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

Clinicopathological characteristics and prognostic factors of small bowel lymphomas: a retrospective single-center study

Background

There is little information on diagnosis and management of small bowel lymphomas, and optimal management strategies are still undefined. This study aims to describe their main clinical and pathological characteristics and identify poor prognostic factors.

Methods

A retrospective observational study of all patients with histological diagnosis of small bowel lymphoma between January 2010 and December 2020 was performed.

Results

We included 40 patients, with male predominance (60%) and mean age of 60.7 years. The ileum was the most common location, and the most common histological subtypes were follicular lymphoma and diffuse large B-cell lymphoma. Clinical presentation was variable from asymptomatic patients (30%) to acute surgical complications (35%) including perforation, intestinal obstruction, ileal intussusception, or severe bleeding. Diagnosis was established by endoscopy in 22 patients (55%), and the most common findings included polyps, single mass, diffuse infiltration, or ulceration, whereas 18 (45%) required surgery because of acute presentations or tumor resection, and lymphoma was diagnosed postoperatively. Surgery was curative in one-third of those patients. Median survival was 52 months. Acute presentation (P = 0.001), symptomatic disease (P = 0.003), advanced stage (P = 0.008), diffuse large B-cell lymphoma (P = 0.007), anemia (P = 0.006), hypoalbuminemia (P < 0.001), elevated lactate dehydrogenase (P = 0.02), elevated C-reactive protein (P < 0.001), and absence of treatment response (P < 0.001) were significant predictors of mortality.

Conclusion

Small bowel lymphoma is a rare malignancy with diverse clinical and endoscopic presentations that require a high index of suspicion. Primary factors associated with worse outcome included acute presentation, advanced stage, histological subtype, biochemical abnormalities, and absence of treatment response.

Duodenal Follicular Lymphoma: Track or Treat?

Duodenal follicular lymphoma (DFL) is a rare variety of non-Hodgkin's lymphoma of the gastrointestinal tract that usually carries a favorable course, recognized as a new entity in 2016. It is usually diagnosed at an early stage located predominantly in the second portion of the duodenum. We report the case of a 74-year-old male patient with epigastric pain in whom gastroscopy revealed white mucosal nodules that were pathologically diagnosed as grade 1-2 DFL. Staging investigations revealed secondary lesions in the spleen and at the base of the tongue together with latero-cervical adenopathy. The tumor was stage IV according to the Lugano staging system. We reviewed the recent (last five years) literature defining the importance of combination therapy in the advanced stage. The patient achieved complete remission of the disease through chemoimmunotherapy following the Rituximab-Bendamustine scheme.

What do we know about duodenal-type follicular lymphoma? From pathological definition to treatment options

Duodenal-type follicular lymphoma (DFL) is a newly recognised variant of follicular lymphoma (FL), although little is known about its biology and clinical evolution. In general, patients tend to have mild symptoms and do not require therapy, comparable with other forms of low-tumour burden asymptomatic FL. Specific pathological features, such as a dendritic cell meshwork, low expression of CD10 and upregulation of activation-induced cytidine deaminase can help the diagnosis. The molecular landscape of DFL is similar to the classical nodal presentation of FL, although studies using gene expression profiling demonstrate a close relation with MALT lymphomas. Markers associated with inflammation have suggested that the microenvironment plays a likely role in the pathogenesis of DFL and its low progression rate. Clinical series published vary between 20-63 patients with an estimated overall survival between 92-100% and a median follow-up ranging between 20 and 107 months. Treatment options include a watch and wait strategy, rituximab monotherapy and radiotherapy. In this review, we summarise current pathological data and treatment studies in DFL.