Cancer Res Treat.  2019 Apr;51(2):547-555. 10.4143/crt.2018.190.

Radiation Therapy Outcome and Clinical Features of Duodenal-Type Follicular Lymphoma

• Lee H
• Oh D
• Yang K
• Ko YH
• Ahn YC
• Kim WS
• Kim SJ

• KMID: 2464402
• DOI: http://doi.org/10.4143/crt.2018.190

Abstract

PURPOSE
Duodenal-type follicular lymphoma (FL) is a rare variant of FL. There is still no consensus on the initial treatment, and clinical features including endoscopic findings are not familiar to most physicians. The objective of this study was to evaluate the outcome of patients who were initially treated with radiation therapy for duodenal-type FL.
MATERIALS AND METHODS
We retrospectively analyzed 20 patients who were consecutively diagnosed with duodenal-type FL between 2008 and 2017. All patients received radiation therapywith curative intent.
RESULTS
The median age of the patients was 52 years (range, 26 to 66 years), and females were predominant. Most patients (n=18, 90%) had stage I disease, and were diagnosed by a regular health examination in an asymptomatic state. The histological grade was one in 19 patients (95%), and the endoscopic findings were diffuse nodular (n=8), whitish granular (n=8), and mixed pattern (n=4). Radiation therapy was delivered to 17 patients with 24 Gy in 12 fractions, and to three patients with 30.6-36 Gy in 18 fractions. All patients were evaluated with endoscopy for response to radiation therapy, and complete response was achieved in 19 patients (95%). At the time of analysis, all patients survived without any evidence of late toxicities related with radiation therapy.
CONCLUSION
Taken together, radiation therapy alone could be effective in controlling duodenal lesion. A further study with longer follow-up duration is warranted to confirm our findings.

Keyword

Duodenum; Follicular lymphoma; Radiation therapy

MeSH Terms

Asymptomatic Diseases
Consensus
Duodenum
Endoscopy
Female
Follow-Up Studies
Humans
Lymphoma, Follicular*
Retrospective Studies

Figure

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  Fig. 1. Initial computed tomography (CT) and positron emission tomography (PET)/CT scan imaging. (A, C, E, G, I, K) Most patients do not have severe wall thickening in the CT scan. (B, D, F, H) 2-Deoxy-2-fluorine-18-fluoro-D-glucose (FDG) uptake is not increased at the primary tumor site in the PET/CT. (J, L) Only two patients show increased FDG uptake (yellow circle).

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  Fig. 2. Endoscopic findings of duodenal-type follicular lymphoma consist of diffuse nodular (A, E, I) and a whitish granular pattern (C, G, K). These lesions disappear after radiation therapy (RT) (B, D, F, H, J, L).

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  Fig. 3. (A) Initial lesions of patient No. 6. (B) Improved lesions on endoscopy at 3-month follow-up after radiation therapy. Biopsy also reveals residual tumor. (C) Endoscopic examination at 6-month follow-up shows no significant change. (D) At 9-month follow-up, the lesion progresses, and re-biopsy shows persistent disease. Finally, re-irradiation of 20 Gy is carried out on this patient. (E) Initial lesions of patient No. 14. (F) Complete response on endoscopy at 3-month follow-up after radiation therapy. (G) Relapse outside the radiation field. Colonoscopy reveals nodular lesions in the terminal ileum. Biopsy proves the presence of follicular lymphoma. (H) Follow-up colonoscopy shows progressive disease. (I) After six cycles of rituximab–cyclophosphamide, vincristine, and prednisone, complete response is achieved, and the patient is alive without evidence of disease.

Reference

References

1. Takata K, Okada H, Ohmiya N, Nakamura S, Kitadai Y, Tari A, et al. Primary gastrointestinal follicular lymphoma involving the duodenal second portion is a distinct entity: a multicenter, retrospective analysis in Japan. Cancer Sci. 2011; 102:1532–6.

2. Kim SJ, Choi CW, Mun YC, Oh SY, Kang HJ, Lee SI, et al. Multicenter retrospective analysis of 581 patients with primary intestinal non-hodgkin lymphoma from the Consortium for Improving Survival of Lymphoma (CISL). BMC Cancer. 2011; 11:321.

