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Villous adenomas of the duodenum
0016-5085/78/7406-1295$02.00/O GABFIIOENTEBOLOGY 74:1295-1297, 1978 Copyright 0 1978 by theAmerican Gastroenterological Association
Vol. 74,No. 6 Printed in U.S.A.
VILLOUS ADENOMAS OF THE DUODENUM MARC COOPERMAN, M.D., JOEL
KATHRYN P. CLAUSEN, M.D.,
CHARLES HECHT, M.D.,
G. LUCAS, M.D., AND LUTHER M. KEITH, M.D.
Departments
of Surgery
and Pathology,
The Ohio State
University
Hospitals,
Columbus,
Ohio
A patient with multiple villous adenomas of the duodenum is described. Endoscopy plays an essential role in the management of these neoplasms. If no evidence of invasive malignancy is found on multiple endoscopic biopsies, wide local excision is the initial procedure of choice. Invasive malignancy found in either the endoscopic biopsy or the surgical specimen is indication for pancreaticoduodenectmy. Since the first description of a villous adenoma of the duodenum by Perry’ in 1893, only 43 additional cases have been reported in the world literature.2, 3Malignant transformation is not unusual, and poses important problems in the management of these rare neoplasms. These tumors have been found in all portions of the duodenum, and in all previous reports have been solitary. ‘I’he following case report describes the first case of multiple villous adenomas arising in the duodenum.
divided, and an extensive Kocher maneuver was performed so that the entire duodenum could be visualized. Palpation demonstrated a soft, mobile mass arising from the anterior wall of the third portion of the duodenum. Through a longitudinal duodenotomy, a 3.5 by 5.~cm tumor was excised. Full thickness of the duodenum was removed with wide margins
Case Report A 55-year-old black woman was admitted to The Ohio State University Hospital with a 3-month history of intermittent cramping epigastric pain. The pain was nonradiating and unrelated to meals. She had had a 10 lb weight loss over the preceding 2 months, but reported no nausea, vomiting, diarrhea, melena, or hematochezia. Her past medical history included adultronset diabetes mellitus and hypertension. Physical examination was normal. Laboratory values on admission were as follows: WBC, 5.0; BBC, 3.59; hematocrit, 31.6; erythrocyte sedimentation rate, 36; platelets, 269,ooO, prothrombin time, 10.6; partial thromboplastin time, 23; blood urea nitrogen, 30; glucose, 109, creatinine, 1.5; Na, 142; K, 3.0; Cl, 99; COZ, 25; total protein, 8.1; albumin, 4.1; lactic dehydrogenase, 394; SGOT, 35; SGPT, 17; alkaline phosphatase, 70; amylase, 119; carcinoembryonic antigen, 2.2. The stool was guaiac-positive. Chest X-ray was normal. ECG showed a possible old posterior myocardial infarct. Barium enema, oral cholecystogram, and intravenous pyelogram were normal. Upper gastrointestinal series showed a fungating mass measuring 3.5 by 7 cm at the junction of the third and fourth portions of the duodenum (fig. 1). Two questionable filling defects were noted in the second portion of the duodenum. Endoscopy was performed and demonstrated three small FIG.1. Large, bulky tumor is easily seen in third portion of the nodules less than 1 cm in size in the first and third portions of the duodenum. In the third portion of the duodenum there duodenum. was a large cauliflower-like mass filling the entire lumen. Multiple biopsies were taken and showed villous adenoma. around the base of the tumor (fig. 2). The proximal duodenum There was no evidence of malignancy. was then inspected through the duodenotomy, and four addiExploratory laparotomy was performed. The hepatic flexure tional smaller polyps were seen in the first and second portions of the colon was mobilized, the gastrocolic ligament was of the duodenum. These were excised through a second duodenotomy, and measured from 7 mm to 3 cm in greatest ReceivedSeptember8, 1977.AcceptedDecember11,1977. dimension. Addressrequestsfor reprintsto: Marc Cooperman,M.D., DepartFrozen sections were obtained of the tumors, and no eviment of Surgery, The Ohio State University Hospitals, 410West dence of malignancy was found. Pathological examination 10thAvenue, Columbus,Ohio 43210. showed all of the excised polyps to have the typical finger-like 1295
1296
Vol. 74, No. 6
CASE REPORTS
projections of villous adenoma (fig. 3). Permanent sections confirmed the absence of carcinoma in the resected specimens. Tbe patient’s postoperative course was uncomplicated. Pathological examination. Like its counterpart in the colon, these villous adenomas consisted of greatly elongated fronds of mucin-secreting columnar epithelial cells, each resting on a
basement membrane. There was no Paneth cell component. Many of the crypts extended to the muscularis mticosae. Each villous frond had a delicate fibrovascular stroma. The stroma contained lymphocytes, many plasma cells, and a few eosinophils. Malignancy was excluded by the absence of necrosis, glandon-gland proliferation, and invasion of stroma or muscularis mucosae. Persistence of lamina propria and fibrovascular stroma in each villous frond was regarded as a benign growth pattern. Cytological atypia was only modest in these lesions. The diagnosis could readily be established on frozen section. As with any bulky villous tumor, many sections must be taken to exclude malignancy definitely.
