Follicular lymphoma Grade 1 of the minor duodenal papilla successfully diagnosed by endoscopic papillectomy

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.

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• References

• 1 Yoshino T, Miyake K, Ichimura K. et al. Increased incidence of follicular lymphoma in the duodenum. Am J Surg Pathol 2000; 24: 688-693
• 2 Jara Letelier DI, Bonotto ML, Ardengh JC. Somatostatinoma of the minor duodenal papilla associated with pancreas divisum treated by endoscopic papillectomy. Endoscopy 2016; 48: E135-E137
• 3 Itoi T, Sofuni A, Itokawa F. et al. Endoscopic resection of carcinoid of the minor duodenal papilla. World J Gastroenterol 2007; 13: 3763-3764