SUCCESSFUL ENDOSCOPIC SUBMUCOSAL DISSECTION FOR MUCOSAL CANCER OF THE DUODENUM

We report a case of mucosal duodenal cancer in a 62‐year‐old woman, which was successfully removed en bloc by endoscopic submucosal dissection (ESD). The patient underwent an upper gastrointestinal endoscopy at our hospital, which revealed an elevated flat mucosal lesion (type IIa) measuring 10 mm in diameter in the second portion of the duodenum. Histopathological examination of a biopsy specimen revealed features suggestive of a tubulovillous adenoma with severe atypia. As the findings suggested that the lesion had an adenocarcinoma component but was confined to the mucosal layer, we decided to carry out ESD and successfully removed the tumor in one piece. The resected tumor was 20 × 15 mm in size. Histopathological examination revealed that the lesion was a well‐differentiated mucosal adenocarcinoma with no lymphovascular invasion. Mucosal duodenal cancer is extremely rare, and ESD of a lesion in the duodenum requires a high level of skill. To the best of our knowledge, this case is the first report of successful ESD carried out in a case of mucosal duodenal cancer.     

EARLY GASTRIC CANCER WITH WIDESPREAD DUODENAL INVASION WITHIN THE MUCOSA

We report a rare case of early gastric cancer confined to the mucosal layer with extensive duodenal invasion, curatively removed with distal gastrectomy. An 84‐year‐old Japanese woman was referred to our hospital with gastric cancer. A barium meal examination and esophagogastroduodenoscopy revealed an irregular nodulated lesion measuring 6.5 x 5.5 cm in the gastric antrum and an aggregation of small nodules in the duodenal bulb. A biopsy specimen showed well‐differentiated adenocarcinoma. The patient underwent distal gastrectomy with partial resection of the duodenal region containing the tumor and regional lymph node dissection, with no complication. Histological examination of the resected tissue confirmed well‐differentiated adenocarcinoma limited to the mucosal layer and without lymph node metastasis. The cancer extended into the duodenum as far as 38 mm distant from the pyloric ring, and the resected margins were free of cancer cells. Gastric cancer located adjacent to the pyloric ring thus has the potential for duodenal invasion, even when tumor invasion is confined to the mucosal layer. In such cases, care should be taken during examinations to detect duodenal invasion, and the distal surgical margin must be negative given sufficient duodenal resection.     

A Case of Minute Duodenal Carcinoma Resected by Endoscopy

Abstract: A 61-year-old man who had experienced epigastric pain for a year underwent an esophagogas. troduodenoscopy (EGD) which revealed a tiny, lobular and uneven-surfaced protrusion (approximately 4 mm in diameter), well demarcated at the base and normal in color, in the duodenal bulb. A biopsy revealed a well differentiated adenocarcinoma. After admission, an endoscopic mucosal resection was performzed for this lesion. The resected tissue was 19 ×14 mm in size and contained a carcinoma measuring 4×3 mm in diameter. Histopathologically, it was a well differentiated tubular adenocarcinoma limited to the mucosa; the lesion had been completely resected. In Japan, 133 cases of early primary duodenal carcinoma have been reported in the literature. However, the so-called minute cancer measuring less than 5 mm in diameter has never been reported before. Dzagnosis, anatomical distribution, and treatment of the reported cases of early duodenal carcinoma were analyzed in this paper.     

Endoscopic Mucosal Resection of Adenocarcinoma at the Minor Duodenal Papilla: A Case Report and Suggestions for the Optimal Treatment Strategy

We herein report an extremely rare case of adenocarcinoma of the minor duodenal papilla (MiDP) which was successfully treated by endoscopic mucosal resection (EMR). An asymptomatic 84-year-old man underwent upper gastrointestinal endoscopy, which revealed a slightly elevated lesion at the MiDP. The biopsy findings were suggestive of adenocarcinoma. Computed tomography, magnetic resonance images and endoscopic ultrasonography did not reveal pancreatic tumor infiltration nor any apparent distant metastases. Therefore, we treated the lesion using EMR with complete resection. No recurrence or metastasis has been detected at 13 months after EMR. Total resection of the MiDP can thus serve as a relatively safe and simple treatment.     

