A Case of Endoscopic Mucosal Resection of Carcinoma in Adenoma at the Minor Duodenal Papilla

Case Reports in Oncology
22 May, 2019 ,

This is a case of a 67-year-old woman, sigmoid colon cancer was incidentally detected on preoperative upper gastrointestinal endoscopy. Endoscopy revealed a slightly elevated lesion at the minor duodenal papilla. The findings of a histopathologic examination were suggestive of adenocarcinoma. Computed tomography and magnetic resonance images identified a minute tumor, whereas endoscopic ultrasonography revealed that the tumor did not spread to the pancreas. Doctors performed endoscopic mucosal resection (EMR) of this lesion. There were no complications, and relapse has not occurred in 3 years. 

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A 67-year-old Japanese woman was admitted to our hospital with a duodenal tumor that was incidentally detected on upper gastrointestinal endoscopy for the preoperative examination of sigmoid colon cancer. Endoscopy revealed a slightly elevated lesion at the minor papilla. Histopathologic examination of the biopsy performed by the previous doctor revealed class IV disease. She had no specific symptoms, and there were no abdominal findings on physical examination. The patient’s medical history was sigmoid colon cancer and hypertension. Her family history was unremarkable. Results of laboratory tests, including pancreatic tumor markers, were normal. Ultrasonography (US) failed to detect this lesion. The main pancreatic duct and bile duct were not dilated. Abdominal computed tomography (CT) revealed a 1.0-cm-sized enhancing mass in the minor duodenal papilla with no apparent distant metastasis. Magnetic resonance cholangiopancreatography showed low intensity on a T1-weighted image and no dilation of the main pancreatic duct or bile duct. Endoscopic US (EUS) detected a hypoechoic lesion in the submucosal layer (12 mm in diameter). EUS clearly showed the muscle layer; thus, we determined that the tumor did not invade the muscle layer. Endoscopic retrograde pancreatography findings were normal. We attempted to evaluate the degree of tumor progression using intraductal US (IDUS) through the minor duodenal papilla; however, it was difficult to insert and thus could not be evaluated. Endoscopic sphincterotomy (EST) was performed to enable histological examination of the deeper layer and IDUS insertion; however, histological results were atypical and IDUS insertion remained difficult. A histological examination was performed before treatment, whereas biopsies from the minor papilla demonstrated the histology of adenoma with mild atypia.

Doctors determined that the tumor was not invasive; additionally, the patient and her family did not request surgical treatment. Therefore, we performed endoscopic mucosal resection (EMR) after obtaining appropriate written informed consent. First, we performed marking using argon plasma coagulation around the tumor. Next, the lesion was completely elevated by submucosal injection of saline and then removed using a snare. The excised specimens were collected using a net. No adverse events, such as bleeding or perforation, were observed.