Surg Today DOI 10.1007/s00595-014-0860-1
CASE REPORT
Primary adenocarcinoma of the minor duodenal papilla with mass-forming chronic pancreatitis: report of a case Kazuhiro Suzumura • Seikan Hai • Nobukazu Kuroda • Tadamichi Hirano • Yasukane Asano • Toshihiro Okada • Yuji Iimuro • Shogo Tanaka • Keiji Nakasho • Jiro Fujimoto
Received: 5 April 2013 / Accepted: 16 December 2013 Ó Springer Japan 2014
Abstract A 70-year-old male was treated for gastric ulcers. Follow-up upper gastrointestinal endoscopy revealed an irregular, elevated tumor in the second portion of the duodenum. Upon pathological inspection of a biopsy specimen, a diagnosis of adenocarcinoma was made, and the patient was admitted to our hospital. Computed tomography showed an irregular mass in the pancreatic head and dilatation of the main pancreatic duct and bile duct. Pancreatic head carcinoma with infiltration of the duodenum was diagnosed, and pylorus-preserving pancreaticoduodenectomy was performed. A histopathological examination of the resected specimen showed moderately differentiated adenocarcinoma in the minor duodenal papilla and chronic pancreatitis in the pancreatic head. Therefore, primary adenocarcinoma of the minor duodenal papilla with mass-forming chronic pancreatitis was diagnosed. Currently, the patient is alive without recurrence 17 months after the surgery. Primary adenocarcinoma of the minor duodenal papilla is extremely rare. We herein report this case, and also provide a review of the literature. Keywords Adenocarcinoma Minor duodenal papilla Mass-forming Pancreatitis Pancreaticoduodenectomy
K. Suzumura (&) S. Hai N. Kuroda T. Hirano Y. Asano T. Okada Y. Iimuro S. Tanaka J. Fujimoto Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya 663-8501, Japan e-mail: [email protected] K. Nakasho Department of Pathology, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya 663-8501, Japan
Introduction The minor duodenal papilla is an opening for the accessory pancreatic duct, and is located in the anterior wall of the second portion of the duodenum approximately 2 cm proximal to the major duodenal papilla [1]. Tumors of the minor duodenal papilla are rare. Some cases of tumors occurring in the minor duodenal papilla have been reported, including cases of adenoma [2], adenomyoma [3], carcinoid tumors [4], somatostatinoma [5] and gangliocytic paraganglioma [6]. Adenocarcinoma of the minor duodenal papilla is extremely rare. The presence of mass-forming chronic pancreatitis may lead to difficulties in differentiating such cancers from other pancreatic tumors [7]. We herein report a case of adenocarcinoma of the minor duodenal papilla with mass-forming chronic pancreatitis.
Case report A 70-year-old male was treated for gastric ulcers at another hospital. There was no history suggestive of alcohol abuse. Follow-up upper gastrointestinal endoscopy revealed an irregular, elevated tumor in the second portion of the duodenum. Upon the pathological inspection of a biopsy specimen, a diagnosis of adenocarcinoma was made, and the patient was admitted to our hospital. We performed upper gastrointestinal endoscopy and found a tumor located 2 cm proximal to the duodenal papilla (Fig. 1). The serum levels of alkaline phosphatase (ALP) and c-glutamyl transpeptidase (c-GTP) were elevated to 1,309 U/l (normal range 115–359 U/l) and 632 U/l (normal range 11–58 U/l), respectively. The level of carbohydrate antigen 19-9 (CA19-9) was elevated to 109.8 U/ml (normal range \37 U/ml), while all other laboratory findings,
123
Surg Today
Fig. 1 Upper gastrointestinal endoscopy revealed an irregular, elevated lesion in the second portion of the duodenum (arrows)
Fig. 3 Magnetic resonance cholangiopancreatography (MRCP) showed obstruction of the main pancreatic duct in the pancreatic head and dilatation of the distal main pancreatic duct and bile duct
Fig. 2 Computed tomography (CT) showed an irregular mass measuring 4 cm in diameter in the pancreatic head (arrows)