A Case of Duodenal Carcinoid Tumor Associated with Carcinoma of the Head of the Pancreas

Abstract: We describe a case of duodenal carcinoid tumor associated with carcinoma of the head of the pancreas. The patient was a 77-year-old man who was admitted to our hospital with jaundice and pruritus cutaneous. Carcinoma of the head of the pancreas was diagnosed on the basis of findings obtained by abdominal computed tomographic scan and endoscopic retrograde cholangiopancreatography. Upper gastrointestinal endoscopy revealed a protrusive hemorrhagic lesion with a flushed surface and a diameter of about 1 cm in the anterior wall of the duodenal bulb. On May 25, 1996, pancreaticoduodenectomy was performed. On histopathological examination, this carcinoma of the pancreatic head was found to be a well-differentiated tubular adenocarcinoma. Immunohisto-chemically, the protrusive lesion in the duodenal bulb stained positive for chromogranine and IMSB and was slightly positive for S-100 protein. It was also slightly positive on Grimelius staining and negative on Masson-Fontana staining. These findings led to a diagnosis of carcinoid tumor arising from the anterior intestinal line.     

Case report of early duodenal cancer with segmental resection and longterm survial. Review of 122 reported Japanese cases

We report a case of early duodenal cancer (2.5 cm in diameter, located in the proximal part) in a 65-year-old female whom segmental resection was performed and a 7- year disease-free survival was achieved. The surgical specimen, showed and a 2.5 × 1.5 × 1.0cm exophytic lesion histopathological examination revealed highly differentiated intramucosal adenocarcinoma. We also report or our review of 122 cases of early duodenal cancer reported in Japan. Intramucosal carcinoma was found in 66%, and submucosal carcinoma in 34% of the patients. The location of the lesion was bulbar in 73 patients (60%), supraampullary in 33 (27%), periamupllary in 5 (4%), and infraampullary in 11 (9%). Distal gastrectomy, including the bulb, was performed in 46 patients, pancreatoduodenectomy in 23, partial resection in 24, endoscopic polypectomy in 25, and segmental resection in 4, including our patient. The frequency of lymph node metastasis is low in early duodenal cancer, so that segmental resection appears to be a reasonable treatment method.     

Unexpected endoscopic full-thickness resection of a duodenal neuroendocrine tumor

A 57-year-old man underwent endoscopy for investigation of a duodenal polyp. Endoscopy revealed a hemispheric submucosal tumor, about 5 mm in diameter, in the anterior wall of the duodenal bulb. Endoscopic biopsy disclosed a neuroendocrine tumor histologically, therefore endoscopic mucosal resection was conducted. The tumor was effectively and evenly elevated after injection of a mixture of 0.2% hyaluronic acid and glycerol at a ratio of 1:1 into the submucosal layer. A small amount of indigo-carmine dye was also added for coloration of injection fluid. The lesion was completely resected en bloc with a snare after submucosal fluid injection. Immediately, muscle-fiber-like tissues were identified in the marginal area of the resected defect above the blue-colored layer, which suggested perforation. The defect was completely closed with a total of 9 endoclips, and no symptoms associated with peritonitis appeared thereafter. Histologically, the horizontal and vertical margins of the resected specimen were free of tumor and muscularis propria was also seen in the resected specimen. Generally, endoscopic mucosal resection is considered to be theoretically successful if the mucosal defect is colored blue. The blue layer in this case, however, had been created by unplanned injection into the subserosal rather than the submucosal layer.     

Mucosal bile duct carcinoma with superficial spread

We describe a case of mucosal bile duct carcinoma with superficial spread in a 69-year-old man with gallstone pancreatitis. The patient was seen at the hospital because of abdominal pain, fever, and jaundice. Endoscopic retrograde cholangiography (ERC) demonstrated a protruding lesion in the lower third of the common bile duct (CBD) showing wall irregularity suggestive of malignancy. Percutaneous transhepatic cholangioscopy (PTCS) disclosed a papillary tumor with granular mucosa extending continuously to the middle third of the CBD. Cholangioscopic biopsy specimens taken from both the papillary tumor and surrounding granular mucosa revealed papillary adenocarcinoma. After this assessment of extent of cancer by PTCS, we performed pancreatoduodenectomy with extrahepatic bile duct resection and regional lymph node dissection. Pathology examination revealed papillary adenocarcinoma limited to the mucosal layer. The resected margin of the bile duct was free of tumor. We also reviewed 25 cases of early mucosal bile duct carcinoma described in detail in the Japanese literature, and we discuss the diagnostic advantages of PTCS.     