3. Swerdlow SH, Campo E, Pileri SA, Harris NL, Stein H, Siebert R, et al. The 2016 revision of the World Health Organization classification of lymphoid neoplasms. Blood. 2016; 127:2375–90.

4. Anderson JR, Armitage JO, Weisenburger DD. Epidemiology of the non-Hodgkin's lymphomas: distributions of the major subtypes differ by geographic locations. Non-Hodgkin's Lymphoma Classification Project. Ann Oncol. 1998; 9:717–20.

5. Yamamoto S, Nakase H, Yamashita K, Matsuura M, Takada M, Kawanami C, et al. Gastrointestinal follicular lymphoma: review of the literature. J Gastroenterol. 2010; 45:370–88.

6. Yoshino T, Miyake K, Ichimura K, Mannami T, Ohara N, Hamazaki S, et al. Increased incidence of follicular lymphoma in the duodenum. Am J Surg Pathol. 2000; 24:688–93.

7. Takata K, Tanino M, Ennishi D, Tari A, Sato Y, Okada H, et al. Duodenal follicular lymphoma: comprehensive gene expression analysis with insights into pathogenesis. Cancer Sci. 2014; 105:608–15.

8. Maeng CH, Ahn SW, Ryu SY, Han S, Ko YH, Ji JH, et al. Treatment outcomes and clinical relevance of the Follicular Lymphoma International Prognostic Index in Korean follicular lymphoma patients treated with chemotherapy. Korean J Intern Med. 2016; 31:560–9.

9. Ahmed N, Owen TE, Rubinger M, Williams G, Nugent Z, Ahmed S, et al. Early stage W.H.O. grade I and II follicular lymphoma treated with radiation therapy alone. PLoS One. 2013; 8:e65156.

10. Harada A, Oguchi M, Terui Y, Takeuchi K, Igarashi M, Kozuka T, et al. Radiation therapy for localized duodenal lowgrade follicular lymphoma. J Radiat Res. 2016; 57:412–7.

11. Solal-Celigny P, Roy P, Colombat P, White J, Armitage JO, Arranz-Saez R, et al. Follicular lymphoma international prognostic index. Blood. 2004; 104:1258–65.

12. Roulland S, Navarro JM, Grenot P, Milili M, Agopian J, Montpellier B, et al. Follicular lymphoma-like B cells in healthy individuals: a novel intermediate step in early lymphomagenesis. J Exp Med. 2006; 203:2425–31.

13. Schmatz AI, Streubel B, Kretschmer-Chott E, Puspok A, Jager U, Mannhalter C, et al. Primary follicular lymphoma of the duodenum is a distinct mucosal/submucosal variant of follicular lymphoma: a retrospective study of 63 cases. J Clin Oncol. 2011; 29:1445–51.

14. Bende RJ, Smit LA, Bossenbroek JG, Aarts WM, Spaargaren M, de Leval L, 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; 162:105–13.

15. Leung WK, Wu MS, Kakugawa Y, Kim JJ, Yeoh KG, Goh KL, et al. Screening for gastric cancer in Asia: current evidence and practice. Lancet Oncol. 2008; 9:279–87.

16. Iwamuro M, Kawai Y, Takata K, Kawano S, Yoshino T, Okada H, et al. Primary intestinal follicular lymphoma: How to identify follicular lymphoma by routine endoscopy. World J Gastrointest Endosc. 2013; 5:34–8.

17. Lowry L, Smith P, Qian W, Falk S, Benstead K, Illidge T, et al. Reduced dose radiotherapy for local control in non-Hodgkin lymphoma: a randomised phase III trial. Radiother Oncol. 2011; 100:86–92.

18. Yahalom J, Illidge T, Specht L, Hoppe RT, Li YX, Tsang R, et al. Modern radiation therapy for extranodal lymphomas: field and dose guidelines from the International Lymphoma Radiation Oncology Group. Int J Radiat Oncol Biol Phys. 2015; 92:11–31.