Comment
FIG. 2. Largest villous adenoma excised with surrounding rim of normal duodenum.
Villous adenomas, found most commonly in the colon, have previously been reported in the stomach,4 duodenum, and small intestine.5 Only 44 cases of villous adenoma of the duodenum have been previously reported. The symptoms most commonly produced by this rare tumor are obstruction and bleeding. Jaundice is rare, but is associated with a high incidence of malignancy. The profuse mucus and electrolyte loss reported with villous adenomas of the colon does not occur with villous adenoma of the duodenum. Radiological examination of the upper gastrointestinal tract. will usually demonstrate the duodenal neoplasm. However, a review of previously reported cases
FIG. 3. Typical finger-like projections of villous adenoma.
June 1978
1297
CASE REPORTS
showed that the correct preoperative diagnosis was made in only 33%.2 Fiberoptic endoscopy proved extremely helpful in the management of this case. The three small tumors in the first portion of the duodenum might well have escaped detection at laparotomy. Multiple biopsies taken through the endoscope confirmed the diagnosis of multiple villous adenomas. It can be anticipated that routine endoscopic examination and biopsy of duodenal neoplasms will greatly increase preoperative diagnostic accuracy and furnish a guide to the probable extent of operation indicated. Invasive or in situ carcinoma arising from a villous adenoma of the duodenum was found in 35% of previously reported cases.2 Pancreaticoduodenectmy is not justified without the presence of biopsy-proved invasive malignancy. Accordingly, all tumors were treated by
wide local excision. If either endoscopic biopsies or examination of the surgical specimen had demonstrated invasive malignancy, a pancreaticoduodenectmy would have been performed. REFERENCES
1. Perry EC: Papilloma of the duodenum. Tram Path01 Sot Lond 44:84,1892-1893
2. Schulten MF, Oyasu RO, Beal JM: Villous adenoma of the 3 duodenum. Am J Surg 132:90-96,1976 4. 5.
Uppaputhangkule V, Maas LC, Galzayd EA: Endoscopic diagnosis of villous adenoma of the duodenum. Gastrointest Endosc 23:97-98, 1976 Meltzer AD, Ostrum VJ, Isard HJ: Villous tumors of the stomach and duodenum. Radiology 87511-513, 1966 Steinberg LS, Shieber W: Villous adenomas of the small intestine. Surgery 711423-428, 1972
Vol. 74,No. 6 Printed in U.S.A.
VILLOUS ADENOMAS OF THE DUODENUM MARC COOPERMAN, M.D., JOEL
KATHRYN P. CLAUSEN, M.D.,
CHARLES HECHT, M.D.,
G. LUCAS, M.D., AND LUTHER M. KEITH, M.D.
Departments
of Surgery
and Pathology,
The Ohio State
University
Hospitals,
Columbus,
Ohio
A patient with multiple villous adenomas of the duodenum is described. Endoscopy plays an essential role in the management of these neoplasms. If no evidence of invasive malignancy is found on multiple endoscopic biopsies, wide local excision is the initial procedure of choice. Invasive malignancy found in either the endoscopic biopsy or the surgical specimen is indication for pancreaticoduodenectmy. Since the first description of a villous adenoma of the duodenum by Perry’ in 1893, only 43 additional cases have been reported in the world literature.2, 3Malignant transformation is not unusual, and poses important problems in the management of these rare neoplasms. These tumors have been found in all portions of the duodenum, and in all previous reports have been solitary. ‘I’he following case report describes the first case of multiple villous adenomas arising in the duodenum.