Primary signet-ring cell carcinoma of the colon at early stage： A case report and a review of the literature

A 67-year-old man, who had undergone surgery to resect multiple gastric cancers 4 years ago, visited our hospital for surveillance colonoscopy. Colonoscopy revealed a discolored, 7-mm in diameter, flat-elevated lesion with central depression in the transverse colon near the splenic flexure. Although the findings of endoscopy and barium enema were suggestive of submucosal invasion, the patient chose to undergo endoscopic mucosal resection. Pathological examination of the resected specimen revealed signet-ring cell carcinoma and a positive surgical margin. A second operation was performed, and no residual tumor or metastasis to lymph nodes was found in the resected specimens. Primary colorectal cancers composed of signet-ring cell carcinoma detected and treated at an early stage are extremely rare. We present a case and review the literature.     

Successful endoscopic removal of a duodenal adenoma occurring in Brunner's gland hyperplasia

A case of duodenal neoplasm in the second portion of the duodenum is presented. Endoscopically, the lesion was characterized by a broad‐based, submucosal tumor‐like protrusion with a shallow central depression. The lesion was successfully removed by endoscopic mucosal resection. Histological examination of the resected specimen revealed the lesion to be composed of Brunner's gland hyperplasia in the submucosal layer and adenomatous glands in the mucosa. Our case suggests that neoplastic transformation possibly occurs in Brunner's gland hyperplasia.     

Endoscopic mucosal resection of duodenal bulb adenocarcinoma with neuroendocrine features: An extremely rare case report

Duodenal adenocarcinoma, especially duodenal bulb with neuroendocrine features (NEF), is extremely rare. Here, we report one such case of duodenal bulb adenocarcinoma with neuroendocrine features. A 63-year-old Han Chinese woman was admitted to our department with the diagnosis of a duodenal bulb polyp and underwent an endoscopic mucosal resection. The pathological findings confirmed it as duodenal bulb adenocarcinoma with NEF. The patient remains curative after one and half a years of follow-up. Duodenal adenocarcinoma with NEF might be a low malignant neuroendocrine tumor rather than a conventional adenocarcinoma. Endoscopic treatment, including endoscopic mucosal resection, might be an ideal option for the adenocarcinomas with NEF.     

GNAS-mutated carcinoma arising from gastric foveolar metaplasia in the duodenum after 9 years of observation

This case involved an 80-year-old man. Screening with esophagogastroduodenoscopy (EGD) in 2004 revealed Brunner’s gland hyperplasia (BGH), 5 mm in size, in the duodenal bulb. The size of the lesion increased and its shape has changed since then, as detected in subsequent EGDs. The lesion had increased in size to 15 mm with a depression and biopsy specimens revealed an adenocarcinoma. The patient underwent endoscopic mucosal resection. Histopathological assessments indicated an adenocarcinoma arising from gastric foveolar metaplasia (GFM) adjacent to BGH. BGH stained positive for MUC6, and GFM and the adenocarcinoma stained positive for MUC5AC. Mutations of the GNAS gene were not detected in the GFM biopsied in 2007. On the other hand, common GNAS mutations (R201H) were detected in GFM and the adenocarcinoma in the endoscopically resected specimen in 2013. Moreover, mutant allele frequencies were higher in the carcinoma than in GFM. The patient remains disease-free for 4 years after endoscopic treatment. This case report further supports the notion that GFM may be a precursor lesion in the process of GNAS-mutated, gastric-type duodenal carcinogenesis.     

EARLY DUODENAL CARCINOMA SUCCESSFULLY TREATED BY ENDOSCOPIC MUCOSAL RESECTION

Two cases with duodenal carcinoma successfully treated by endoscopic mucosal resection are reported. Case 1 had a semipedunculate polyp, and case 2 had a flat elevated lesion with a central depression in the second portion of the duodenum. Histologic examination showed tubular adenocarcinoma in adenoma in case 1 and an intramucosal adenocarcinoma in case 2, indicating that complete endoscopic resection had been achieved in both cases. Endoscopic mucosal resection appears to be a safe and efficient method for management of early carcinoma of the duodenum as well as in other regions of the gastrointestinal tract.     