including the levels of total bilirubin and the carcinoembryonic antigen (CEA) level, were within the normal ranges. The level of the IgG4 was not elevated, at 60.4 mg/dl (normal range 4.8–106 mg/dl). Computed tomography (CT) showed an irregular mass measuring 4 cm in diameter in the pancreatic head and dilatation of the main pancreatic duct and bile duct without any apparent distant metastasis (Fig. 2). Magnetic resonance cholangiopancreatography (MRCP) showed obstruction of the main pancreatic duct in the pancreatic head and dilatation of distal main pancreatic duct and bile duct (Fig. 3). Based on these findings, the most probable preoperative diagnosis was considered to be pancreatic
123
Fig. 4 The resected specimen showed an irregular, elevated tumor measuring 12 9 11 mm in the minor duodenal papilla (white arrow minor duodenal papilla, black arrow major duodenal papilla)
head carcinoma with infiltration of the duodenum, and pylorus-preserving pancreaticoduodenectomy with regional lymph node (12 lymph nodes) dissection was performed. After the pylorus-preserving pancreaticoduodenectomy, reconstruction by the modified Child method was done. We were able to perform a curative resection. The resected specimen showed an irregular, elevated tumor measuring 12 9 11 mm in the minor duodenal papilla (Fig. 4). The specimen exhibited diffuse pancreatic sclerosis with an ill-defined tumor in the pancreatic head. A
Surg Today Fig. 5 The histopathological examination of the resected specimen. a There was moderately differentiated adenocarcinoma in the minor duodenal papilla (H&E staining 9 100) (arrow orifice) and b chronic pancreatitis in the pancreatic head (H&E staining 9 100). c) The tumor had not invaded the main pancreatic duct (H&E staining 9 40)
histopathological examination of the resected specimen revealed moderately differentiated adenocarcinoma in the minor duodenal papilla (Fig. 5a) and chronic pancreatitis in the pancreatic head (Fig. 5b). The carcinoma cells were primarily located in the minor duodenal papilla with invasion into the muscularis propria of the duodenal wall and the pancreatic parenchyma, but the tumor had not reached the main pancreatic duct (Fig. 5c). There were no findings of lymph node metastasis. According to the TNM classification system, the final pathological stages were pT3, pN0, M0, pStage IIA for adenocarcinoma of the minor duodenal papilla. Based on these pathological findings, we diagnosed the patient with primary
adenocarcinoma of the minor duodenal papilla and massforming chronic pancreatitis of the pancreatic head. The patient’s postoperative course was uneventful, and he was discharged from the hospital on the 30th day after surgery. He is currently alive without recurrence 17 months after undergoing surgery.
Discussion The minor duodenal papilla, which is occasionally difficult to distinguish macroscopically, can be identified in virtually all male cases. The minor duodenal papilla is located
123
123
Died from other disease a
Our case 10
Adenoca. Adenocarcinoma, Mod. diff. adenoca. Moderately differentiated adenocarcinoma, ND not described, Pap. adenoca. Papillary adenocarcinoma, PD pancreaticoduodenectomy, PPPD pylorus-preserving pancreaticoduodenectomy, SSPPD subtotal stomach-preserving pancreaticoduodenectomy, Well diff. adenoca. Well differentiated adenocarcinoma
3 m, alive (no recurrence)
17 m, alive (no recurrence) (-) (-) Normal Mod. diff. adenoca. 12 9 11 PPPD None M 70
16 m, alive (no recurrence)
Fujimoto [18] 9
2013
(-) (-) Normal Well diff. adenoca. 896 PPPD None M 74
Alive
Okuma [17] 8
2012
(-) (-) Normal Well diff. adenoca. 12 9 10 PPPD None M 76
24 m, alive (no recurrence)
Takami [16] 7
2011
(-) (?) Normal Pap. ? well ? mod. diff. adenoca. 20 9 15 SSPPD None M 81
8 m, alive (no recurrence)
Matheus [15] 6
2011
(-) ND Adenoca. Mod. diff. adenoca. 10 PPPD Abdominal pain, jaundice F 50
32 m, alive (no recurrence)
Parthasarathy [14]
2008
(-) (?) Adenoca. Mod. diff. adenoca. 15 9 12 PD Fever, jaundice F 60
Alive
5
2008
(-)
(-) (?)
