Confocal endoscopy-assisted diagnosis of duodenal follicular lymphoma: a rare case report

Abstract

Figures

Endoscopic image. a Gastroscopy showing scattered white irregular erosive lesions and mucosal thickening at the junction of the duodenal bulb and descending duodenum. b CLE revealing irregular glandular structures, focal loss of glandular architecture, thickening and dilation of lymphatic vessels, disorganized tissue arrangement, and increased fluorescein sodium leakage. Abbreviation: CLE, confocal laser endomicroscopy.

Histopathological examination. Histopathological examination demonstrating neoplastic follicles, consistent with FL.Abbreviation: FL, follicular lymphoma.

Imaging examination. a PET/CT scan demonstrating uneven thickening of the intestinal walls in the descending and horizontal sections of the duodenum, along with multiple areas of abnormal uptake within the abdominal cavity. b Abdominal enhanced CT scan confirming the absence of extraintestinal involvement, with no evidence of abnormal lesions or extension beyond the intestinal walls.

Full text

Duodenal follicular lymphoma (D-FL), a rare gastrointestinal lymphoma, poses diagnostic challenges due to nonspecific symptoms 1 2 . This case highlights the utility of confocal laser endomicroscopy (CLE) in early detection and management.

A 59-year-old woman with bronchial asthma presented with epigastric pain and bloating. Gastroscopy revealed mucosal thickening and erosions at the duodenal bulb-descending junction ( Fig. 1 a ). CLE identified disrupted glandular architecture, dilated lymphatic vessels, and fluorescein leakage, prompting targeted biopsies ( Fig. 1 b , Video 1 ). Histopathology confirmed neoplastic follicles ( Fig. 2 ), while immunohistochemistry (CD20+, CD10+, Bcl-6+, BCL2+, and Ki-67+) and IG gene rearrangement confirmed follicular lymphoma. PET/CT ( Fig. 3 a ) and abdominal CT ( Fig. 3 b ) localized disease to the duodenum without extraintestinal involvement (stage II).

Endoscopic image. a Gastroscopy showing scattered white irregular erosive lesions and mucosal thickening at the junction of the duodenal bulb and descending duodenum. b CLE revealing irregular glandular structures, focal loss of glandular architecture, thickening and dilation of lymphatic vessels, disorganized tissue arrangement, and increased fluorescein sodium leakage. Abbreviation: CLE, confocal laser endomicroscopy.

Confocal laser endomicroscopy in the application of duodenal follicular lymphoma.Video 1

Histopathological examination. Histopathological examination demonstrating neoplastic follicles, consistent with FL.Abbreviation: FL, follicular lymphoma.

Imaging examination. a PET/CT scan demonstrating uneven thickening of the intestinal walls in the descending and horizontal sections of the duodenum, along with multiple areas of abnormal uptake within the abdominal cavity. b Abdominal enhanced CT scan confirming the absence of extraintestinal involvement, with no evidence of abnormal lesions or extension beyond the intestinal walls.

Treatment began with Rituximab-CVP (cyclophosphamide, vincristine, and prednisone) for four cycles, achieving remission. Due to asthma-related concerns, therapy was switched to Rituximab-Lenalidomide, which was well-tolerated. Regular follow-up was advised to monitor progression.

CLE’s real-time, high-resolution imaging enabled early detection of microarchitectural abnormalities, guiding precise biopsies and minimizing invasive sampling. Multimodal imaging (PET/CT, CT) confirmed localized disease, underscoring its role in staging. This case illustrates the synergy of advanced endoscopy, histopathology, and imaging in diagnosing D-FL. Personalized treatment, balancing efficacy and comorbidities, optimized outcomes without compromising safety.

In conclusion, CLE enhances early diagnosis of D-FL by visualizing microscopic changes, complementing traditional methods. Combined with tailored therapies and rigorous follow-up, it improves diagnostic accuracy and long-term management in rare gastrointestinal malignancies.

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