Abstract
Introduction: Follicular lymphoma (FL) is the second most common subtype of non-Hodgkin’s lymphoma (NHL) and the most common low-grade lymphoma in adults. The typical patient presentation is painless peripheral adenopathy with waxing and waning lymph node enlargement. Patients are usually asymptomatic aside from lymphadenopathy. Initial screening is conducted via general physical examination, laboratory examination, and imaging examination with enhanced computed tomography (CT). Diagnosis of FL is best made by excisional lymph node biopsy. The pathogenesis of FL is incompletely understood but thought to be associated with a t(14,18) translocation resulting in over-expression of the BCL2 oncogene and dysregulation of programmed cell death. This tumor has a distinct nodular growth pattern consisting of a mixture of centrocytes and centroblasts, making it one of the few forms of NHL that can be diagnosed accurately based on morphology alone. In this report, we discuss how a routine endocrinology workup and a history of ineffective transitions of care led to the delayed diagnosis of non-Hodgkin’s B cell follicular lymphoma.
Case: A 65 year-old Caucasian male established care with a new Primary Care Provider (PCP) in the clinic in 2020 and had no family history of autoimmune disease or cancer. His social history was unremarkable aside from infrequent alcohol use. Medical history was significant for Hyperaldosteronism diagnosed in 2017, Hypertension, Hyperlipidemia, and Gastroesophageal Reflux Disease (GERD). Since prior records of a full workup could not be obtained, he was referred to a specialist for workup of hyperaldosteronism. The patient did not follow up with recommendations until two years later in 2022, when a CT abdomen was completed and revealed a large lobulated heterogeneously enhancing 14 x 11 cm mass at the root of small bowel mesentery and multiple 3 cm round-to-oval mesenteric and retroperitoneal lymph nodes suggestive of lymphoma. The patient underwent laparoscopic abdominal node biopsy and pathology was consistent with low grade non-Hodgkin’s B cell follicular lymphoma. Results were positive for IGH/BCL2 fusion t(14,18) in 840 of the cells analyzed. Positron Emission Tomography/Computed Tomography (PET-CT) that followed showed a 12 x 10 cm soft tissue abdominal mass with intense Fluorodeoxyglucose (FDG) uptake. He was subsequently started on therapy with Obinutuzumab and Bendamustine for stage 1 bulky low grade non-Hodgkin’s B cell follicular lymphoma. Upon reviewing available previous medical records, a CT Urogram ordered in 2016 for hematuria had revealed an incidental 3 x 3.8 x 4 cm soft tissue mass in the mid left abdomen worrisome for lymphadenopathy and malignancy. The patient failed to follow up with medical recommendations; therefore, no biopsies were completed. Additionally, this patient changed PCPs several times and lacked proper communication of plans and availability of medical records, which delayed his diagnosis.
Discussion: This case illustrates the need for better continuity of care between providers to prevent delayed or missed diagnoses. This includes obtaining personal health records, which are important for evaluating a patient’s profile, analyzing treatment results, planning treatment protocols, and planning strategies for future medical care. Additionally, imaging concerning lymphoma should be followed with discussions about excisional lymph node biopsy as well possible approaches to treatment.
