Clinical Significance of Small Intestinal Involvement Detected by Double-Balloon Enteroscopy In Patients with Non-Hodgkin's Lymphoma

Small intestinal lesions without abdominal symptoms are not usually evaluated because of anatomical difficulties with the diagnostic approach to the small intestine. Double-balloon enteroscopy (DBE) can detect gastrointestinal tract lesions of lymphoma, in addition biopsy samples can only be obtained using DBE. Here, we examined the feasibility of DBE to detect small intestinal involvement as well as the clinical significance of such involvement in patients with non-Hodgkin's lymphoma (NHL).

We prospectively screened consecutive patients with first-onset NHL who were admitted to our hospital between March 2004 and August 2009. Among them, adults aged between 18 and 85 years were eligible for inclusion if (1) they had lymphoma infiltration in the stomach, duodenum or colon proven by gastrointestinal endoscopy or colonoscopy, (2) small intestinal involvement was suspected by computed tomography (CT) or Ga scintigraphy (Ga-Scinti)/ 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), or (3) any gastrointestinal symptoms were present. All patients provided written informed consent. Patients underwent DBE using a Fujinon system. Patients with CD20⁺ B-cell lymphoma received 6–8 cycles of either R-CHOP or R-THP-COP therapy. The R-THP-COP regimen included THP, an anthracycline derivative of DOX with reportedly lower cardiotoxicity than DOX. The patients with CD20-lymphoma received 6–8 cycles of CHOP or THP-COP therapy. Patients with bulky disease underwent radiotherapy ranging from 30 to 40 Gy after chemotherapy. Patients who relapsed or whose disease progressed after first line chemotherapy, and those who were resistant to first line chemotherapy, received the P-IMVP-16/CBDCA (methylprednisolone, ifosfamide, methotrexate, etoposide and carboplatin) regimen with or without R as a second line therapy. Some patients with refractory or relapsed NHL who responded to (R)-P-IMVP-16/CBDCA received high-dose chemotherapy followed by autologous stem cell transplantation.

Among 318 patients with histologically confirmed NHL between 2004 and 2009. 58 patients were eligible for DBE. Unfortunately, we could not achieve the informed consent in 16 patients and clinical conditions were too severe to undergo DBE in 4 patients. After all, we could undergo DBE in 38 patients. Their median age of the 38 patients was 65 years (range, 38–82). We confirmed small intestinal involvement in 21 (55%) of 38 patients by DBE. Complete remission (CR) or CR uncertain (CRu) rates of patients with small intestinal involvement of lymphoma (n=21, 48%) was significantly lower than that in other patients (n=297, 71%) or that in patients without small intestinal involvement confirmed by DBE (n=17, 88%). The 3-y OS rate of the patients with small intestinal involvement of lymphoma (n=21, 41%) was significantly lower than that in other patients (n=297, 77%) (P<0.0001) and that in patients without small intestinal involvement confirmed by DBE (n=17, 88%). The impact of small intestinal involvement on survival was compared using multivariate analysis with those of current clinicopathological prognostic factors. Small intestinal involvement of lymphoma was the significant prognostic factor in all lymphoma patients (3.25; 1.50–6.40; p = 0.0039) and in the patients who underwent DBE (4.59; 1.03–32.5; p = 0.0444). Aspiration pneumonia developed in 3 of 38 patients after DBE, but they improved with antibiotic therapy. No deaths were associated with DBE.

The small intestinal involvement might indicate a poor prognosis. DBE can directly and precisely evaluate the lesions and thus help to determine the most appropriate treatment strategy for such patients.

No relevant conflicts of interest to declare.