(-) Normal
Normal Well diff. adenoca.
Well diff. adenoca. 11 9 8
50 9 30 SSPPD
PPPD None
Transient abdominal pain M
M 70
60
Wakatsuki [1] 4
2008
Kajiwara [12] 3
2007
42 m, deada
ND ND
ND (?)
ND Normal
Normal Mod. diff. adenoca.
Adenoca. 10
25 9 20 PPPD
PD Gastric discomfort
Transient epigastric pain M
M 70
77 1998
2006
Yamao [10]
Ohya [11]
1
2
Operation Chief complaint(s) Sex Age Year Author [ref] Case
Table 1 Reported cases of adenocarcinoma of the minor duodenal papilla
Size (mm)
Histology
Major papilla
Invasion of the pancreas
Lymph node metastasis
Prognosis
Surg Today
in the anterior wall of the second portion of the duodenum approximately 2 cm proximal to the major duodenal papilla, and its primary function is to drain pancreatic fluid from the dorsal pancreas to the duodenum in the embryo [8, 9]. Neoplasms of the minor duodenal papilla are rare, and most reported cases have been found to be benign tumors, such as carcinoid tumors and adenomas. Adenocarcinoma of the minor duodenal papilla is considered to be an extremely rare disease, with only 10 cases having been reported, including our case (Table 1) [10–18]. Among these cases, the tumors affected patients from 50 to 81 years (average 69 years) of age, consisting of eight males and two females. Two cases involved synchronous carcinomas of both the major and minor duodenal papilla. No lymph node metastasis was observed in any of these cases. The lack of specific symptoms makes diagnosing primary adenocarcinoma of the minor duodenal papilla difficult. Among the reports of this tumor, five patients, including our patient, had no symptoms, four patients experienced abdominal pain and one patient developed jaundice. No specific symptoms for tumors of the minor duodenal papilla have been identified, and all reported cases were discovered incidentally on upper gastrointestinal endoscopy. Therefore, careful observation of the minor duodenal papilla is necessary when routine upper gastrointestinal endoscopy is performed. The cause of the mass-forming chronic pancreatitis in the present case was unclear. There was no history suggestive of alcohol abuse, and the IgG4 level was within the normal range. In addition, the tumor had not invaded the main pancreatic duct, so the etiology of the patient’s massforming chronic pancreatitis of the pancreatic head is unknown. Regarding the treatment of primary adenocarcinoma of the minor duodenal papilla, pancreaticoduodenectomy has been performed in all reported cases. Recently, the use of endoscopic resection (papillectomy) was reported in patients with tumors of the major duodenal papilla, and a few malignant cases in the early stage were treated with papillectomy, although a few complications were observed [19–21]. For the evaluation of tumor staging, endoscopic ultrasonography (EUS) for tumors of the minor duodenal papilla is considered to be useful [10]. The diagnosis of whether or not the tumor has infiltrated into the pancreatic parenchyma is important. However, it is difficult to determine the depth of invasion of the tumor and the presence of lymph node metastasis using EUS and CT. Therefore, expanding the indications for papillectomy of malignant tumors of the duodenal papilla will require further accumulation of case information. In our case, EUS was not performed because we preoperatively diagnosed pancreatic head carcinoma with infiltration of the duodenum.
Surg Today
With respect to the prognosis, all patients who underwent curative resection were still alive at the time of the publication of the report, with the exception of one patient who died from another disease. Therefore, curative resection is an effective treatment for primary adenocarcinoma of the minor duodenal papilla, and can provide long-term survival. Conflict of interest Kazuhiro Suzumura and the co-authors have no conflicts of interest to declare.
