A 70-year-old asymptomatic woman underwent screening esophagogastroduodenoscopy, which
revealed a bulging minor duodenal papilla with redness and rough surface ([Fig. 1 a – c]). Biopsy was suggestive of adenocarcinoma. Laboratory data included normal blood
counts and standard serum biochemical tests. Abdominal computed tomography (CT) showed
a slightly contrast-enhanced duodenal tumor, approximately 1 cm in size without regional
lymphadenitis in the second part of the duodenum; however, choledocholith was also
noted incidentally ([Fig. 2 a]). Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography
(ERCP) showed a normal pancreatic duct ([Fig. 2 b, c]) and choledocholith.
Fig. 1 Treatment of the tumor. Endoscopic views (a – e). a – c The minor duodenal papilla with a tumor causing redness and rough surface (arrowheads).
The ampulla of Vater was intact (arrows). d Endoscopic papillectomy of the minor duodenal papilla along with resection of the
tumor using a polypectomy snare. e Immediately after endoscopic papillectomy, the orifice of the Santorini duct was
confirmed (arrow). f The resected specimen, approximately 1.7 cm in size.
Fig. 2 Imaging studies. a Abdominal computed tomography scan, showing a slightly contrast-enhanced duodenal
tumor, approximately 1 cm in size without regional swollen lymph nodes in the second
part of the duodenum (arrow) and an incidental choledocholith (arrowhead). b, c Magnetic resonance cholangiopancreatography (b) and endoscopic retrograde cholangiopancreatography (c) showed a normal pancreatic duct. d 18-F fluorodeoxyglucose-positron emission tomography/computed tomography after endoscopic
papillectomy showed uptake in the third part of the duodenum and surrounding lymph
node (arrows)
The choledocholith was removed and endoscopic biliary stenting was performed by ERCP.
We then performed endoscopic papillectomy of the minor duodenal papilla to confirm
the diagnosis ([Fig. 1 d – f], [Video 1]). Histological and immunohistochemical examination revealed follicular lymphoma
Grade 1, which was positive for CD20/CD10/BCL-2 but negative for CD3/CD5/BCL1 ([Fig. 3]). Bone marrow biopsy showed no abnormal findings; however, 18-F fluorodeoxyglucose-positron
emission tomography/computed tomography revealed uptake in the third part of the duodenum
and surrounding lymph node ([Fig. 2 d]), indicating a diagnosis of stage II1 (Lugano International Conference Classification).
The patient progressed well after endoscopic papillectomy and was discharged 10 days
postoperatively. Following advice from the hematologist, the patient commenced watch-and-wait
monitoring.
Video 1 Endoscopic papillectomy of the minor duodenal papilla and resection of the tumor
using a polypectomy snare after removal of a choledocholith and endoscopic biliary
stenting by endoscopic retrograde cholangiopancreatography.
Fig. 3 Histological images of the resected specimen stained with hematoxylin and eosin,
showing follicular lymphoma Grade 1. The Santorini duct was confirmed (arrow). a × 12.5. b × 60.
Follicular lymphoma of the duodenum is rare, comprising only 3.6 % of all gastrointestinal
tract lymphomas [1]. Follicular lymphoma of the minor duodenal papilla is very rare. In addition, only
a few cases of minor duodenal papilla tumors other than adenocarcinoma, such as somatostatinoma
and carcinoid, have been reported to be treated with endoscopic papillectomy [2]
[3]. To the best of our knowledge, this is the first case report in English of a follicular
lymphoma of the minor duodenal papilla being successfully diagnosed using endoscopic
papillectomy. Endoscopic papillectomy may provide an endoscopic technique for diagnosis
of the follicular lymphoma of the minor duodenal papilla.
Endoscopy_UCTN_Code_CCL_1AB_2AZ_3AB
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos