Forty-eight patients were included, and nine (18.8%) patients were found to have been incorrectly diagnosed at the initial biopsy examination as having MALT lymphoma (= 4), necrotic tissue (= 2), duodenitis (= 1), or suspected lymphoma of unspecified subtype (= 2). assisted enteroscopy. 2Required before chemotherapy with anthracycline-based regimens or autologous stem cell transplantation. 3Required only for patients with suspected CNS involvement. HIV: Human immunodeficiency computer virus; CNS: Central nervous system; sIL-2R: Soluble interleukin-2 receptor; CT: Computed tomography; PET: Positron emission tomography; FISH: Fluorescence in situ hybridization; PCR: Polymerase chain reaction; LDH: Lactate dehydrogenase; BCL-2: B-cell lymphoma 2. CLINICAL AND LABORATORY ASSESSMENT As a general rule, comprehensive assessment of clinical features and laboratory test results are important for all those patients with newly diagnosed follicular lymphoma. Patients (S)-Leucic acid with main intestinal follicular lymphoma generally lack systemic symptoms, whereas systemic follicular lymphoma patients with secondary gastrointestinal involvement may exhibit symptoms. Since most gastrointestinal lesions are neither mass-forming nor ulcerative, more than half of patients present without gastrointestinal follicular lymphoma-related manifestations. Yamamoto et al examined 150 previously reported cases and noted that 65 patients (43.3%) were asymptomatic while 14 (9.3%) presented (S)-Leucic acid with ambiguous gastrointestinal symptoms including abdominal discomfort and heartburn. Other symptoms include abdominal pain (= 43, 28.7%), intestinal obstruction-related symptoms such as nausea and vomiting (= 12, 8.0%), and intestinal bleeding such as tarry and bloody stool (= 9, 6.0%). A multi-institutional survey in Japan summarizing 125 patients with main gastrointestinal follicular lymphoma reported that 96 patients (76.8%) were asymptomatic. The remaining patients presented with abdominal pain (= 10, 8.0%), abdominal pain (= 13, 10.4%), intestinal obstruction (= 5, 4.0%), or diarrhea (= 1, 0.8%). Information about allergies, previous illnesses and surgeries, performance status, and results of physical exams of the peripheral lymph nodes, liver, spleen, and Waldeyers ring (S)-Leucic acid should also be recorded at the initial presentation. Blood tests should include hemoglobin, 2-microglobulin, and lactate dehydrogenase (LDH) levels, since this information is usually indispensable for PCDH8 risk stratification according to FILIPI and FLIPI2, as explained below[14,15]. ENDOSCOPIC FEATURES When it entails the gastrointestinal tract, main gastrointestinal follicular lymphoma most frequently affects the small intestine[1,17]. In most patients, this disease is usually diagnosed by esophagogastroduodenoscopy as whitish lesions in the duodenum (Physique ?(Physique11)[16-18]. The typical endoscopic image has been described in various terms such as small polypoid nodules, multiple polypoid lesions, multiple small polyps, multiple nodules, or multiple granules. Other macroscopic features are infrequent, but it can present as erosions or ulcers. Open in a separate window Physique 1 Endoscopic features of intestinal follicular lymphoma in a 63-year-old woman. A: This case was diagnosed as follicular lymphoma with duodenal and jejunal lesions, and mesenteric lymph node involvement. The duodenal lesions are observed as multiple whitish nodules; B: Magnifying observation discloses opaque white depositions; C: Narrow-band imaging visualizes dilated microvessels on the surface of the white depositions; D: Video capsule enteroscopy shows multiple whitish granules in the jejunum; E: Double-balloon enteroscopy images of a jejunal lesion. Any jejunal and ileal involvement shows a morphology similar to the duodenal lesions (Physique ?(Physique1D1D and E)[16,20-22]. Since these lesions generally remain small, most of these cases are asymptomatic or only exhibit symptoms not related to the lymphoma lesions. In rare instances, small intestinal lesions form ulcers, luminal stenosis, and heavy tumors accompanied by ulcers and/or wall thickening, probably resulting from an increased quantity of infiltrated lymphoma cells within the small intestinal wall[23,24]. Among follicular lymphoma cases presenting with intestinal involvement, 66.7% to 100% of the patients presented with multiple follicular lymphoma lesions in the jejunum and/or ileum[4,20-22,24-26]. As explained below, the sensitivity of CT and positron emission tomography (PET) scanning is not sufficient to diagnose the intestinal lesions of follicular lymphoma. Therefore, main intestinal follicular lymphoma patients under consideration for radiotherapy should be investigated by CT or PET scanning and also by enteroscopy examinations such as video capsule enteroscopy or balloon-assisted enteroscopy. Gastric involvement of follicular lymphoma has been occasionally reported. It can vary from protruding lesions to superficial, shallow stressed out lesions. Only eight case reports of follicular lymphomas with colorectal involvement that describe detailed features have been reported[29-36]. Among the reported cases, the endoscopic images in one patient showed.