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| LETTER TO EDITOR |
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| Year : 2020 | Volume
: 28
| Issue : 4 | Page : 267-268 |
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Primary non-hodgkin's lymphoma of the duodenum: An uncommon location
Reddy Ravikanth1, Pooja Majumdar2
1 Department of Radiology, Holy Family Hospital, Thodupuzha, Kerala, India
2 Department of Medicine, Indian Naval Hospital Ship, Visakhapatnam, Andhra Pradesh, India
| Date of Submission | 16-Oct-2019 |
| Date of Decision | 19-Nov-2019 |
| Date of Acceptance | 07-Jan-2020 |
| Date of Web Publication | 19-Feb-2019 |
Correspondence Address:
Dr. Reddy Ravikanth
Department of Radiology, Holy Family Hospital, Thodupuzha - 685 605, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JMU.JMU_100_19
How to cite this article:
Ravikanth R, Majumdar P. Primary non-hodgkin's lymphoma of the duodenum: An uncommon location. J Med Ultrasound 2020;28:267-8 |
Dear Editor,
A 31-year-old gentleman presented to the surgery department with complaints of epigastric pain and vomiting for 4 months. Initially, it started with a feeling of heaviness after meals which later progressed to dull pain-aching aggravated with food intake and with no specific relieving factor. He had no complaints of difficulty while swallowing and well-tolerated semisolid and liquid diet, with no major discomfort and vomiting. The patient underwent upper gastrointestinal endoscopy which showed proximal dilatation of the stomach with food contents and hypertrophied mucosa, bulging into the lumen from pyloric antrum to the duodenal bulb and second part of duodenum. Transabdominal ultrasonography revealed polypoidal lesion involving the descending part of duodenum (region of ampulla of Vater) [Figure 1], and endoscopic mucosal biopsy was performed. The lesion shows well-circumscribed follicles, composed of a uniform population of large cells. Immunohistochemically, CD20, Bcl-2, and Bcl-6 are positive in the follicular area, while CD10 and CD3 are negative. The tumor cells show a high (~80%–90%) proliferation index as evident by tumor cell nuclei staining for Ki-67. MUM1 was found to be expressed by about 70% of the cells [Figure 2]a and [Figure 2]b. Computerized tomography scan of the chest demonstrated no mediastinal lymphadenopathy. The patient was diagnosed with diffuse large cell lymphoma of the duodenum-Stage IV non-Hodgkin's lymphoma (NHL), according to the Modified Ann Arbor staging. Due to inoperability of the mass lesion, chemotherapy was initiated with R-CHOP regimen (rituximab-cyclophosphamide, doxorubicin, vincristine and prednisone) and received a total of six cycles of chemotherapy. Following chemotherapy, the patient made an uneventful recovery and computed tomography scan of the abdomen revealed no evidence of residual tumor at 30 months. | Figure 1: Transabdominal transverse ultrasonography image demonstrating polypoidal lesion (stars) involving the descending part of duodenum (region of ampulla of Vater)
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 | Figure 2: (a) Histopathology image in a proven case of diffuse large B-cell lymphoma of the duodenum demonstrating cells with vesicular chromatin, prominent nucleoli, and moderate-to-abundant amount of cytoplasm (H and E, ×400) (b) Immunohistochemistry image in a proven case of diffuse large B-cell lymphoma of the duodenum demonstrating positivity for CD20 (×200). CD20 antibody staining protocol for immunohistochemistry was adopted. Chromogen substrate reagent used was DAB and counterstain used was Mayer's hematoxylin for membrane staining pattern
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Duodenum is an uncommon location for primary non-Hodgkin's tumor of the gastrointestinal tract.[1] Diffuse, large cell lymphoma of B-cell origin is currently recognized as a predominant entity representing primary NHL arising in the gastrointestinal tract.[2] Gastrointestinal tract is the most common site and accounts for 40% of extranodal lymphomas with diffuse large B-cell lymphoma and marginal zone lymphoma of mucosa-associated lymphoid tissue (lymphoma) constituting the most common subtypes.[3] Alexander reported the first case of duodenal lymphoma in 1877.[4] Mizobuchi et al.[5] described a case of primary non-Hodgkin's T-cell lymphoma of the duodenum. In the small intestine, T-cell NHLs predominate in the jejunum associated with coeliac disease and B-cell NHLs are frequently found in the ileum. Ultrasonographic appearances are variable and range from focal nodular thickening to diffuse thickening with parietal infiltration. Aneurysmal dilatation is most suggestive of lymphoma involvement in the gastrointestinal tract. The differential diagnoses of small bowel NHL are mainly adenocarcinoma and stromal tumors.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Yin L, Chen CQ, Peng CH, Chen GM, Zhou HJ, Han BS, et al. Primary small-bowel non-Hodgkin's lymphoma: A study of clinical features, pathology, management and prognosis. J Int Med Res 2007;35:406-15.  |
| 2. | Zaarour M, Busack C, Munker R. Obstructing duodenal diffuse large B-cell lymphoma with peritoneal lymphomatosis with exceptional response to R-CHOP. Cureus 2019;11:e4621. |
| 3. | Graham RL, Mardones MA, Krause JR. Primary follicular lymphoma of the duodenum. Proc (Bayl Univ Med Cent) 2015;28:381-3. |
| 4. | Alexander RG. Lymphomatous tumor of the duodenum. Lancet 1877;2:954. |
| 5. | Mizobuchi S, Yamashiro T, Ohmori Y, Ogoshi S, Sonobe H. Primary T-cell lymphoma of the duodenum: Report of a case. Surg Today 1999;29:354-7. |
[Figure 1], [Figure 2]
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