References 1. Suda K. Histopathology of the minor duodenal papilla. Dig Surg. 2010;27:137–9. 2. Sugiyama M, Kimura W, Muto T, Yahagi N, Ichinose M, Miki K. Endoscopic resection of adenoma of the minor papilla. Hepatogastroenterology. 1999;46:189–92. 3. Fukuda A, Yazumi S, Sawada M, Seno H, Nabeshima M, Fujii H, et al. Adenomyoma of the minor duodenal papilla. Gastrointest Endosc. 2005;61:475–9. 4. Noda Y, Watanabe H, Iwafuchi M, Furuta K, Ichihara N, Satoh M, et al. Carcinoids and endocrine cell micronests of the minor and major duodenal papillae. Cancer. 1992;70:1825–33. 5. Borobia FG, Fabregat J, Jorba R, Poves I, Biondo S, Serrano T, et al. Exocrine pancreatic insufficiency caused by a somatostatinoma of the minor and major duodenal papilla in a patient with neurofibromatosis. Eur J Surg. 2001;167:154–6. 6. Nakamura T, Ozawa T, Kitagawa M, Takehira Y, Yamada M, Yasumi K, et al. Endoscopic resection of gangliocytic paraganglioma of the minor duodenal papilla: case report and review. Gastrointest Endosc. 2002;55:270–3. 7. Morikawa T, Onogawa T, Maeda S, Takadate T, Shirasaki K, Yoshida H, et al. Solid pseudopapillary neoplasms of the pancreas: an 18-year experience at a single Japanese Institution. Surg Today. 2013;43:26–32. 8. Baldwin WN. The pancreatic ducts in man, together with a study of the microscopical structure of the minor duodenal papilla. Anat Res. 1911;5:197–228.
9. Kamisaka T. Clinical significance of the minor duodenal papilla and accessory pancreatic duct. J Gastroenterol. 2004;39:605–15. 10. Yamao K, Ohhashi K, Furukawa T, Mizutani S, Matsumoto S, Banno T, et al. Primary carcinoma of the duodenal minor papilla. Gastrointest Endosc. 1998;48:634–6. 11. Ohya T, Takemura Y, Tazuma S. Adenocarcinoma of the minor duodenal papilla detected by upper endoscopy. Gastroenterol Endosc. 2006;48:2662–3. 12. Kajiwara M, Fujii S, Takahashi S, Konishi M, Nakagohri T, Gotohda N, et al. Adenocarcinoma of the minor duodenal papilla with intraepithelial spread to the pancreatic duct. Virchows Arch. 2007;451:1075–81. 13. Wakatsuki T, Irisawa A, Takagi T, Koyama Y, Hoshi S, Takenoshita S, et al. Primary adenocarcinoma of the minor duodenal papilla. Yonsei Med J. 2008;49:333–6. 14. Parthasarathy S, Pottakkat B, Yootla M, Reddy SN, Reddy KM. Synchronous adenocarcinomas of the papilla major and minor. JOP. 2008;9:332–4. 15. Matheus AS, Jukemura J, Montagani AL, Kunitake T, Patzina RA, da Cunha JE. Synchronous adenocarcinoma of the major and minor duodenal papilla. J Gastrointest Surg. 2008;12:1301–3. 16. Takami K, Moriya T, Kamiga T, Abe T, Miseki T, Oku T, et al. Adenocarcinoma of the minor duodenal papilla: report of a case. Case Rep Gastroenterol. 2011;5:172–8. 17. Okuma T, Ozaki T, Abe S, Yamamura K, Shigaki H, Sawayama H, et al. Adenocarcinoma of the minor duodenal papilla: report of a case. Surg Today. 2011;41:568–71. 18. Fujimoto J, Suzumura K, Kuroda N, Iimuro Y, Yada A, Nakasho K. A case of primary adenocarcinoma of the minor duodenal papilla (in Japanese with English abstract). J Jpn Soc Clin Surg. 2012;73:1970–3. 19. Goldberg M, Zamir O, Hadary A, Nissan S. Wide local excision as an alternative treatment for periampullary carcinoma. Am J Gastroenterol. 1987;82:1169–71. 20. Ponchon T, Berger F, Chavaillon A, Bory R, Lambert R. Contribution of endoscopy to diagnosis and treatment of tumors of the ampulla of Vater. Cancer. 1989;64:161–7. 21. Jung S, Kim MH, Seo DW, Lee SK. Endoscopic snare papillectomy of adenocarcinoma of the major duodenal papilla. Gastrointest Endosc. 2001;54:622.
