Impact of double-balloon endoscopy on the diagnosis of jejunoileal involvement in primary intestinal follicular lymphomas: a case series

In recent years, primary gastrointestinal follicular lymphoma has been increasingly detected in the duodenum on esophagogastroduodenoscopy (EGD). Primary gastrointestinal follicular lymphomas are frequently distributed to multiple sites in the gastrointestinal tract. Therefore, investigation into the spread of follicular lymphomas in the small bowel is important in order to determine the most appropriate treatment strategy. The performance of double-balloon endoscopy (DBE) in the diagnosis of jejunoileal follicular lymphoma lesions has not been fully evaluated. We aimed to investigate the value of DBE in addition to computed tomography (CT) and ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG-PET) in the diagnosis of jejunoileal follicular lymphoma. DBE with biopsy was performed in seven patients with primary duodenal follicular lymphoma diagnosed by EGD, in order to investigate jejunoileal involvement. Jejunoileal follicular lymphoma lesions were detected by DBE in six out of the seven patients (three in the jejunum and three in the jejunum and ileum), whereas CT and ¹⁸F-FDG-PET failed to detect the existence of these lesions. Endoscopic findings of the jejunoileal lesions revealed multiple white nodules and white villi, which were similar to those of duodenal lesions. DBE was more useful for the diagnosis of jejunoileal involvement in primary intestinal follicular lymphoma than CT and ¹⁸F-FDG-PET. The use of DBE will become important for determining the most appropriate treatment for gastrointestinal follicular lymphoma.

References

• 1 Amer M H, el-Akkad S. Gastrointestinal lymphoma in adults: clinical features and management of 300 cases.  Gastroenterology. 1994;  106 846-858
• 2 Nakamura S, Matsumoto T, Iida M. et al . Primary gastrointestinal lymphoma in Japan. A clinicopathologic analysis of 455 patients with special reference to its time trends.  Cancer. 2003;  97 2462-2473
• 3 Shia J, Teruya-Feldstein J, Pan D. et al . Primary follicular lymphoma of the gastrointestinal tract: a clinical and pathologic study of 26 cases.  Am J Surg Pathol. 2002;  26 216-224
• 4 Damaj G, Verkarre V, Delmer A. et al . Primary follicular lymphoma of the gastrointestinal tract: a study of 25 cases and a literature review.  Ann Oncol. 2003;  14 623-629
• 5 Yoshino T, Miyake K, Ichimura K. et al . Increased incidence of follicular lymphoma in the duodenum.  Am J Surg Pathol. 2000;  24 688-693
• 6 Jerusalem G, Beguin Y, Najjar F. et al . Positron emission tomography (PET) with ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) for the staging of low-grade non-Hodgkin’s lymphoma (NHL).  Ann Oncol. 2001;  12 825-830
• 7 Lewin K J, Ranchod M, Dorfman R F. Lymphomas of the gastrointestinal tract: a study of 117 cases presenting with gastrointestinal disease.  Cancer. 1978;  42 693-707
• 8 Harris N L, Jaffe E S, Stein H. et al . A revised European-American classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group.  Blood. 1994;  84 1361-1392
• 9 Rohatiner A, d’Amore F, Coiffier B. et al . Report on a workshop convened to discuss the pathological and staging classifications of gastrointestinal tract lymphoma.  Ann Oncol. 1994;  5 397-400
• 10 Yamamoto H, Kita H, Sunada K. et al . Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases.  Clin Gastroenterol Hepatol. 2004;  2 1010-1016
• 11 Bende R J, Smit L A, Bossenbroek J G. et al . Primary follicular lymphoma of the small intestine: alpha4beta7 expression and immunoglobulin configuration suggest an origin from local antigen-experienced B cells.  Am J Pathol. 2003;  162 105-113
• 12 Nakamura S, Matsumoto T, Umeno J. et al . Endoscopic features of intestinal follicular lymphoma: the value of double-balloon enteroscopy.  Endoscopy. 2007;  39 E26-E27
• 13 Iddan G, Meron G, Glukhovsky A. et al . Wireless capsule endoscopy.  Nature. 2000;  405 417
• 14 Flieger D, Keller R, May A. et al . Capsule endoscopy in gastrointestinal lymphomas.  Endoscopy. 2005;  37 1174-1180
• 15 van Deursen C TBM, Goedhard J G, Jie K SG. et al . Primary intestinal follicular lymphoma diagnosed by video capsule endoscopy and double-balloon enteroscopy.  Endoscopy. 2008;  40 E8-E9
• 16 Hoffmann M, Chott A, Püspök A. et al . ¹⁸F-fluorodeoxyglucose positron emission tomography (¹⁸F-FDG-PET) does not visualize follicular lymphoma of the duodenum.  Ann Hematol. 2004;  83 276-278
• 17 Chim C S, Loong F, Leung A Y. et al . Primary follicular lymphoma of the small intestine.  Leuk Lymphoma. 2004;  45 1463-1466
• 18 Czuczman M S, Weaver R, Alkuzweny B. et al . Prolonged clinical and molecular remission in patients with low-grade or follicular non-Hodgkin’s lymphoma treated with rituximab plus CHOP chemotherapy: 9-year follow-up.  J Clin Oncol. 2004;  22 4711-4716