Duodenal MALT Lymphoma Presenting With Obstructive Jaundice: Report of a Case and Review of the Literature

Successful Use of a Multidisciplinary Approach to Treat a Perforated Duodenal Malignant Lymphoma in an Elderly Patient

Treatment of duodenal malignant lymphoma is difficult due to life-threatening complications such as intestinal obstruction, perforation, and pancreatitis. Thus, multidisciplinary procedures are required alongside surgical intervention. Contrast abdominal CT images of a 75-year-old female suffering from vomiting revealed thickening of the duodenal wall (from the second to third segment). Gastrojejunostomy and biopsy identified the tumor as diffuse large B-cell lymphoma. A diagnosis of stage II duodenal lymphoma was made. The lymphoma continued to grow, resulting in jaundice and intestinal perforation, which was first treated with two cycles of rituximab and antibiotics. Thereafter, less intensive chemotherapy (two cycles each of R-mini-CHP, CHP, and R-CHOP) was administered, which led to significant improvement upon assessment by PET-CT. Residual lymphoma was treated with consolidation radiotherapy (50 Gy in 25 fractions) over 5 weeks after chemotherapy. The patient attained a complete response and has been disease-free for more than 4 years. Thus, duodenal perforated lymphoma can be treated successfully using a multidisciplinary approach that combines surgery, immunochemotherapy, and radiation therapy.

Early, Isolated Duodenal Mucosa-Associated Lymphoid Tissue Lymphoma Presenting without Symptoms or Grossly Apparent Endoscopic Lesions and Diagnosed by Random Duodenal Biopsies

Clinical data regarding mucosa-associated lymphoid tissue lymphoma (MALToma) solely involving the duodenum are sparse because of the relative rarity of the disease. A comprehensive literature review revealed only 17 cases reported until 2004, and only a moderate number of cases have been reported since. MALToma can be asymptomatic in its very early stages but frequently produces localized or nonspecific symptoms, including early satiety, abdominal pain, vomiting, and involuntary weight loss in later stages. While gastric MALToma is strongly associated with gastric Helicobactor pylori infection, duodenal MALToma is often unassociated with H. pylori infection. A 74-year-old female presented with only dysphagia (without symptoms referable to a duodenal lesion), without systemic 'B' symptoms, and with no evident duodenal lesions at esophagogastroduodenoscopy; however, she was diagnosed with duodenal MALToma by pathologic examination of random duodenal biopsies performed to exclude celiac disease. An important clinical feature of this case is that duodenal MALToma was diagnosed by pathologic analysis of duodenal biopsies despite (1) no endoscopically apparent duodenal lesions; (2) duodenal involvement without gastric involvement; (3) lack of symptoms attributable to duodenal MALToma, and (4) absence of evident H. pylori infection. This work shows that early duodenal MALToma can be difficult to diagnose because of absent symptoms, absence of gastric involvement, absence of endoscopic abnormalities, and absence of H. pylori infection; it may require random duodenal biopsies for diagnosis.

F-18 FDG PET/CT evaluation of radiotherapy response in rare case of mucosa-associated lymphoid tissue lymphoma

We experienced two cases of mucosa-associated lymphoid tissue (MALT) lymphoma arising at unusual locations and used F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) to evaluate their response to radiation therapy (RT). A 62-year-old male with proven prostatic MALT lymphoma and a 43-year-old woman with proven duodenal MALT lymphoma had diffuse FDG uptake in the lesion. Both cases were treated with RT; following FDG, PET/CT showed decreased FDG uptake in each lesion. Neither patient had evidence of recurrence at more than 18 months after RT. FDG PET/CT is useful for indicating the treatment site in MALT lymphoma and in evaluation of therapeutic response following RT.