123
CASE REPORT
Primary adenocarcinoma of the minor duodenal papilla with mass-forming chronic pancreatitis: report of a case Kazuhiro Suzumura • Seikan Hai • Nobukazu Kuroda • Tadamichi Hirano • Yasukane Asano • Toshihiro Okada • Yuji Iimuro • Shogo Tanaka • Keiji Nakasho • Jiro Fujimoto
Received: 5 April 2013 / Accepted: 16 December 2013 Ó Springer Japan 2014
Abstract A 70-year-old male was treated for gastric ulcers. Follow-up upper gastrointestinal endoscopy revealed an irregular, elevated tumor in the second portion of the duodenum. Upon pathological inspection of a biopsy specimen, a diagnosis of adenocarcinoma was made, and the patient was admitted to our hospital. Computed tomography showed an irregular mass in the pancreatic head and dilatation of the main pancreatic duct and bile duct. Pancreatic head carcinoma with infiltration of the duodenum was diagnosed, and pylorus-preserving pancreaticoduodenectomy was performed. A histopathological examination of the resected specimen showed moderately differentiated adenocarcinoma in the minor duodenal papilla and chronic pancreatitis in the pancreatic head. Therefore, primary adenocarcinoma of the minor duodenal papilla with mass-forming chronic pancreatitis was diagnosed. Currently, the patient is alive without recurrence 17 months after the surgery. Primary adenocarcinoma of the minor duodenal papilla is extremely rare. We herein report this case, and also provide a review of the literature. Keywords Adenocarcinoma Minor duodenal papilla Mass-forming Pancreatitis Pancreaticoduodenectomy
K. Suzumura (&) S. Hai N. Kuroda T. Hirano Y. Asano T. Okada Y. Iimuro S. Tanaka J. Fujimoto Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya 663-8501, Japan e-mail: [email protected] K. Nakasho Department of Pathology, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya 663-8501, Japan
Introduction The minor duodenal papilla is an opening for the accessory pancreatic duct, and is located in the anterior wall of the second portion of the duodenum approximately 2 cm proximal to the major duodenal papilla [1]. Tumors of the minor duodenal papilla are rare. Some cases of tumors occurring in the minor duodenal papilla have been reported, including cases of adenoma [2], adenomyoma [3], carcinoid tumors [4], somatostatinoma [5] and gangliocytic paraganglioma [6]. Adenocarcinoma of the minor duodenal papilla is extremely rare. The presence of mass-forming chronic pancreatitis may lead to difficulties in differentiating such cancers from other pancreatic tumors [7]. We herein report a case of adenocarcinoma of the minor duodenal papilla with mass-forming chronic pancreatitis.
Case report A 70-year-old male was treated for gastric ulcers at another hospital. There was no history suggestive of alcohol abuse. Follow-up upper gastrointestinal endoscopy revealed an irregular, elevated tumor in the second portion of the duodenum. Upon the pathological inspection of a biopsy specimen, a diagnosis of adenocarcinoma was made, and the patient was admitted to our hospital. We performed upper gastrointestinal endoscopy and found a tumor located 2 cm proximal to the duodenal papilla (Fig. 1). The serum levels of alkaline phosphatase (ALP) and c-glutamyl transpeptidase (c-GTP) were elevated to 1,309 U/l (normal range 115–359 U/l) and 632 U/l (normal range 11–58 U/l), respectively. The level of carbohydrate antigen 19-9 (CA19-9) was elevated to 109.8 U/ml (normal range \37 U/ml), while all other laboratory findings,
123
Surg Today
Fig. 1 Upper gastrointestinal endoscopy revealed an irregular, elevated lesion in the second portion of the duodenum (arrows)
Fig. 3 Magnetic resonance cholangiopancreatography (MRCP) showed obstruction of the main pancreatic duct in the pancreatic head and dilatation of the distal main pancreatic duct and bile duct
Fig. 2 Computed tomography (CT) showed an irregular mass measuring 4 cm in diameter in the pancreatic head (arrows)