Duodenal Lipoma -A Report of Two Cases Resected by Endoscopic Polypectomy-

Duodenal lipomas are rarely reported. We reported two asymptomatic pedunculated duodenal lipomas successfully resected by endoscopic polypectomy. Case 1 was a 48-year-old Chinese female who came for a physical check-up. Upper gastrointestinal series and endoscopic examination revealed a 2.0 × 1.0 cm pedunculated polyp in the posterior wall of the bulb. Case 2 was a 67-year-old female. A 1.7 times 1.0 cm olive-shaped pedunculated polyp was found by endoscopic examination during a health check-up. Both tumors were polypectomised by endoscopy and proven to be duodenal lipomas pathologically. The diagnosis of duodenal lipoma has largely been made by surgery and autopsy in the past. It may be made nowadays with abdominal computed tomography and repeated deep biopsies. Duodenal lipomas may be treated by endoscopic polypectomy if the tumor is small and pedunculated.>     

Early duodenal adenocarcinoma arising in gastric metaplasia treated by endoscopic resection

Early duodenal carcinoma is a rare entity. Most duodenal carcinomas are diagnosed at a more advanced stage. This report describes the case of a 59-year-old lady with an early duodenal adenocarcinoma diagnosed at check-up gastroduodenoscopy in an outpatient clinic who was referred to us for further investigation and management. The initial upper endoscopy at our department revealed a type IIa+c lesion in the proximal duodenum (10 - 12 mm diameter, flat elevated lesion with central depression). Using chromoendoscopy and magnification endoscopy the lesion could be well demarcated and neoplastic changes in the architecture of the intestinal villi could be detected. After submucosal epinephrine-saline injection, the lesion was removed by endoscopic resection without complications. Histopathological examination revealed the rare entity of an early duodenal carcinoma arising from incomplete-type gastric metaplasia in the duodenum. In summary, the presented paper describes a case of successful endoscopic treatment of an early duodenal carcinoma arising from incomplete gastric metaplasia.     

A case of EMRC for basaloid squamous carcinoma of the cervical esophagus

Basaloid squamous carcinoma (BSC) of the esophagus is a rare esophageal tumor. A 79-year-old man with a history of proximal gastrectomy for gastric adenocarcinoma in 2000 was followed-up by esophagogastroduodenoscopy (EGD) annually. In June 2010, EGD revealed a new protruding lesion in the cervical esophagus. The small lesion was approximately 5 mm in size. A biopsy specimen showed poorly differentiated squamous cell carcinoma. We performed endoscopic mucosal resection using a cap-fi tted endoscope (EMRC). The histological diagnosis of the endoscopically resected specimen was BSC and the invasion depth was limited to the muscularis mucosae. Horizontal and vertical margins were negative. We report the case of superfi cial BSC in the cervical esophagus successfully resected by EMRC.     

A Type IIc Like Advanced Carcinoma of the Sigmoid Colon —A Case Report—

Abstract: We studied a patient with a sigmoid colon carcinoma, which looked like a type IIc carcinoma when it was, in fact, an advanced carcinoma. This lesion was considered to have developed from an early carcinoma with a depressed appearance. A 79-year-old woman was admitted complaining of a small amount of rectal bleeding. A barium enema examination revealed a flat elevated lesion with converging folds. A colonoscopy revealed a slightly reddish lesion with a central depression 40～50 cm from the anal verge. A biopsy specimen revealed the features of a well differentiated adenocarcinoma. A sigmoidectomy with lymph node dissection was performed. The resected specimen showed a tumor which looked like a so-called type IIc advanced carcinoma, measuring 10×6 mm in size. This lesion was histologically diagnosed as being a well differentiated adenocarcinoma without any adenomatous component. The tumor showed a massive invasion into the submucosal layer and a slight invasion into the proper muscle layer.     

