Treatment for superficial non-ampullary duodenal epithelial tumors

Because of the low prevalence of non-ampullary duodenal epithelial tumors(NADETs),standardized clinical management of sporadic superficial NADETs,including diagnosis,treatment,and follow-up,has not yet been established.Retrospective studies have revealed certain endoscopic findings suggestive of malignancy.Duodenal adenoma with high-grade dysplasia and mucosal cancer are candidates for local resection by endoscopic or minimally invasive surgery.The use of endoscopic treatment including endoscopic mucosal resection(EMR)and endoscopic submucosal dissection(ESD),for the treatment for superficial NADETs is increasing.EMR requires multiple sessions to achieve complete remission and repetitive endoscopy is needed after resection.ESD provides an excellent complete resection rate,however it remains a challenging method,considering the high risk of intraoperative or delayed perforation.Minimally invasive surgery such as wedge resection and pancreas-sparing duodenectomy are beneficial for superficial NADETs that are technically difficult to remove by endoscopic treatment.Pancreaticoduodenectomy remains a standard surgical procedure for treatment of duodenal cancer with submucosal invasion,which presents a risk of lymph node metastasis.Endoscopic or surgical treatment outcomes of superficial NADETs without submucosal invasion are satisfactory.Establishing an endoscopic diagnostic tool to differentiate superficial NADETs between adenoma and cancer as well as between mucosal and submucosal cancer is required to select the most appropriate treatment.

Endoscopic and biopsy diagnoses of superficial, nonampullary, duodenal adenocarcinomas

AIM: To investigate the accuracy of endoscopic or biopsy diagnoses of superficial nonampullary duodenal epithelial tumors(NADETs).METHODS:Clinicopathological data were reviewed for84 superficial NADETs from 74 patients who underwent surgery or endoscopic resection between September2002 and August 2014 at a single prefectural cancer center.Superficial NADETs were defined as lesions confined to the mucosa or submucosa.Demographic and clinicopathological data were retrieved from charts,endoscopic and pathologic reports.Endoscopic reports included endoscopic diagnosis,location,gross type,diameter,color,and presence or absence of biopsy.Endoscopic diagnoses were made by an endoscopist in charge of the examination before biopsy specimens were obtained.Endoscopic images were obtained using routine,front-view,high-resolution video endoscopy,and chromoendoscopy with indigocarmine was performed for all lesions.Endoscopic images were reviewed by at least two endoscopists to assess endoscopic findings indicative of carcinoma.Preoperative diagnoses based on endoscopy and biopsy findings were compared with histological diagnoses of resected specimens.Sensitivity,specificity,and accuracy were assessed for endoscopic diagnosis and biopsy diagnosis.RESULTS:The majority(81%)of the lesions were located in the second portion of the duodenum.The median lesion diameter was 14.5 mm according to final histology.Surgery was performed for 49 lesions from 39 patients,and 35 lesions from 35 patients were endoscopically resected.Final histology confirmed 65carcinomas,15 adenomas,and 3 hyperplasias.A finaldiagnosis of duodenal carcinoma was made for 91%(52/57)of the lesions diagnosed as carcinoma by endoscopy and 93%(42/45)of the lesions diagnosed as carcinoma by biopsy.The sensitivity,specificity,and accuracy of endoscopic diagnoses were 80%,72%,and 78%,respectively,whereas those of biopsy diagnoses were 72%,80%,and 74%,respectively.Preoperative diagnoses of carcinomas were made in88%(57/65)of the carcinoma lesions via endoscopy or biopsy.Endoscopic findings associated with carcinoma were red color,depression,and mixed-type morphology.CONCLUSION:Preoperative endoscopy and biopsy showed similar accuracies in the diagnosis of carcinoma in patients with superficial NADETs.