[Problems in diagnosis and therapy of juxtapapillary, tubulovillous adenoma]

Tubulovillous adenoma of the duodenum have a high potential for malignant transformation. An exact preoperative staging and an accurate histological examination are essential in order to choose a proper therapeutic strategy. We report on difficulties in the diagnostic and therapeutic process of a patient with a tubulovillous, juxtapapillary, duodenal adenoma. The adenoma had 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 changes 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 underwent duodenopancreatectomy and remains without signs of tumor recurrence so far.

1. Microinvasion of the submucosa can not be excluded endosonographically. Therefore endosonography can not specify the dignity of an unknown tumor with a sufficient safety, especially if there is only an intramural growth of the tumor without transmural spread. 2. Because of high recurrence rates and a distinct frequency of malignant transformation of duodenal adenomas, a submucosal resection should only be performed in high-risk patient. 3. In that patients the resected material has to be examined as accurately and subtly as possible to rule out a submucosal microinvasion. 4. Based on the above mentioned radical surgery (duodenopancreatectomy) should be performed in all normal risk patients with juxtapapillary adenomas.