Endoscopy 2011; 43: E346-E347
DOI: 10.1055/s-0030-1256843
Unusual cases and technical notes

© Georg Thieme Verlag KG Stuttgart · New York

Magnifying endoscopy findings in follicular lymphoma of the rectum using narrow band imaging

M.  Kuroha1 , K.  Endo1 , Y.  Sato1 , H.  Shiga1 , Y.  Kakuta1 , S.  Takahashi1 , Y.  Kinouchi1 , T.  Shimosegawa1
  • 1Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
Further Information

M. Kuroha

Division of Gastroenterology
Tohoku University Graduate School of Medicine

1-1 Seiryo
Aoba
Sendai 980-8574
Japan

Fax: +81-22-7177177

Email: kuroha@med.tohoku.ac.jp

Publication History

Publication Date:
21 October 2011 (online)

Table of Contents

Follicular lymphoma (FL) of the gastrointestinal tract is a rare disease [1] [2]. We report a case of primary FL of the rectum, in which the characteristic endoscopic findings were observed in detail using magnifying endoscopy with narrow band imaging (NBI).

A 56-year-old woman presented with rectal bleeding. Colonoscopy revealed multiple, smooth-surfaced whitish granules in the rectum. Each granule was irregular in size and had a diameter of about 3 – 5 mm and were visualized more clearly after spraying with indigo carmine ([Fig. 1]).

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Fig. 1 Colonoscopy findings following indigo carmine spraying, in a 56-year-old woman with rectal bleeding.

By using magnifying endoscopy with NBI, large areas of irregular microvasculature were clearly observed on the surface of each granule ([Fig. 2 a]), with the microvessels appearing dilated and convoluted ([Fig. 2 b]).

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Fig. 2  Large area of irregular microvasculature on the surface of the granule (narrow-band imaging [NBI] view). b The microvessels were dilated and convoluted (magnified high-resolution NBI view).

Since the biopsy specimens were insufficient to distinguish normal lymphoid hyperplasia from FL, endoscopic mucosal resection (EMR) of the granular area was carried out to obtain bigger tissue samples. Histopathologic examination of the EMR specimens disclosed infiltration of small- to medium-sized, atypical lymphoid cells in the subepithelial layer. Immunohistochemical analysis revealed that the neoplastic lymphoid cells were positive for CD10, CD20, and bcl-2, but negative for CD3 and CD5 ([Fig. 3]).

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Fig. 3 Immunohistochemical analysis demonstrating that lymphoid neoplastic cells were positive for CD10.

Positron emission tomography (PET) showed increased uptake only in the rectum, and additional diagnostic procedures showed no extraintestinal infiltration of the FL. Based on these findings, a diagnosis of primary FL of the rectum was made. The patient underwent radiation therapy and chemotherapy including rituximab. After treatment, endoscopy of the rectum showed complete resolution of the nodules ([Fig. 4]).

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Fig. 4 Colonoscopic view of the rectum after treatment showing the absence of nodules. No cancer cells were observed in the endoscopic mucosal resection scar.

The endoscopic findings of FL of the rectum have not been clarified. In the present case, magnifying endoscopy with NBI revealed irregular microvasculature on the surface of a FL, a feature that is never seen in lymphoid hyperplasia. NBI is a potentially useful diagnostic tool for distinguishing between normal lymphoid hyperplasia and malignant lymphoma such as rectal FL.

Endoscopy_UCTN_Code_CCL_1AD_2AC

Competing interests: None

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References

  • 1 LeBrun D P, Kamel O W, Cleary M L et al. Follicular lymphomas of the gastrointestinal tract. Pathologic features in 31 cases and bcl-2 oncogenic protein expression.  Am J Pathol. 1992;  140 1327-1335
  • 2 Yamamoto S, Nakase H, Yamashita K et al. Gastrointestinal follicular lymphoma: review of the literature.  J Gastroenterol. 2010;  45 370-388

M. Kuroha

Division of Gastroenterology
Tohoku University Graduate School of Medicine

1-1 Seiryo
Aoba
Sendai 980-8574
Japan

Fax: +81-22-7177177

Email: kuroha@med.tohoku.ac.jp

#

References

  • 1 LeBrun D P, Kamel O W, Cleary M L et al. Follicular lymphomas of the gastrointestinal tract. Pathologic features in 31 cases and bcl-2 oncogenic protein expression.  Am J Pathol. 1992;  140 1327-1335
  • 2 Yamamoto S, Nakase H, Yamashita K et al. Gastrointestinal follicular lymphoma: review of the literature.  J Gastroenterol. 2010;  45 370-388

M. Kuroha

Division of Gastroenterology
Tohoku University Graduate School of Medicine

1-1 Seiryo
Aoba
Sendai 980-8574
Japan

Fax: +81-22-7177177

Email: kuroha@med.tohoku.ac.jp

Zoom Image

Fig. 1 Colonoscopy findings following indigo carmine spraying, in a 56-year-old woman with rectal bleeding.

Zoom Image
Zoom Image

Fig. 2  Large area of irregular microvasculature on the surface of the granule (narrow-band imaging [NBI] view). b The microvessels were dilated and convoluted (magnified high-resolution NBI view).

Zoom Image

Fig. 3 Immunohistochemical analysis demonstrating that lymphoid neoplastic cells were positive for CD10.

Zoom Image

Fig. 4 Colonoscopic view of the rectum after treatment showing the absence of nodules. No cancer cells were observed in the endoscopic mucosal resection scar.