A case of grade1 follicular lymphoma diagnosed by laparoscopic lymph node resection: differentiating from late lymph node recurrence of endometrial cancer

Abstract

Follicular lymphoma is a common hematologic malignancy; however, it is less common among all malignant diseases and is difficult to suspect in advance due to the lack of specific clinical findings. Here, we report a case in which a late recurrence of corpus cancer was first suspected and finally diagnosed as follicular lymphoma. A 67-year-old female presented to our department with enlarged pelvic lymph nodes. She was diagnosed with breast cancer (HER2-posiotive with lymph node metastasis) and corpus cancer (endometrioid carcinoma grade 2, stage IA) 16 years prior, received definitive therapy and was followed up. A positron emission tomography scan was performed, and an accumulation of 18F-fluorodeoxyglucose (FDG) was detected in multiple lymph nodes, including the lymph nodes with no change in size or enlargement. We performed laparoscopic resection of the enlarged and FDG-accumulated lymph nodes and a pathological examination. The patient was diagnosed with follicular lymphoma (FL) grade 1 and is currently under observation at the Department of Hematology. FL can be considered when there is a discrepancy between the change in lymph node size and the degree of FDG accumulation. A pathological examination is useful for accurate diagnosis. Therefore, it is important to consider tissue collection; however, care must be taken to minimize the invasiveness of the procedure for the patient.

Keywords: Corpus cancer; Distinguishing from late recurrence; FDG accumulation; Laparoscopy; Low-grade follicular lymphoma.

Fig. 1

Changes in Computed tomography (CT) imaging findings. A CT image taken on November X + 16 years. B CT image taken on March X + 15 years. C CT image taken on March X + 16 years. Yellow circle indicates the gradually increasing lymph nodes

Fig. 2

Positron emission tomography (PET) findings. A Distribution of FDG accumulation in the abdominal cavity. B–E Fusion image of FDG accumulation and CT. B FDG accumulation with increasing size at the right external iliac lymph node site (Red arrow). SUVmax 4.3. C FDG accumulation with increasing size at the right obturator lymph node site (Red arrow). SUVmax 2.9. D FDG accumulation with un-changed size at the left obturator lymph node site (Blue arrow). SUVmax 3.4. E FDG accumulation with un-changed size at the left external iliac lymph node site (Blue arrow). SUVmax 4.8

Fig. 3

Detailed examination of targeted lymph node site. Red dotted circle indicates the position of targeted lymph nodes. A Images of equilibrium phase CT. B Images of arterial phase CT. The target lymph node located on the cranial side was situated near the internal and external iliac arteries branches, lateral to the common iliac vein. C Images of arterial phase CT. D Images of equilibrium phase CT. The caudal target lymph node was located posterior to the external iliac vein and lateral to the internal iliac artery

Fig. 4

Intraoperative findings. A, B Both the target lymph nodes were identified at the same location as inferred from the prior CT images. C, D Both target lymph nodes were correctly dissected laparoscopically

Fig. 5

Pathological findings. Black bar indicates 100 um. A Hematoxylin and Eosin staining, × 100 magnification. The neoplastic follicle extending beyond the nodal capsule. B–E Immunohistochemical results: positive for Bcl-2 (B), CD10 (C), CD20 (D) and Ki-67 labelling index 30% (E)