Rare case of Primary duodenal papilla lymphoma producing obstructive jaundice: a Report

China: Dr Jicai Wang and the team have reported a rare case of Primary duodenal papilla lymphoma producing obstructive jaundice. The case revealed that when a reliable histological assessment cannot be achieved, surgery plays a crucial role in treating obstructive jaundice.

The Case study has been published in BMC Surgery.

The result was based on a case report of a 59-year-old man who underwent endoscopic ultrasonography for obstructive jaundice and found a duodenal papilla tumor. Light microscopy revealed a non-Hodgkin's lymphoma. The tumor was aggressive B-cell lymphoma, as shown by immunohistochemical staining. Molecular targeted therapy combined with CHOP regimen chemotherapy was performed.

On June 16, 2020, a 59-year-old male was hospitalized at a hospital's Department of Gastroenterology because of skin and sclera jaundice for more than 15 days and gradual weight loss of around 5 kg. He had a record of brain stem infarction, left lower limb paralysis, and choking on drinking water on occasion. He denied having ever had hepatitis, TB, or any other infectious condition. Physical examination revealed that he had a chronic illness look, with skin and sclera jaundice, but no visible swelling of superficial lymph nodes and no evident symptoms in the belly.

Abdominal ultrasonography on June 17 revealed cholecystitis, gallbladder enlargement, cholestasis, and dilatation of both intrahepatic and extrahepatic bile channels. On June 18, MRCP and abdominal MRI were performed to look for malignant lesions of the duodenal papilla, significant enlargement of intrahepatic and extrahepatic bile ducts, and bile stasis in the common bile duct, and a big gallbladder. On June 19, an ultrasonography gastroscopy revealed a 2.5 2.5 cm tumor near the duodenal papilla, with ulcers on the surface, coated in white and yellow slough with contact bleeding.

After discussing and gaining informed permission from the patient and his family, we prepared the patient for pancreaticoduodenectomy on June 29. On June 30, however, the histological investigation revealed significant chronic active inflammation with ulcers invaded by a considerable number of atypical cells. Mitotic structures could be seen, and the cytoplasm of the tumor cells was clear and brilliant. LCA ( +), CD34 (vascular +), Ki67 (Li80 percent), CD20 ( +), LCA ( +), CD34 (vascular +) were the immunohistochemical findings. On the basis of these findings, aggressive non-B-cell Hodgkin's lymphoma was identified. Following a visit with a hematologist, the surgical plan was canceled, and chemotherapy was recommended.

In conclusion, duodenal papillary lymphoma-induced obstructive jaundice is relatively uncommon. Histology, immunohistochemistry, and molecular detection must be established for diagnosis and therapy. Treatment and prognosis varied depending on histological subtype. When a reliable histological diagnosis cannot be achieved, surgery plays a crucial role in treating obstructive jaundice. Following a diagnosis, chemotherapy should be an important part of the treatment plan.

Reference: Wang, J., Han, J., Xu, H. et al. Primary duodenal papilla lymphoma producing obstructive jaundice: a case report. BMC Surg 22, 110 (2022). https://doi.org/10.1186/s12893-022-01558-3