Successful treatment of refractory low grade duodenal lymphoma with rituximab, an anti-CD20 monoclonal antibody

Protein-losing Enteropathy Complicated with Primary Intestinal Follicular Lymphoma

Protein-losing enteropathy (PLE) is a rare syndrome characterized by hypoproteinemia due to gastrointestinal (GI) protein loss. Primary intestinal follicular lymphoma (PIFL), a specific variant of follicular lymphoma with essential only GI involvement, has not been reported as an etiology of PLE. We herein report a case of PLE complicated with PIFL that was successfully treated with rituximab, resulting in rapid improvement of PLE and a complete response of PIFL. Macroscopic findings of ulcerative lesions with diffuse involvement, which were precisely described by capsule and double-balloon enteroscopy at the diagnosis, also improved following the treatment. This case provides a clue suggesting factors that promote PLE in PIFL.

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.

Non-Hodgkin's lymphoma revealed by an ilio-colic intussusception in a Moroccan patient: a case report

Intussusceptions are rare but well-known causes of the small bowel obstruction in adults and an underlying cause is present in the majority of cases. Lymphoma's involvement of the ileum is one of the rare causes of intussusception. CT is a sensitive examination that diagnoses intussusceptions and provides an excellent pre-operative evaluation including possible extension and dissemination especially in intestinal lymphomas. The treatment is almost always surgical and the pathological study is needed for diagnostic confirmation. Authors present an unusual case of intestinal intussusception due to lymphoma of the terminal part of the ileum in a 49-year-old man. Computed tomography confirmed the diagnosis of intussusception and non-Hodgkin's lymphoma of B-cell was diagnosed by histological examination after surgical treatment. Primary intestinal lymphomas differ from gastric lymphomas in clinical features, treatment, and prognosis. They are not well characterized and the standardized concepts for their clinical diagnosis and management are absent. The aim of this rare observation is to shed light on NHL of the small bowel, its clinical and radiological diagnosis and its treatment especially in forms revealed by intussusceptions in adults.

Primary duodenal follicular lymphoma successfully treated with rituximab

Non-Hodgkin's lymphoma (NHL) of the gastrointestinal (GI) tract is the most common extranodal lymphoma, accounting for approximately 40% of all extranodal NHLs. Initial treatment of duodenal lymphoma includes surgery, chemotherapy and radiotherapy, alone or in combination. Here, we present a case of stage I primary duodenal follicular lymphoma (FL) showing a complete response after rituximab therapy. Rituximab alone can be an effective alternative treatment for duodenal FL.

Primary small-bowel non-Hodgkin's lymphoma: a study of clinical features, pathology, management and prognosis

The records of 34 patients diagnosed with primary small bowel non-Hodgkin's lymphoma during a 10-year period between January 1996 and December 2005, including 27 cases for which complete follow-up records were available, were studied. Abdominal pain (70.6% of patients) was the main presenting symptom, followed by intestinal obstruction (38.2%). The most common primary site was the ileum (58.8%), followed by the jejunum (26.5%) and duodenum (17.6%); one case had tumours at two sites in the small bowel. Twenty-seven patients had small bowel B-cell lymphoma (24 diffuse large B-cell lymphoma; three mucosa-associated lymphoid tissue B-cell lymphoma) and seven patients had small bowel T-cell lymphoma. Cumulative survival in patients with small bowel B-cell lymphoma was higher than that in patients with small bowel T-cell lymphoma. Data on 16 male and eight female patients with diffuse large B-cell lymphoma showed that 62.5% of these patients presented with disease stages I or II and 37.5% with stages III or IV. Cumulative survival in patients at stages IE or IIE was significantly higher than that of patients at stages IIIE or IVE. Four of five patients who died from diffuse large B-cell lymphoma had abnormal levels of lactate dehydrogenase and serum albumin.

Small follicular lymphoma arising near the ampulla of vater: a distinct subtype of duodenal lymphoma?

A 49-yr-old Japanese woman underwent upper gastrointestinal endoscopy because of nonspecific dyspepsia. Endoscopy revealed a flat elevated lesion about 15 mm in diameter adjacent to the duodenal papilla, the surface of which was uneven and covered with whitish granules. Based on the results of histological examination with immunohistochemistry (positive for CD10, CD20, CD79a, and bcl-2 protein, negative for CD5 and cyclin D1), a diagnosis of grade 1/3 follicular lymphoma was established. Systemic staging examinations suggested the lymphoma was restricted to the mucosa and superficial portion of the submucosa in the duodenal wall. The patient was treated with a combination of CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisolone) and monoclonal anti-CD20 antibody (rituximab), in addition to radiotherapy. After six courses of this combination chemotherapy, complete regression of the lymphoma was observed. Although reports of small duodenal lymphoma (<20 mm or localized to the mucosa or submucosa) are extremely rare, the features of this case are characteristic of small duodenal lymphoma in terms of evolution around the ampulla of Vater, low-grade follicular type, occurrence in a women, occurrence in the fourth decade of life, and favorable outcome, and this type of tumor may need to be distinguished by pathogenesis and clinical behavior from various other gastrointestinal lymphomas.