PMC3368354_01
Endoscopic images of the duodenal second portion. Irregular erosions with peripheral edematous whitish mucosa were seen (a). The erosions were emphasized by indigo carmine dye spraying (b). Close-up views of the lesions demonstrated complete loss of villi within the erosions and whitish enlarged villi in the peripheral mucosa (c and d).
CRIM2012-582607.001.jpg
PMC3368354_01_CRIM2012-582607.001.jpg
fig1
Esophagogastroduodenoscopy revealed irregular-shaped erosions aboral to the ampulla of Vater (Figure 1).
Histological findings of the biopsy samples. The initial biopsy specimens taken from the border of erosions contained small number of duodenal villi. Lymphoma cells were scanty, and therefore, the specimens were inadequate for pathological diagnosis ((a) hematoxylin and eosin staining, original magnification x40). Second biopsy specimens taken from the peripheral whitish mucosa showed lymphoid follicles composed of small-to-medium-sized lymphoid cells ((b) hematoxylin and eosin staining, original magnification x40). Lymphoma cells also infiltrated into the duodenal villi ((c) hematoxylin and eosin staining, original magnification x200). Lymphoma cells were positive for CD10 ((d) original magnification x40) and BCL2 staining ((e) original magnification x40).
CRIM2012-582607.002.jpg
PMC3368354_01_CRIM2012-582607.002.jpg
fig2
These samples contained small-to-medium-sized lymphoid cells, but the number of lymphoid cells was not enough to make a definitive diagnosis of any type of lymphoma (Figure 2(a)). The specimen contained lymphoid follicles in the duodenal mucosa, and these were comprised of small-to-medium-sized lymphoid cells, which had also infiltrated into the villi (Figures 2(b) and 2(c)). CD20, CD10 (Figure 2(d)), and BCL2 (Figure 2(e)), but negative for CD3. Colonoscopy revealed no abnormality.
18F-FDG PET images of the patient. Positive tracer uptake in the duodenum was shown in the horizontal section ((a), arrow) and coronal sections ((b, c), arrows). No abnormal uptake in other organs including the lymph nodes was detected.
CRIM2012-582607.003.jpg
PMC3368354_01_CRIM2012-582607.003.jpg
fig3
Computed tomography (CT) scanning of the neck, chest, abdomen, and pelvis showed neither lymphadenopathy nor a thickened gastrointestinal wall including the duodenum. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) scanning detected positive tracer uptake in the inferior duodenal angle, whereas in other organs there were no abnormal accumulations of 18F-FDG (Figure 3).
Endoscopic image after local radiation therapy. Both of the duodenal erosions and the whitish mucosa totally disappeared after completion of the radiation therapy. Only a slight deformity of the duodenal mucosa was noted, and this seemed to be a vestige of the lymphoma lesion (arrow). Histological examination confirmed complete remission of the follicular lymphoma.
CRIM2012-582607.004.jpg
PMC3368354_01_CRIM2012-582607.004.jpg
fig4
Esophagogastroduodenoscopy was performed one month after completion of the radiation therapy, and it revealed disappearance of the lymphomatous lesions in the duodenum (Figure 4).