Carbohydrate antigen 19‐9‐producing early protruded gastric carcinoma prolapsing into the duodenal bulb

The patient was an 81‐year‐old man who was admitted to the Arita Gastrointestinal Hospital for anemia. Upper gastrointestinal series and endoscopic examinations revealed transpyloric prolapse of a pedunculated polypoid gastric carcinoma with an abnormal mucosal fold from the posterior wall of the lesser curvature of the gastric antrum. Biopsy and histological examination led to a diagnosis of papillary adenocarcinoma. The incarcerated tumor could not be restored endoscopically into the stomach, the lesion head was ulcerated, and the serum carbohydrate antigen (CA) 19‐9 was elevated to 379.7 U/mL. Surgery was indicated. Intraoperatively, the tumor was found in the duodenal bulb; it was easily manipulated into the stomach, and distal gastrectomy was performed. The tumor, 5.0 × 4.2 × 2.5 cm, was diagnosed histologically as papillary adenocarcinoma of the stomach infiltrating into the submucosal layer. The carcinoma cells stained positively for CA19‐9 antibody. The postoperative course was uneventful, the anemia improved, and the serum CA19‐9 level decreased to within normal range. The patient remains alive 15 months after the surgery. This may be the first report of a patient with Type 0 I early gastric cancer characterized by both CA19‐9 production and transpyloric prolapse.     

Bleeding duodenal hemangioma: morphological changes and endoscopic mucosal resection

Recently, the development of endoscopic procedures has increased the availability of minimally invasive treatments; however, there have been few case reports of duodenal hemangioma treated by endoscopic mucosal resection. The present report describes a case of duodenal hemangioma that showed various endoscopic changes over time and was treated by endoscopic mucosal resection. An 80-year-old woman presented with tarry stools and a loss of appetite. An examination of her blood revealed severe anemia, and her hemoglobin level was 4.2 g/dL. An emergency upper gastrointestinal endoscopy was performed. A red, protrusive, semipedunculated tumor (approximately 20 mm in diameter) with spontaneous bleeding on its surface was found in the superior duodenal angle. Given the semipedunculated appearance of the tumor, it was suspected to be an epithelial tumor with a differential diagnosis of hyperplastic polyp. The biopsy results suggested a telangiectatic hemangioma. Because this lesion was considered to be responsible for her anemia, endoscopic mucosal resection was performed for diagnostic and treatment purposes after informed consent was obtained. A histopathological examination of the resected specimen revealed dilated and proliferated capillary lumens of various sizes, which confirmed the final diagnosis of duodenal hemangioma. Neither anemia nor tumor recurrence has been observed since the endoscopic mucosal resection (approximately 1 year). Duodenal hemangiomas can be treated endoscopically provided that sufficient consideration is given to all of the possible treatment strategies. Interestingly, duodenal hemangiomas show morphological changes that are influenced by various factors, such as mechanical stimuli.     

GASTRIC ADENOCARCINOMA OF FUNDIC GLAND TYPE (CHIEF CELL PREDOMINANT TYPE) TREATED WITH ENDOSCOPIC ASPIRATION MUCOSECTOMY

Upper endoscopy screening in an asymptomatic 56‐year‐old man showed a small, yellowish elevated lesion with a central depression on the posterior wall in the gastric cardia. Biopsy specimens from this lesion were suspicious of carcinoid tumor. We suspected this lesion to be a sporadic gastric carcinoid tumor with a diameter of 5 mm, limited to the mucosal layer. We then performed an endoscopic aspiration mucosectomy with a cap‐fitted endoscope. Microscopically, the lesion obtained from the resected specimen was minimally invasive to the submucosa and showed highly differentiated columnar cells in irregularly anastomosing glands. Immunohistology was positive for pepsinogen‐I, and MUC6, partially positive for H⁺/K⁺‐ATPase, and negative for MUC5AC. In addition, it was positive for synaptophysin and CD56, and negative for chromogranin A. We finally diagnosed the patient as having gastric adenocarcinoma of fundic gland type (chief cell predominant type) with minimal invasion (100 µm) to the submucosa. Surveillance endoscopy with biopsy specimens and abdominal computed tomography at 1 year revealed no evidence of tumor recurrence. We herein report this rare case of gastric adenocarcinoma of fundic gland type (chief cell predominant type).