomach were classified as S type in 3 cases (9.6%), P type in 6 (19%), PU type in 13 (42%), and F type in 9 (29%). In the stomach, the ulcerated phenotype was more frequent for diffuse large B-cell lymphoma (DLBCL) (89.5%) than for other histological types (41.7%; P = 0.01). In the intestine, 23 tumors were classified as S type in 4 cases (17%), P type in 1 (4%), PU type in 6 (26%), F type in 1 (4%), and MN in 11 (48%). Eleven of the 14 cases (78.6%) of intestinal follicular lymphoma lesions showed MN type. In the colon, eight tumors were classified as S type in 2 cases (25%), P type in 2 (25%), PU type in 1 (13%), and F type in 3 (38%). Conclusion: We have clarified the endoscopic features of GI NHL using macroscopic classifications. The ulcerated phenotype was the most frequent endoscopic finding for DLBCL.

Primary Colorectal Follicular Lymphoma Observed by Magnifying Endoscopy, with a Five-year Follow-up

Colorectal involvement is very rare in cases of follicular lymphoma. Colonoscopy of a 69-year-old man revealed an aggregation of multiple whitish nodules in the sigmoid colon. Magnifying endoscopy with narrow-band imaging demonstrated a coiled and elongated microvascular pattern on the surface and crystal violet staining showed a type I pit pattern. A biopsy showed follicular lymphoma (Grade 1), and no other involvement of lymphoma was detected. Following a diagnosis of primary colorectal follicular lymphoma stage I (Lugano classification), the patient was monitored by watch-and-wait therapy. We documented the endoscopic images of colorectal follicular lymphoma in the present case.

Colorectal Manifestation of Follicular Lymphoma

OBJECTIVE

Due to their rarity, the endoscopic features and clinical backgrounds of colorectal follicular lymphoma lesions have not yet been fully investigated. The aim of this study was to reveal the characteristics of this disease entity.

METHODS

A database search performed at the Department of Pathology of our institute identified 12 follicular lymphoma patients with involvement in the cecum, colon, and/or rectum. Data regarding the endoscopic, radiological, biological, and pathological examinations performed were retrospectively reviewed from their clinical records.

RESULTS

The mean age of the patients (5 men, 7 women) was 58.7 years. Five patients were classified as being Lugano system stage I, while the other seven patients were stage IV. In all of the patients, colorectal follicular lymphoma presented with papular (n=4), polypoid (n=4), and flat elevated lesions (n=4). No erosions or ulcers were seen in any of the lesions. The initial pathological diagnoses included extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (n=2) and colitis/proctitis with infiltration of inflammatory cells (n=3), in addition to the correct diagnosis of follicular lymphoma (n=7).

CONCLUSION

Colorectal involvement of follicular lymphoma shows no erosions or ulcers. These lesions could be macroscopically observed as papular, polypoid and flat elevated lesions. Making a correct diagnosis of this disease based on the findings of biopsied samples is sometimes challenging. In such cases, multiple biopsies and/or endoscopic mucosal resection is required, in addition to appropriate consultation with pathologists.

Histological diagnosis of follicular lymphoma by biopsy of small intestinal normal mucosa

Due to advances in double-balloon endoscopy, various types of malignant lymphoma of the small intestine have been observed at very early stages. We report here that after remission of diffuse large B-cell lymphoma, follicular lymphoma recurred in the mucosa of the small intestine. Furthermore, these lesions were diagnosed by biopsy from normal mucosa as diminutive erosions and reddish looking. If a small intestinal lesion is suspected of being a malignant lymphoma, a double-balloon endoscopy should be carried out, and a biopsy should be taken and inspected.

Factors associated with the clinical impact of capsule endoscopy in patients with overt obscure gastrointestinal bleeding

BACKGROUND AND STUDY AIMS

Capsule endoscopy (CE) does not necessarily identify positive findings in patients with overt obscure gastrointestinal bleeding (OGIB). We aimed to identify factors predictive of positive CE findings and those of re-bleeding after negative CE in overt OGIB.

PATIENTS AND METHODS

We retrospectively analyzed 68 patients who underwent CE for overt OGIB. CE findings, therapeutic interventions, and clinical course after CE were reviewed. Clinical variables associated with positive CE findings and those associated with re-bleeding after negative CE findings were investigated.

RESULTS

Positive CE finding was found in 36 (53%) patients. Marked decrease in hemoglobin value [OR; 18.8, 95% CI; 3.4-152.0] and earlier CE examination within a week after the last episode of bleeding [OR; 8.0, 95% CI; 2.2-35.9] were factors associated with positive CE findings. Nine (28%) of 32 patients with negative CE findings re-bled. Marked decrease in hemoglobin value was more frequent in patients with re-bleeding than those without (P = 0.07).

CONCLUSION

Patients with massive and overt OGIB are the best candidates for CE. Earlier CE, virtually within a week, contributes to the better diagnostic yield of the procedure. Careful follow-up seems necessary for patients with massive bleeding even in cases of negative CE findings.