including the levels of total bilirubin and the carcinoembryonic antigen (CEA) level, were within the normal ranges. The level of the IgG4 was not elevated, at 60.4 mg/dl (normal range 4.8–106 mg/dl). Computed tomography (CT) showed an irregular mass measuring 4 cm in diameter in the pancreatic head and dilatation of the main pancreatic duct and bile duct without any apparent distant metastasis (Fig. 2). Magnetic resonance cholangiopancreatography (MRCP) showed obstruction of the main pancreatic duct in the pancreatic head and dilatation of distal main pancreatic duct and bile duct (Fig. 3). Based on these findings, the most probable preoperative diagnosis was considered to be pancreatic
123
Fig. 4 The resected specimen showed an irregular, elevated tumor measuring 12 9 11 mm in the minor duodenal papilla (white arrow minor duodenal papilla, black arrow major duodenal papilla)
head carcinoma with infiltration of the duodenum, and pylorus-preserving pancreaticoduodenectomy with regional lymph node (12 lymph nodes) dissection was performed. After the pylorus-preserving pancreaticoduodenectomy, reconstruction by the modified Child method was done. We were able to perform a curative resection. The resected specimen showed an irregular, elevated tumor measuring 12 9 11 mm in the minor duodenal papilla (Fig. 4). The specimen exhibited diffuse pancreatic sclerosis with an ill-defined tumor in the pancreatic head. A
Surg Today Fig. 5 The histopathological examination of the resected specimen. a There was moderately differentiated adenocarcinoma in the minor duodenal papilla (H&E staining 9 100) (arrow orifice) and b chronic pancreatitis in the pancreatic head (H&E staining 9 100). c) The tumor had not invaded the main pancreatic duct (H&E staining 9 40)
histopathological examination of the resected specimen revealed moderately differentiated adenocarcinoma in the minor duodenal papilla (Fig. 5a) and chronic pancreatitis in the pancreatic head (Fig. 5b). The carcinoma cells were primarily located in the minor duodenal papilla with invasion into the muscularis propria of the duodenal wall and the pancreatic parenchyma, but the tumor had not reached the main pancreatic duct (Fig. 5c). There were no findings of lymph node metastasis. According to the TNM classification system, the final pathological stages were pT3, pN0, M0, pStage IIA for adenocarcinoma of the minor duodenal papilla. Based on these pathological findings, we diagnosed the patient with primary
adenocarcinoma of the minor duodenal papilla and massforming chronic pancreatitis of the pancreatic head. The patient’s postoperative course was uneventful, and he was discharged from the hospital on the 30th day after surgery. He is currently alive without recurrence 17 months after undergoing surgery.
Discussion The minor duodenal papilla, which is occasionally difficult to distinguish macroscopically, can be identified in virtually all male cases. The minor duodenal papilla is located
123
123
Died from other disease a
Our case 10
Adenoca. Adenocarcinoma, Mod. diff. adenoca. Moderately differentiated adenocarcinoma, ND not described, Pap. adenoca. Papillary adenocarcinoma, PD pancreaticoduodenectomy, PPPD pylorus-preserving pancreaticoduodenectomy, SSPPD subtotal stomach-preserving pancreaticoduodenectomy, Well diff. adenoca. Well differentiated adenocarcinoma
3 m, alive (no recurrence)
17 m, alive (no recurrence) (-) (-) Normal Mod. diff. adenoca. 12 9 11 PPPD None M 70
16 m, alive (no recurrence)
Fujimoto [18] 9
2013
(-) (-) Normal Well diff. adenoca. 896 PPPD None M 74
Alive
Okuma [17] 8
2012
(-) (-) Normal Well diff. adenoca. 12 9 10 PPPD None M 76
24 m, alive (no recurrence)
Takami [16] 7
2011
(-) (?) Normal Pap. ? well ? mod. diff. adenoca. 20 9 15 SSPPD None M 81
8 m, alive (no recurrence)
Matheus [15] 6
2011
(-) ND Adenoca. Mod. diff. adenoca. 10 PPPD Abdominal pain, jaundice F 50
32 m, alive (no recurrence)
Parthasarathy [14]
2008
(-) (?) Adenoca. Mod. diff. adenoca. 15 9 12 PD Fever, jaundice F 60
Alive
5
2008
(-)
(-) (?)
