Borderline cases between benignancy and malignancy of the duodenum diagnosed successfully by endoscopic submucosal dissection

Abstract

OBJECTIVE. Due to advances in endoscopic equipment, primary duodenal tumors are found more frequently than in the past. We performed endoscopic submucosal dissection (ESD) to diagnose and treat four non-ampullary duodenal tumors. MATERIAL AND METHODS. During endoscopic treatment, marks were placed around the circumference of the tumor and sufficient amounts of physiological saline with epinephrine were injected into the submucosal layer to elevate the lesion. An incision was made around the lesion using a long-type needle knife and the isolated lesion was resected completely "en bloc". In this procedure, a cylindrical transparent hood was attached to the endoscopy apparatus to allow for satisfactory visualization of the procedure. RESULTS. The mean age of the patients was 69 years. The patients consisted of two males and two females. Gross examination showed three flat, elevated lesions and one polypoid lesion. Tumor size ranged from 10 to 31 mm in maximum diameter. Histological examination revealed two cases of well-differentiated adenocarcinomas and two cases of tubular adenomas with severe atypia. Procedure-related complications consisting of perforation occurred in two cases and were resolved under close postoperative observation including antibiotics, use of a nasogastric tube and nil per oral feeding status. The mean follow-up period was 18 months and none of the patients experienced tumor recurrence after the treatment. CONCLUSIONS. Since tissue obtained from endoscopic biopsies can sometimes prove difficult for definitive histological diagnosis, ESD may play an important role in the management of cases appearing to border on malignancy. In addition, ESD allows for minimally invasive treatment without sacrificing the possibility of cure for duodenal carcinoma.

Endoscopic management of nonampullary duodenal polyps

“…Two series have described the use of ESD for the treatment of duodenal adenomas and early duodenal cancers, showing excellent success rates. High rates of en bloc resection were achieved, aiding histopathological staging [Honda et al 2009;Takahashi et al 2009]. However the complication rate of ESD is greater than EMR with perforation occurring in 4 of 13 ESD cases (31%) and late bleeding in 2 of 13 (15%).…”

“…With the increasingly widespread use of endoscopy over the past few decades, duodenal adenomas are being detected at an earlier and often asymptomatic stage. Recent series of endoscopically managed duodenal polyps report 66-80% of patients to be asymptomatic at the time of diagnosis [Abbass et al 2010;Alexander et al 2009;Perez et al 2003;Takahashi et al 2009]. However, all adenomas carry a risk of malignant potential, so depending on the patient's fitness and life expectancy, resection of adenomas should be considered.…”

“…The addition of adrenaline (epinephrine) to the solution can prevent early bleeding, giving a clearer field of view, and has been used in several series. The use of indigocarmine in the mixture stains the submucosa blue helping delineate the submucosal layer from the underlying muscle layer [Alexander et al 2009;Honda et al 2009;Kedia et al 2010;Takahashi et al 2009]. Endoscopic resection without preinjection of submucosal lifting solution may lead to incomplete resection of adenomatous material resulting in higher rates of recurrence [Apel et al 2005].…”

An early superficial non-ampullary duodenal tumor cured with endoscopic submucosal dissection: A case report

“…Furthermore, a definition for early NADC has not been established according to the depth of tumor invasion and the risk of lymph node metastasis (17). Previous studies have used the regulations for early colorectal or gastric cancer (18,19) and for tumor invasion into the lamina propria, muscularis mucosa (T1a), or submucosa (T1b), neglecting lymph node metastasis (20). It is easier to determine the margins of early duodenal flat lesion using endoscopy examination than to distinguish the depth of tumor infiltration, for example T1a from T1b duodenal cancer.…”

Treatment Strategies in Colorectal Cancer

“…Endoscopic mucosal resection is more specific for removal of sessile polyps limited to the mucosa and submucosa (Sm1a + b) and is typically used for complete excision of lesions up to 2 cm [8]. Endoscopic submucosal dissection is usually adopted for larger gastrointestinal lesions, where it more easily promotes the en bloc resection, yet it carries greater risk of perforation (31%) and late bleeding (15%) [9]. Lesions with a deep level of invasion (Sm1c, Sm2, or Sm3) or rectal lesions (specifically those of the distal third) showed higher incidence of lymph node metastasis 12-25% and should be treated by a definitive oncologic segmental resection due to the high risk of regional lymph node involvement.…”