Gastrointestinal follicular lymphoma: review of the literature

Gastrointestinal follicular lymphoma (GI-FL) is a relatively rare disease, accounting for only 1%-3.6% of gastrointestinal non-Hodgkin's lymphoma. Although the duodenum and terminal ileum are considered to be the most common sites of origin, the development of wireless capsule endoscopy and double-balloon enteroscopy has increased the detection of GI-FL in every part of the small intestine. Approximately 70% of patients with GI-FL are estimated to have multiple lesions throughout the entire gastrointestinal tract. FL is a low-grade lymphoma that usually develops very slowly. If the lymphoma causes no symptoms, immediate treatment may not be necessary. Standard therapy has not yet been established for GI-FL, but chemotherapy, radiotherapy, monoclonal antibody therapy, or a combination of these therapies, is sometimes performed based on the therapeutic regimens for nodal FL. Regimens including conventional chemotherapy with rituximab, which achieve high response rates in nodal FL, are commonly used for GI-FL. The long-term clinical outcome of GI-FL is unclear. The results of a few series on the long-term outcomes of patients with GI-FL treated with conventional therapy indicate a median relapse-free time ranging from 31 to 45 months. On the other hand, in patients with GI-FL who were followed without treatment, the median time to disease progression was 37.5 months. Thus, whether to initiate aggressive therapy or whether to continue watchful waiting in patients with GI-FL is a critically important decision. Ongoing research on biomarkers to guide individualized GI-FL therapy may provide invaluable information that will lead to the establishment of a standard therapeutic regimen.

Double-balloon endoscopy depicts diminutive small bowel lesions in gastrointestinal lymphoma

The aim was to determine the prevalence of small bowel involvement in patients with gastrointestinal (GI) lymphoma by double-balloon endoscopy (DBE). We examined 29 patients with primary GI lymphoma by oral and anal DBEs. Clinicopathologic features related to the prevalence of diminutive small bowel involvement and the clinical outcome were retrospectively investigated. Diminutive small bowel lesions were found in 14 patients. The prevalence of the lesions was not different between patients with primary small bowel lymphoma and those with primary extra-small bowel lymphoma (50% versus 47%, P = 0.6). However, clinical stage was more advanced in patients with the lesions than in those without (P < 0.05). The lesions were more frequently found in T-cell lymphoma (100%) and follicular lymphoma (77%) than in the other types of lymphoma (15%) (P < 0.05). Diminutive small intestinal lesions occur in patients with GI lymphoma, especially in those with follicular lymphoma and T-cell lymphoma. GI lymphomas of these histologic types are candidates for scrutiny by DBE.

Characterization of follicular lymphoma in the small intestine using double-balloon endoscopy

Follicular lymphomas occur rarely in the gastrointestinal tract, representing only 1-3% of all gastrointestinal tract B-cell non-Hodgkin lymphomas. We describe endoscopic analysis of 3 cases of follicular lymphoma in the small intestine using double-balloon endoscopy. Double-balloon endoscopy revealed multiple nodular lesions and elevated white patches, multiple polypoid lesions, and scattered white polypoid and nodular lesions in the duodenum and small intestine. Fuji Intelligent Chromo Endoscopy demonstrated small, whitish nodules, and narrow-band imaging showed a coiled, elongated vascular pattern within the elevated lesions. These cases are the first follicular lymphomas in the small intestine evaluated using narrow-band imaging or Fuji Intelligent Chromo Endoscopy to be reported.

Bowel preparations for capsule endoscopy: a comparison between simethicone and magnesium citrate

BACKGROUND

Bowel preparation for capsule endoscopy (CE) has not been standardized.

OBJECTIVE

This study aimed to compare CE images between patients prepared by simethicone and those prepared by magnesium citrate.

DESIGN

Retrospective analysis of case series of our hospital from 2004 to 2007.

SETTING

Single center.

PATIENTS AND INTERVENTIONS

CE images of 75 patients receiving bowel preparation either by 200 mg of simethicone (n=39) or by 34 g of magnesium citrate (n=36) were retrospectively investigated. Grades of fluid transparency and mucosal invisibility by air bubbles and food residue were compared between the 2 preparations. Capsule transit time, frequency of positive findings, and interobserver variations between 2 observers were also investigated.

MAIN OUTCOME MEASUREMENTS

Image quality and diagnostic yield of CE.

RESULTS

Fluid transparency in the first and the third time segments of the small intestine was better in patients prepared by magnesium citrate than in those prepared by simethicone (P= .001 and P= .03, respectively). On the other hand, mucosal invisibility was not different in any part of the small intestine between the 2 groups. Neither gastric transit time nor small-bowel transit time was different between the 2 groups. The diagnostic yield of CE correlated significantly with fluid transparency (P= .04), but it did not correlate with mucosal invisibility.

LIMITATIONS

Single-center retrospective study.

CONCLUSION

Magnesium citrate seems to be a recommended preparation for CE compared with simethicone. The fluid transparency, rather than the mucosal invisibility, may be a factor associated with the diagnostic yield of CE.

Capsule endoscopy in neoplastic diseases

Until recently, diagnosis and management of small-bowel tumors were delayed by the difficulty of access to the small bowel and the poor diagnostic capabilities of the available diagnostic techniques. An array of new methods has recently been developed, increasing the possibility of detecting these tumors at an earlier stage. Capsule endoscopy (CE) appears to be an ideal tool to recognize the presence of neoplastic lesions along this organ, since it is non-invasive and enables the entire small bowel to be visualized. High-quality images of the small-bowel mucosa may be captured and small and flat lesions recognized, without exposure to radiation. Recent studies on a large population of patients undergoing CE have reported small-bowel tumor frequency only slightly above that reported in previous surgical series (range, 1.6%-2.4%) and have also confirmed that the main clinical indication to CE in patients with small-bowel tumors is obscure gastrointestinal (GI) bleeding. The majority of tumors identified by CE are malignant; many were unsuspected and not found by other methods. However, it remains difficult to identify pathology and tumor type based on the lesion’s endoscopic appearance. Despite its limitations, CE provides crucial information leading in most cases to changes in subsequent patient management. Whether the use of CE in combination with other new diagnostic (MRI or multidetector CT enterography) and therapeutic (Push-and-pull enteroscopy) techniques will lead to earlier diagnosis and treatment of these neoplasms, ultimately resulting in a survival advantage and in cost savings, remains to be determined through carefully-designed studies.