Predictive factors for the progression of primary localized stage small-bowel follicular lymphoma

The Role of Small Bowel Capsule Endoscopy in Determining the Treatment Strategy for Duodenal Follicular Lymphoma: A Single-Center Retrospective Study

Objectives: In this single-center retrospective study, we aimed to verify the extent of duodenal follicular lymphoma (DFL) and investigate the role and clinical significance of video capsule endoscopy (VCE) in the treatment process. Methods: We analyzed the clinical and imaging data of 40 patients diagnosed with DFL. Results: Imaging workup and bone marrow biopsies revealed DFL only in the gastrointestinal tract (stage I) in 22 patients and in local lymph nodes (stage II1), distant lymph nodes (stage II2), pancreas (stage II2Epancreas), and extranodal regions (stage IV) in 1, 3, 1, and 13 patients, respectively. Fifteen of the 23 patients with localized (stages I and II1) DFL underwent VCE for comprehensive small bowel evaluation, which revealed lesion extension beyond the duodenum in 10 patients (66.7%). A watch-and-wait strategy was implemented for one patient and systemic chemotherapy was administered to the remaining nine. Of the eight patients without VCE, seven and one received radiotherapy and observation, respectively. Nine of the 23 patients (39.1%) received systemic treatment based on positive VCE results. Only one of the 17 patients with advanced-stage DFL (stages II2 and IV) accepted radiotherapy; 16 underwent systemic chemotherapy. During follow-up (median, 48.4 months), two relapse events occurred in the advanced stage, with no lymphoma-associated deaths. DFL tends to be indolent and has favorable outcomes. Conclusions: Proactive VCE for diagnosing DFL is recommended to determine small bowel involvement, which may influence subsequent treatment decisions.

Recent updates on treatment options for primary follicular lymphoma of the gastrointestinal tract

BACKGROUND

Primary gastrointestinal follicular lymphoma is a subtype of follicular lymphoma that originates directly from the gastrointestinal tract. Pathologically, it exhibits substantial similarities with the secondary gastrointestinal involvement observed in nodal follicular lymphoma. However, primary gastrointestinal follicular lymphoma presents clinically distinct features, necessitating divergent considerations in treatment selection compared with nodal follicular lymphoma.

AREAS COVERED

This narrative review focused on recent articles (2018-2023) regarding the long-term prognosis and treatment options for gastrointestinal follicular lymphoma. In addition, a brief overview of gastrointestinal follicular lymphomas is provided.

EXPERT OPINION

Patients with primary gastrointestinal follicular lymphoma often present with a low tumor burden. Lymphoma lesions typically remain asymptomatic for several years or may undergo spontaneous regression without immediate treatment. Therefore, a 'watch and wait' approach is justified. Conversely, when large tumor masses are identified in the gastrointestinal tract, the potential for tumor bleeding or intestinal obstruction requires timely therapeutic interventions.

Epidemiological features and prognosis for primary gastrointestinal follicular lymphoma

Primary gastrointestinal follicular lymphoma (PGI-FL) is a rare extra-nodal lymphoma. Its epidemiology and prognosis remain unclear. We performed a retrospective analysis of eligible patients with 1648 PGI-FL and 34 892 nodal FL (N-FL) in the Surveillance, Epidemiology and End Results (SEER) database. The age-adjusted average annual incidence of PGI-FL was 0.111/100000. The median overall survival (OS) for PGI-FL and N-FL patients was 207 and 165 months respectively. The 5-year diffuse large B-cell lymphoma (DLBCL) transformation rates were 2.1% and 2.6% respectively. Age, sex, grade, Ann Arbor stage, primary site and radiation were independent prognostic factors (p < 0.05). Nomograms were constructed to predict 1-, 5- and 10-year OS and disease-specific survival (DSS). The receiver operating characteristic curves and calibration plots showed the established nomograms had robust and accurate performance. Patients were classified into three risk groups according to nomogram score. In conclusion, the incidence of PGI-FL has increased over the past 40 years, and PGI-FL has a better prognosis and a lower DLBCL transformation rate than N-FL. The nomograms were developed and validated as an individualized tool to predict survival. Patients were divided into three risk groups to assist clinicians in identifying high-risk patients and choosing the optimal individualized treatments.

Disease surveillance evaluation of primary small-bowel follicular lymphoma using capsule endoscopy images based on a deep convolutional neural network (with video)

BACKGROUND AND AIMS

Capsule endoscopy (CE) is useful in evaluating disease surveillance for primary small-bowel follicular lymphoma (FL), but some cases are difficult to evaluate objectively. This study evaluated the usefulness of a deep convolutional neural network (CNN) system using CE images for disease surveillance of primary small-bowel FL.

METHODS

We enrolled 26 consecutive patients with primary small-bowel FL diagnosed between January 2011 and January 2021 who underwent CE before and after a watch-and-wait strategy or chemotherapy. Disease surveillance by the CNN system was evaluated by the percentage of FL-detected images among all CE images of the small-bowel mucosa.

RESULTS

Eighteen cases (69%) were managed with a watch-and-wait approach, and 8 cases (31%) were treated with chemotherapy. Among the 18 cases managed with the watch-and-wait approach, the outcome of lesion evaluation by the CNN system was almost the same in 13 cases (72%), aggravation in 4 (22%), and improvement in 1 (6%). Among the 8 cases treated with chemotherapy, the outcome of lesion evaluation by the CNN system was improvement in 5 cases (63%), almost the same in 2 (25%), and aggravation in 1 (12%). The physician and CNN system reported similar results regarding disease surveillance evaluation in 23 of 26 cases (88%), whereas a discrepancy between the 2 was found in the remaining 3 cases (12%), attributed to poor small-bowel cleansing level.

CONCLUSIONS

Disease surveillance evaluation of primary small-bowel FL using CE images by the developed CNN system was useful under the condition of excellent small-bowel cleansing level.

Review of lymphoma in the duodenum: An update of diagnosis and management

The presentation, subtype, and macroscopic images of lymphoma vary depending on the site of the tumor within the gastrointestinal tract. We searched PubMed for publications between January 1, 2012 and October 10, 2022, and retrieved 130 articles relating to duodenal lymphoma. A further 22 articles were added based on the manual screening of relevant articles, yielding 152 articles for full-text review. The most predominant primary duodenal lymphoma was follicular lymphoma. In this review, we provide an update of the diagnosis and man-agement of representative lymphoma subtypes occurring in the duodenum: Follicular lymphoma, diffuse large B-cell lymphoma, extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue, mantle cell lymphoma, and T-cell lymphomas.