(-) Normal
Normal Well diff. adenoca.
Well diff. adenoca. 11 9 8
50 9 30 SSPPD
PPPD None
Transient abdominal pain M
M 70
60
Wakatsuki [1] 4
2008
Kajiwara [12] 3
2007
42 m, deada
ND ND
ND (?)
ND Normal
Normal Mod. diff. adenoca.
Adenoca. 10
25 9 20 PPPD
PD Gastric discomfort
Transient epigastric pain M
M 70
77 1998
2006
Yamao [10]
Ohya [11]
1
2
Operation Chief complaint(s) Sex Age Year Author [ref] Case
Table 1 Reported cases of adenocarcinoma of the minor duodenal papilla
Size (mm)
Histology
Major papilla
Invasion of the pancreas
Lymph node metastasis
Prognosis
Surg Today
in the anterior wall of the second portion of the duodenum approximately 2 cm proximal to the major duodenal papilla, and its primary function is to drain pancreatic fluid from the dorsal pancreas to the duodenum in the embryo [8, 9]. Neoplasms of the minor duodenal papilla are rare, and most reported cases have been found to be benign tumors, such as carcinoid tumors and adenomas. Adenocarcinoma of the minor duodenal papilla is considered to be an extremely rare disease, with only 10 cases having been reported, including our case (Table 1) [10–18]. Among these cases, the tumors affected patients from 50 to 81 years (average 69 years) of age, consisting of eight males and two females. Two cases involved synchronous carcinomas of both the major and minor duodenal papilla. No lymph node metastasis was observed in any of these cases. The lack of specific symptoms makes diagnosing primary adenocarcinoma of the minor duodenal papilla difficult. Among the reports of this tumor, five patients, including our patient, had no symptoms, four patients experienced abdominal pain and one patient developed jaundice. No specific symptoms for tumors of the minor duodenal papilla have been identified, and all reported cases were discovered incidentally on upper gastrointestinal endoscopy. Therefore, careful observation of the minor duodenal papilla is necessary when routine upper gastrointestinal endoscopy is performed. The cause of the mass-forming chronic pancreatitis in the present case was unclear. There was no history suggestive of alcohol abuse, and the IgG4 level was within the normal range. In addition, the tumor had not invaded the main pancreatic duct, so the etiology of the patient’s massforming chronic pancreatitis of the pancreatic head is unknown. Regarding the treatment of primary adenocarcinoma of the minor duodenal papilla, pancreaticoduodenectomy has been performed in all reported cases. Recently, the use of endoscopic resection (papillectomy) was reported in patients with tumors of the major duodenal papilla, and a few malignant cases in the early stage were treated with papillectomy, although a few complications were observed [19–21]. For the evaluation of tumor staging, endoscopic ultrasonography (EUS) for tumors of the minor duodenal papilla is considered to be useful [10]. The diagnosis of whether or not the tumor has infiltrated into the pancreatic parenchyma is important. However, it is difficult to determine the depth of invasion of the tumor and the presence of lymph node metastasis using EUS and CT. Therefore, expanding the indications for papillectomy of malignant tumors of the duodenal papilla will require further accumulation of case information. In our case, EUS was not performed because we preoperatively diagnosed pancreatic head carcinoma with infiltration of the duodenum.
Surg Today
With respect to the prognosis, all patients who underwent curative resection were still alive at the time of the publication of the report, with the exception of one patient who died from another disease. Therefore, curative resection is an effective treatment for primary adenocarcinoma of the minor duodenal papilla, and can provide long-term survival. Conflict of interest Kazuhiro Suzumura and the co-authors have no conflicts of interest to declare.
