Giant villous adenoma of the duodenum

Abstract

Villous adenomas of the duodenum are rare and are often difficult to diagnose because of their non-specific symptoms. Of the 90 cases of villous adenoma of the duodenum reported in the literature, malignancy was discovered in almost half'. The present paper reports the largest villous adenoma of the duodenum yet described. Case reportA 73-year-old woman was admitted with a history of two episodes of fever with shivering. Other symptoms were pain in the right hypochondrium which often radiated to the back, anorexia and a weight loss of 9 kg (14 per cent of usual body weight). Laboratory data were: ESR, 22; haematocrit, 31.6 per cent; haemoglobin, 11 g/dl; serum amylase, 47 milliunits/ml (normal value (n.v.) i 36); alkaline phosphatase, 844 milliunits/ml (n.v. < 220); AST, 70 milliunits/ml (n.v. < 29); ALT, 55 milliunits/ml (n.v. < 36); GT, 598 milliunits/ml (n.v. < 36).Abdominal ultrasound showed a dilated common bile duct (14 mm) without evidence of stones, and suspicious periampullary mass. CT scan revealed dilated pancreatic and common bile ducts, but no mass in the head of the pancreas. Hypotonic duodenography showed a large multilobulated lesiom-partially occluding the second part of the duodenum. Endoscopy confirmed the presence of a wide multilobular lesion around the papilla of Vater. Biopsies of this mass were consistent with a diagnosis of duodenal villous adenoma (low grade dysplasia), Surgery was performed because of the dilated pancreatic and common bile ducts, and the large size and high probability of malignant change in the villous adenoma. At laparotomy the common bile duct appeared dilated, without obvious abnormality in the consistency of the head of the pancreas. Duodenotomy revealed a wide verrucous neoplasm of the second portion of the duodenum. Biopsies of this mass were consistent with duodenal villous adenoma (medium-grade dysplasia). Biopsy of a small, hard and reddish formation adjacent to the papilla revealed the presence of adenocarcinoma. Pancreaticoduodenectomy was performed. Pathological examination of the specimen revealed a 13 cm polypoid lesion of the second portion of the duodenum involving the papilla of Vater. Histological examination of the reddish lesion showed a muscus-secreting adenocarcinoma arising in the villous adenoma and invading the muscle layer. DiscussionAdenomas constitute about half of the benign neoplasms of the duodenum'. They include adenomatous polyps, Brunner's gland adenomas and villous adenomas. Whereas adenomas of Brunner's glands never degenerate', malignancy occurs in villous adenomas of the duodenum with variable frequency. Endoscopy should be performed in all cases of radiographically suspected duodenal tumours'. It permits specific pre-operative diagnosis of duodenal villous adenoma. but does not exclude cancer. The treatment of villous adenoma of the duodenum is still debated. Endoscopic resection may be justifiable for small villous adenomas arising in the first, third or fourth part of the duodenum but in all other cases laparotomy is indicated. ...

Villous Duodenal Adenoma

“…If the tumor location is more distal, simple duodenal resection is sufficient. Because the risk for malignant transformation is high, serial endoscopic follow-up examinations are recommended for patients who undergo simple local resection (4,5). references filling defects.…”

“…Endoscopy should be performed in all cases of clinically or radiologically suspected tumors, to permit a specific preoperative diagnosis of duodenal villous adenoma. However, endoscopic findings are insufficient for excluding cancer (5). Accurate preoperative histologic diagnosis of malignancy is difficult because of the frequently large size of duodenal villous tumors and the small size of samples retrievable with endoscopic forceps.…”