Problems in diagnosis and therapy of the peripapillary tubulovillous adenoma

Tubulovillous adenoma of the duodenum have a high potential for malignant t ransformation. An exact preoperative staging and an accurate histological e xamination are essential in order to choose a prop er therapeutic strategy. We report on difficulties in the diagnostic and therapeutic process of a pa tient With a tubulovillous, juxtapapillary, duodenal adenoma. The adenoma h ad been resected by means of submucosal excision after infiltrative growth had been excluded endosonographically and malignancy had been ruled out by the histological examination of a taken biopsy. Furthermore no malignant ch anges had been found in the resected material. However an early recurrence of the tumor questioned the correctness of the first diagnosis. In fact, a retrospective histological examination of the resected specimen revealed an adenocarcinoma, which had been overlooked primarily. Finally the patient u nderwent duodenopancreatectomy and remains without signs of tumor recurrenc e so far. Conclusions: 1. Microinvasion of the submucosa can not be excluded endosonographically. Therefore endosonography can not specify the dignity of an unknown tumor wi th a sufficient safety, especially if there is only an intramural growth of the turner without transmural spread. 2. Because of high recurrence rates and a distinct frequency of malignant t ransformation of duodenal adenomas, a submucosal resection should only he p erformed in high-risk patient. 3. In that patients the resected material has to he examined as accurately and subtly as possible to rule out a submucosal microinvasion. 4. Based on the above mentioned radical surgery (duodenopancreatectomy) sho uld he performed in all normal risk patients with juxtapapillary adenomas.