© Georg Thieme Verlag KG Stuttgart · New York
Colloid carcinoma of the minor duodenal papilla
05 July 2007 (online)
A 43-year-old woman presented with intermittent epigastric pain and nausea. Her hemoglobin concentration was 10.3 g/dL. Abdominal imaging revealed a 4-cm cystic mass in the pancreatic head ([Figure 1]). ERCP showed an ulcerated polypoid mass at the minor duodenal papilla ([Figure 2]). Cannulation of the normal-appearing major papilla showed a dilated, 4-mm main pancreatic duct and a stricture of the main duct in the head of the gland ([Figure 3]). Cannulation through the mass showed contrast in the ectatic dorsal pancreatic duct, which confirmed involvement of the minor papilla by tumor. Pancreas divisum was not present. A pancreaticoduodenectomy (Whipple procedure) revealed a polypoid gelatinous mass measuring 3 × 2 × 1.5 cm protruding from the minor papilla. Histologically the tumor showed mucin pools containing malignant epithelial cells ([Figure 4]). Resection margins and 15 peripancreatic lymph nodes were free of tumor. Despite an uncomplicated immediate postoperative course, CA 19 - 9 levels are rising 22 months later along with possible liver metastases.
Figure 1 Computed tomography showing cystic mass in the head of the pancreas.
Figure 2 Ulcerated, polypoid mass at the minor duodenal papilla.
Figure 3 Stricture of the proximal duct of Wirsung seen at ERCP.
Figure 4 Histological appearance of the tumor with pools of mucin containing scant malignant glandular epithelial cells. (H&E; original magnification × 20).
Tumors of the minor papilla are uncommon, but carcinoid tumors , somatostatinomas , and a case of a nonendocrine ductal adenocarcinoma  have been reported. Reasons for the rarity of recorded tumors in this location may be a low incidence but also the lack of symptoms caused by small indolent endocrine neoplasms and the absence of jaundice owing to patency of the major papilla . Aggressive neoplasms may overgrow adjacent structures, thus obscuring their origin at the minor papilla . Mucinous noncystic (colloid) carcinoma of the pancreas represents only 1 % - 2 % of all pancreatic nonendocrine neoplasms   and has not been described in the minor papilla previously. It is characterized histologically by extracellular mucin lakes with “floating” malignant epithelial cells  . It is important to distinguish colloid carcinoma from mucin-producing adenocarcinoma, signet-ring cell carcinoma and mucinous cystic neoplasms because the prognosis of colloid carcinoma is significantly better than that of ordinary pancreatic ductal adenocarcinoma, with a 5-year survival rate of 57 %  .
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D. J. Desilets, MD, PhD
Department of Medicine
Division of Gastroenterology
Baystate Medical Center
Tufts University School of Medicine
759 Chestnut Street