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Primary Follicular Lymphoma in the Small Intestine

A Rare Cause of Bowel Obstruction
      A woman between 60 and 70 years of age experienced nausea, vomiting, and epigastric pain radiating throughout the abdomen for several days. Physical examination revealed abdominal tenderness with epigastric prominence, without peritoneal irritation. Dynamic computed tomography (CT) showed dilatation of the small intestine and two points of bowel obstruction due to intestinal wall thickening (Figure 1A, arrow), increased mesenteric fatty tissue (Figure 1B), and enlarged mesenteric lymph nodes (Figure 1B, arrowhead). Based on her history of appendectomy, we considered the possibility of adhesive bowel obstruction. Conservative treatment was unsuccessful; surgery was needed. Laparotomy revealed stenosis due to two tumors (110 cm and 125 cm in diameter, respectively) arising from the Treitz ligament, and mesenteric lymphadenopathy along the distribution of the mesenteric artery.
      Figure thumbnail gr1
      Figure 1Abdominal computed tomography. A, Intestinal obstruction (arrows). B, Mesenteric fatty tissue and enlarged lymph nodes (arrowheads).
      The stenosed areas of the small intestine were partially resected (Figure 2A, marked by asterisks). Histological and immunohistochemical examination revealed a follicular lymphoma (FL) (Figure 2B) with CD20-positive tumor cells (Figure 2C) and a CD10-positive germinal center of the lymphoid follicle (Figure 2D). The patient was diagnosed with a grade 3A FL, was evaluated for residual disease using positron emission tomography, and underwent chemotherapy.
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      Figure 2Histological findings of intestinal follicular lymphoma. A, Resected portion of the small intestine showing two stenotic points (asterisks). B, Hematoxylin-eosin staining. C, CD20. D, CD10 immunohistochemical staining.
      Primary gastrointestinal FL is often asymptomatic and relatively rare, accounting for 1% to 3.6% of gastrointestinal lymphomas.
      • Egea-Valenzuela J.
      • Castillo-Espinosa J.M.
      • Sánchez-Torres A.
      • Alberca-de-las-Parras F.
      • Carballo-Álvarez F.
      Diagnosis of follicular lymphoma of the small bowel by video capsule endoscopy.
      Intestinal obstruction is a rare presentation.
      • Higuchi N.
      • Sumida Y.
      • Nakamura K.
      • et al.
      Impact of double-balloon endoscopy on the diagnosis of jejunoileal involvement in primary intestinal follicular lymphomas: a case series.
      In one study of patients with abnormal mesenteric fat concentration and signs of malignant disease on CT, 28% had a malignant disease, of which 36% were lymphomas (17% FLs and 9% diffuse large B-cell lymphomas).
      • Ehrenpreis E.D.
      • Roginsky G.
      • Gore R.M.
      Clinical significance of mesenteric panniculitis-like abnormalities on abdominal computerized tomography in patients with malignant neoplasms.
      An abnormal mesenteric fat concentration on CT should raise suspicion of malignancy, especially lymphoma.

      Potential Competing Interests

      The authors report no potential competing interests.

      Acknowledgments

      The authors thank Ms Tomoe Hayashi (Department of Hematology, Kanazawa Municipal Hospital) for the treatment of follicular lymphoma and Dr Ryota Yoshida (Department of Gastroenterology, Kanazawa Municipal Hospital) for contributing to the discussion on gastroenterology.

      References

        • Egea-Valenzuela J.
        • Castillo-Espinosa J.M.
        • Sánchez-Torres A.
        • Alberca-de-las-Parras F.
        • Carballo-Álvarez F.
        Diagnosis of follicular lymphoma of the small bowel by video capsule endoscopy.
        Rev Esp Enferm Dig. 2014; 106: 51-52
        • Higuchi N.
        • Sumida Y.
        • Nakamura K.
        • et al.
        Impact of double-balloon endoscopy on the diagnosis of jejunoileal involvement in primary intestinal follicular lymphomas: a case series.
        Endoscopy. 2009; 41: 175-178
        • Ehrenpreis E.D.
        • Roginsky G.
        • Gore R.M.
        Clinical significance of mesenteric panniculitis-like abnormalities on abdominal computerized tomography in patients with malignant neoplasms.
        World J Gastroenterol. 2016; 22: 10601-10608