divided, and an extensive Kocher maneuver was performed so that the entire duodenum could be visualized. Palpation demonstrated a soft, mobile mass arising from the anterior wall of the third portion of the duodenum. Through a longitudinal duodenotomy, a 3.5 by 5.~cm tumor was excised. Full thickness of the duodenum was removed with wide margins
Case Report A 55-year-old black woman was admitted to The Ohio State University Hospital with a 3-month history of intermittent cramping epigastric pain. The pain was nonradiating and unrelated to meals. She had had a 10 lb weight loss over the preceding 2 months, but reported no nausea, vomiting, diarrhea, melena, or hematochezia. Her past medical history included adultronset diabetes mellitus and hypertension. Physical examination was normal. Laboratory values on admission were as follows: WBC, 5.0; BBC, 3.59; hematocrit, 31.6; erythrocyte sedimentation rate, 36; platelets, 269,ooO, prothrombin time, 10.6; partial thromboplastin time, 23; blood urea nitrogen, 30; glucose, 109, creatinine, 1.5; Na, 142; K, 3.0; Cl, 99; COZ, 25; total protein, 8.1; albumin, 4.1; lactic dehydrogenase, 394; SGOT, 35; SGPT, 17; alkaline phosphatase, 70; amylase, 119; carcinoembryonic antigen, 2.2. The stool was guaiac-positive. Chest X-ray was normal. ECG showed a possible old posterior myocardial infarct. Barium enema, oral cholecystogram, and intravenous pyelogram were normal. Upper gastrointestinal series showed a fungating mass measuring 3.5 by 7 cm at the junction of the third and fourth portions of the duodenum (fig. 1). Two questionable filling defects were noted in the second portion of the duodenum. Endoscopy was performed and demonstrated three small FIG.1. Large, bulky tumor is easily seen in third portion of the nodules less than 1 cm in size in the first and third portions of the duodenum. In the third portion of the duodenum there duodenum. was a large cauliflower-like mass filling the entire lumen. Multiple biopsies were taken and showed villous adenoma. around the base of the tumor (fig. 2). The proximal duodenum There was no evidence of malignancy. was then inspected through the duodenotomy, and four addiExploratory laparotomy was performed. The hepatic flexure tional smaller polyps were seen in the first and second portions of the colon was mobilized, the gastrocolic ligament was of the duodenum. These were excised through a second duodenotomy, and measured from 7 mm to 3 cm in greatest ReceivedSeptember8, 1977.AcceptedDecember11,1977. dimension. Addressrequestsfor reprintsto: Marc Cooperman,M.D., DepartFrozen sections were obtained of the tumors, and no eviment of Surgery, The Ohio State University Hospitals, 410West dence of malignancy was found. Pathological examination 10thAvenue, Columbus,Ohio 43210. showed all of the excised polyps to have the typical finger-like 1295
1296
Vol. 74, No. 6
CASE REPORTS
projections of villous adenoma (fig. 3). Permanent sections confirmed the absence of carcinoma in the resected specimens. Tbe patient’s postoperative course was uncomplicated. Pathological examination. Like its counterpart in the colon, these villous adenomas consisted of greatly elongated fronds of mucin-secreting columnar epithelial cells, each resting on a
basement membrane. There was no Paneth cell component. Many of the crypts extended to the muscularis mticosae. Each villous frond had a delicate fibrovascular stroma. The stroma contained lymphocytes, many plasma cells, and a few eosinophils. Malignancy was excluded by the absence of necrosis, glandon-gland proliferation, and invasion of stroma or muscularis mucosae. Persistence of lamina propria and fibrovascular stroma in each villous frond was regarded as a benign growth pattern. Cytological atypia was only modest in these lesions. The diagnosis could readily be established on frozen section. As with any bulky villous tumor, many sections must be taken to exclude malignancy definitely.
Comment
FIG. 2. Largest villous adenoma excised with surrounding rim of normal duodenum.
Villous adenomas, found most commonly in the colon, have previously been reported in the stomach,4 duodenum, and small intestine.5 Only 44 cases of villous adenoma of the duodenum have been previously reported. The symptoms most commonly produced by this rare tumor are obstruction and bleeding. Jaundice is rare, but is associated with a high incidence of malignancy. The profuse mucus and electrolyte loss reported with villous adenomas of the colon does not occur with villous adenoma of the duodenum. Radiological examination of the upper gastrointestinal tract. will usually demonstrate the duodenal neoplasm. However, a review of previously reported cases
FIG. 3. Typical finger-like projections of villous adenoma.
June 1978
1297
CASE REPORTS
showed that the correct preoperative diagnosis was made in only 33%.2 Fiberoptic endoscopy proved extremely helpful in the management of this case. The three small tumors in the first portion of the duodenum might well have escaped detection at laparotomy. Multiple biopsies taken through the endoscope confirmed the diagnosis of multiple villous adenomas. It can be anticipated that routine endoscopic examination and biopsy of duodenal neoplasms will greatly increase preoperative diagnostic accuracy and furnish a guide to the probable extent of operation indicated. Invasive or in situ carcinoma arising from a villous adenoma of the duodenum was found in 35% of previously reported cases.2 Pancreaticoduodenectmy is not justified without the presence of biopsy-proved invasive malignancy. Accordingly, all tumors were treated by
wide local excision. If either endoscopic biopsies or examination of the surgical specimen had demonstrated invasive malignancy, a pancreaticoduodenectmy would have been performed. REFERENCES
1. Perry EC: Papilloma of the duodenum. Tram Path01 Sot Lond 44:84,1892-1893
2. Schulten MF, Oyasu RO, Beal JM: Villous adenoma of the 3 duodenum. Am J Surg 132:90-96,1976 4. 5.
Uppaputhangkule V, Maas LC, Galzayd EA: Endoscopic diagnosis of villous adenoma of the duodenum. Gastrointest Endosc 23:97-98, 1976 Meltzer AD, Ostrum VJ, Isard HJ: Villous tumors of the stomach and duodenum. Radiology 87511-513, 1966 Steinberg LS, Shieber W: Villous adenomas of the small intestine. Surgery 711423-428, 1972