References 1. Suda K. Histopathology of the minor duodenal papilla. Dig Surg. 2010;27:137–9. 2. Sugiyama M, Kimura W, Muto T, Yahagi N, Ichinose M, Miki K. Endoscopic resection of adenoma of the minor papilla. Hepatogastroenterology. 1999;46:189–92. 3. Fukuda A, Yazumi S, Sawada M, Seno H, Nabeshima M, Fujii H, et al. Adenomyoma of the minor duodenal papilla. Gastrointest Endosc. 2005;61:475–9. 4. Noda Y, Watanabe H, Iwafuchi M, Furuta K, Ichihara N, Satoh M, et al. Carcinoids and endocrine cell micronests of the minor and major duodenal papillae. Cancer. 1992;70:1825–33. 5. Borobia FG, Fabregat J, Jorba R, Poves I, Biondo S, Serrano T, et al. Exocrine pancreatic insufficiency caused by a somatostatinoma of the minor and major duodenal papilla in a patient with neurofibromatosis. Eur J Surg. 2001;167:154–6. 6. Nakamura T, Ozawa T, Kitagawa M, Takehira Y, Yamada M, Yasumi K, et al. Endoscopic resection of gangliocytic paraganglioma of the minor duodenal papilla: case report and review. Gastrointest Endosc. 2002;55:270–3. 7. Morikawa T, Onogawa T, Maeda S, Takadate T, Shirasaki K, Yoshida H, et al. Solid pseudopapillary neoplasms of the pancreas: an 18-year experience at a single Japanese Institution. Surg Today. 2013;43:26–32. 8. Baldwin WN. The pancreatic ducts in man, together with a study of the microscopical structure of the minor duodenal papilla. Anat Res. 1911;5:197–228.
9. Kamisaka T. Clinical significance of the minor duodenal papilla and accessory pancreatic duct. J Gastroenterol. 2004;39:605–15. 10. Yamao K, Ohhashi K, Furukawa T, Mizutani S, Matsumoto S, Banno T, et al. Primary carcinoma of the duodenal minor papilla. Gastrointest Endosc. 1998;48:634–6. 11. Ohya T, Takemura Y, Tazuma S. Adenocarcinoma of the minor duodenal papilla detected by upper endoscopy. Gastroenterol Endosc. 2006;48:2662–3. 12. Kajiwara M, Fujii S, Takahashi S, Konishi M, Nakagohri T, Gotohda N, et al. Adenocarcinoma of the minor duodenal papilla with intraepithelial spread to the pancreatic duct. Virchows Arch. 2007;451:1075–81. 13. Wakatsuki T, Irisawa A, Takagi T, Koyama Y, Hoshi S, Takenoshita S, et al. Primary adenocarcinoma of the minor duodenal papilla. Yonsei Med J. 2008;49:333–6. 14. Parthasarathy S, Pottakkat B, Yootla M, Reddy SN, Reddy KM. Synchronous adenocarcinomas of the papilla major and minor. JOP. 2008;9:332–4. 15. Matheus AS, Jukemura J, Montagani AL, Kunitake T, Patzina RA, da Cunha JE. Synchronous adenocarcinoma of the major and minor duodenal papilla. J Gastrointest Surg. 2008;12:1301–3. 16. Takami K, Moriya T, Kamiga T, Abe T, Miseki T, Oku T, et al. Adenocarcinoma of the minor duodenal papilla: report of a case. Case Rep Gastroenterol. 2011;5:172–8. 17. Okuma T, Ozaki T, Abe S, Yamamura K, Shigaki H, Sawayama H, et al. Adenocarcinoma of the minor duodenal papilla: report of a case. Surg Today. 2011;41:568–71. 18. Fujimoto J, Suzumura K, Kuroda N, Iimuro Y, Yada A, Nakasho K. A case of primary adenocarcinoma of the minor duodenal papilla (in Japanese with English abstract). J Jpn Soc Clin Surg. 2012;73:1970–3. 19. Goldberg M, Zamir O, Hadary A, Nissan S. Wide local excision as an alternative treatment for periampullary carcinoma. Am J Gastroenterol. 1987;82:1169–71. 20. Ponchon T, Berger F, Chavaillon A, Bory R, Lambert R. Contribution of endoscopy to diagnosis and treatment of tumors of the ampulla of Vater. Cancer. 1989;64:161–7. 21. Jung S, Kim MH, Seo DW, Lee SK. Endoscopic snare papillectomy of adenocarcinoma of the major duodenal papilla. Gastrointest Endosc. 2001;54:622.
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