Endoscopy 2007; 39: E221
DOI: 10.1055/s-2007-966565
Unusual cases and technical notes

© Georg Thieme Verlag KG Stuttgart · New York

Colloid carcinoma of the minor duodenal papilla

H.  Varnholt1, 4 , R.  B.  Wait2 , J.  D.  Mueller1 , D.  J.  Desilets3
  • 1Department of Pathology, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts, USA
  • 2Department of Surgery, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts, USA
  • 3Department of Gastroenterology, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts, USA
  • 4Department of Pathology, University of Cologne, Germany
Further Information

Publication History

Publication Date:
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 [1], somatostatinomas [2], and a case of a nonendocrine ductal adenocarcinoma [3] 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 [3]. Aggressive neoplasms may overgrow adjacent structures, thus obscuring their origin at the minor papilla [3]. Mucinous noncystic (colloid) carcinoma of the pancreas represents only 1 % - 2 % of all pancreatic nonendocrine neoplasms [4] [5] and has not been described in the minor papilla previously. It is characterized histologically by extracellular mucin lakes with “floating” malignant epithelial cells [4] [5]. 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 % [4] [5].

Endoscopy_UCTN_Code_CCL_1AB_2AZ_3AB

References

D. J. Desilets, MD, PhD

Department of Medicine

Division of Gastroenterology

Baystate Medical Center

Tufts University School of Medicine

759 Chestnut Street

Springfield

MA 01199

USA

Fax: +1-413-794-8828

Email: david.desilets@bhs.org