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CC BY 4.0 · Endoscopy 2025; 57(S 01): E560-E561
DOI: 10.1055/a-2590-8569
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Confocal endoscopy-assisted diagnosis of duodenal follicular lymphoma: a rare case report

Lilan Fan‡
1   Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuchang District, Wuhan City, Hubei Province, China
2   Center for Pathology and Molecular Diagnostics, Wuhan University, Wuhan, China
,
Xing Huang‡
1   Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuchang District, Wuhan City, Hubei Province, China
2   Center for Pathology and Molecular Diagnostics, Wuhan University, Wuhan, China
,
Jun Luo
3   Department of Pathology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (Ringgold ID: RIN89674)
2   Center for Pathology and Molecular Diagnostics, Wuhan University, Wuhan, China
,
Lijing Yang
4   Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China (Ringgold ID: RIN89674)
,
Qiu Zhao
1   Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuchang District, Wuhan City, Hubei Province, China
2   Center for Pathology and Molecular Diagnostics, Wuhan University, Wuhan, China
,
Jing Liu
1   Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases, Wuchang District, Wuhan City, Hubei Province, China
2   Center for Pathology and Molecular Diagnostics, Wuhan University, Wuhan, China
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Duodenal follicular lymphoma (D-FL), a rare gastrointestinal lymphoma, poses diagnostic challenges due to nonspecific symptoms [1] [2]. This case highlights the utility of confocal laser endomicroscopy (CLE) in early detection and management.

A 59-year-old woman with bronchial asthma presented with epigastric pain and bloating. Gastroscopy revealed mucosal thickening and erosions at the duodenal bulb-descending junction ([Fig. 1] a). CLE identified disrupted glandular architecture, dilated lymphatic vessels, and fluorescein leakage, prompting targeted biopsies ([Fig. 1] b, [Video 1]). Histopathology confirmed neoplastic follicles ([Fig. 2]), while immunohistochemistry (CD20+, CD10+, Bcl-6+, BCL2+, and Ki-67+) and IG gene rearrangement confirmed follicular lymphoma. PET/CT ([Fig. 3] a) and abdominal CT ([Fig. 3] b) localized disease to the duodenum without extraintestinal involvement (stage II).

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Fig. 1 Endoscopic image. a Gastroscopy showing scattered white irregular erosive lesions and mucosal thickening at the junction of the duodenal bulb and descending duodenum. b CLE revealing irregular glandular structures, focal loss of glandular architecture, thickening and dilation of lymphatic vessels, disorganized tissue arrangement, and increased fluorescein sodium leakage. Abbreviation: CLE, confocal laser endomicroscopy.
Confocal laser endomicroscopy in the application of duodenal follicular lymphoma.Video 1

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Fig. 2 Histopathological examination. Histopathological examination demonstrating neoplastic follicles, consistent with FL.Abbreviation: FL, follicular lymphoma.
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Fig. 3 Imaging examination. a PET/CT scan demonstrating uneven thickening of the intestinal walls in the descending and horizontal sections of the duodenum, along with multiple areas of abnormal uptake within the abdominal cavity. b Abdominal enhanced CT scan confirming the absence of extraintestinal involvement, with no evidence of abnormal lesions or extension beyond the intestinal walls.

Treatment began with Rituximab-CVP (cyclophosphamide, vincristine, and prednisone) for four cycles, achieving remission. Due to asthma-related concerns, therapy was switched to Rituximab-Lenalidomide, which was well-tolerated. Regular follow-up was advised to monitor progression.

CLE’s real-time, high-resolution imaging enabled early detection of microarchitectural abnormalities, guiding precise biopsies and minimizing invasive sampling. Multimodal imaging (PET/CT, CT) confirmed localized disease, underscoring its role in staging. This case illustrates the synergy of advanced endoscopy, histopathology, and imaging in diagnosing D-FL. Personalized treatment, balancing efficacy and comorbidities, optimized outcomes without compromising safety.

In conclusion, CLE enhances early diagnosis of D-FL by visualizing microscopic changes, complementing traditional methods. Combined with tailored therapies and rigorous follow-up, it improves diagnostic accuracy and long-term management in rare gastrointestinal malignancies.

Endoscopy_UCTN_Code_CCL_1AB_2AZ_3AB

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E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/).

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Conflict of Interest

The authors declare that they have no conflict of interest.


Correspondence

Jing Liu, MD
Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Hubei Clinical Center and Key Lab of Intestinal and Colorectal Diseases
No. 169 Donghu Road
430071 Wuchang District, Wuhan City
Hubei Province, China   

Publication History

Article published online:
13 June 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

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Zoom
Fig. 1 Endoscopic image. a Gastroscopy showing scattered white irregular erosive lesions and mucosal thickening at the junction of the duodenal bulb and descending duodenum. b CLE revealing irregular glandular structures, focal loss of glandular architecture, thickening and dilation of lymphatic vessels, disorganized tissue arrangement, and increased fluorescein sodium leakage. Abbreviation: CLE, confocal laser endomicroscopy.
Zoom
Fig. 2 Histopathological examination. Histopathological examination demonstrating neoplastic follicles, consistent with FL.Abbreviation: FL, follicular lymphoma.
Zoom
Fig. 3 Imaging examination. a PET/CT scan demonstrating uneven thickening of the intestinal walls in the descending and horizontal sections of the duodenum, along with multiple areas of abnormal uptake within the abdominal cavity. b Abdominal enhanced CT scan confirming the absence of extraintestinal involvement, with no evidence of abnormal lesions or extension beyond the intestinal walls.