Is a duodenal adenoma cancer?

No, it is a benign tumor. But over time it can turn into cancer, and cancer is sometimes already present deep inside a large adenoma even when the biopsy did not show it. That is why duodenal adenomas are usually removed, taking into account the procedural risk and the patient’s condition.

Can the tumor be removed without surgery?

Most small adenomas can — endoscopically, during an upper endoscopy. An ampullary adenoma without extension into the ducts is removed by endoscopic papillectomy. Surgery is considered when endoscopic removal is technically impossible, an ampullary adenoma extends more than 2 cm into the ducts, or there are signs of cancer.

What is the major duodenal papilla and why is a tumor there special?

It is where the bile duct and the pancreatic duct open into the duodenum. Even a small papillary tumor can block bile flow and cause jaundice, and removing it requires special attention to the openings of both ducts: after endoscopic papillectomy a temporary pancreatic duct stent is usually placed.

What is a Whipple procedure?

It is a pancreaticoduodenectomy — removal of the duodenum, the head of the pancreas and the lower end of the bile duct with the lymph nodes, with digestion restored through a loop of small bowel. It is performed for ampullary and duodenal cancer and for large adenomas that cannot be removed any other way.

How often is endoscopy needed after an adenoma is removed?

The first check is a few months after removal, then on a schedule that depends on the adenoma’s size and pathology. In familial adenomatous polyposis, upper endoscopy continues for life.

Duodenal and ampullary tumors: from endoscopy to Whipple

Duodenal tumors are most often found by chance — during an upper endoscopy done for another reason. They include benign adenomas, which can turn into cancer over time, and malignant tumors. The major duodenal papilla deserves special attention: this is where the bile duct and the pancreatic duct open into the bowel, and a tumor here can cause jaundice. Treatment ranges from endoscopic removal without an incision to pancreaticoduodenectomy — depending on the tumor’s size, its position relative to the papilla, and its pathology.

Kateryna Valikhnovska, MD, surgical oncologist, during a laparoscopic operation — The laparoscopic stage of an operation: the lights in the operating room are dimmed because the surgeon works from the camera image on the monitor.

Why duodenal tumors develop

The most common tumors are adenomas: benign growths of the lining that can become cancer over the years. Most arise without an obvious cause, but in familial adenomatous polyposis duodenal and papillary adenomas develop over time in most patients, so these people need regular upper endoscopy with inspection of the papilla.

Malignant tumors include duodenal adenocarcinoma and ampullary cancer. The duodenum can also host neuroendocrine tumors and stromal tumors (GIST), and among benign lesions — lipomas and Brunner gland hamartomas, which usually do not need removal.

Are there symptoms

Small adenomas and tumors cause no symptoms. A papillary tumor can block bile flow: jaundice appears — often painless — along with dark urine, pale stools and itching; sometimes the first sign is acute pancreatitis. Large tumors bleed, which shows up as anemia or black stools, or narrow the bowel, causing vomiting after meals.

If jaundice develops, its cause must first be established, and bile drainage is done when indicated — see the malignant obstructive jaundice page.

Examinations needed

Upper endoscopy with biopsy, and to assess the papilla — inspection with a side-viewing duodenoscope: a standard endoscope does not show the papilla well.
Endoscopic ultrasound — depth of wall invasion, extension of a papillary tumor into the bile and pancreatic ducts, state of the lymph nodes.
Contrast-enhanced abdominal CT and MRI with MRCP — assessment of the ducts, pancreas, blood vessels, lymph nodes and liver; for malignant tumors — also chest CT.
CA 19-9 tumor marker and a chemistry panel with bilirubin — if a malignant tumor or jaundice is suspected.
Colonoscopy — when a duodenal adenoma is found, if it has not been done before.

A biopsy of an adenoma does not always detect cancer already present deep within it, so the final verdict comes from pathology of the entire removed tumor.

When surgery is possible

Non-ampullary adenomas without signs of deep invasion are removed endoscopically — most often by snare resection; submucosal dissection is done only in expert centers. Ampullary adenomas without extension into the ducts or with limited extension are removed by endoscopic papillectomy, usually with a pancreatic duct stent. The duodenal wall is thin and the risk of complications is higher than in the stomach or colon, so these procedures are done in experienced centers.

Surgery is recommended when the tumor cannot be removed safely by endoscopy, when an ampullary adenoma extends more than 2 cm into the ducts, and for cancer — provided there are no distant metastases and the major blood vessels are not involved to an extent that rules out complete removal.

If surgery is not possible now

With distant metastases, chemotherapy becomes the basis of treatment. If the tumor blocks the bile duct, bile flow is restored with a stent; if it narrows the duodenum — with a duodenal stent or a bypass between the stomach and small bowel, so the patient can eat.

For locally advanced tumors where complete removal is doubtful, chemotherapy may be given first, after which the MDT reconsiders surgery.

How the operation is performed

The extent depends on the tumor’s location. A small benign tumor that could not be removed endoscopically is sometimes excised through an opening in the duodenal wall — transduodenal excision, and when the papilla is excised, the duct openings are reconstructed. Tumors of the third and fourth parts of the duodenum, away from the papilla, are removed by segmental duodenal resection — without operating on the pancreas.

For cancer of the papilla and the adjacent duodenum, and for large adenomas extending into the ducts, a pancreaticoduodenectomy (Whipple procedure) is performed: removal of the duodenum, the head of the pancreas, the lower end of the bile duct and the gallbladder with the lymph nodes. The pancreatic duct, bile duct and stomach are then joined to a loop of small bowel.

A duodenal adenoma is not cancer, but it is not a reason to wait either. Removed in time, it usually does not get the chance to turn malignant.

Kateryna Valikhnovska, MD, surgical oncologist

Recovery after surgery

After endoscopic removal, patients are usually discharged within a few days. After segmental resection or transduodenal excision, recovery is similar to ordinary bowel surgery. Care follows the enhanced recovery after surgery (ERAS) program.

Pancreaticoduodenectomy is a major operation with a longer hospital stay; the main risk is leakage from the pancreas-to-bowel connection. Afterward, enzyme supplements with meals are often needed, and blood glucose is monitored in all patients. After resection for cancer, adjuvant chemotherapy is discussed; the medical oncologist decides on the regimen.

Follow-up

After endoscopic removal of an adenoma, surveillance endoscopies are mandatory: the first after a few months, then on schedule, because adenomas can recur at the removal site. In polyposis, upper endoscopy continues for life. After surgery for cancer, CT and CA 19-9 are done regularly; the doctor sets the schedule.

What to bring to the consultation

upper endoscopy and endoscopic ultrasound reports describing the tumor’s position relative to the papilla, with images if possible;
the pathology report; tissue blocks and slides — for review by another laboratory;
CT or MRI with MRCP discs and reports;
chemistry panel with bilirubin, CA 19-9;
the procedure report and discharge summary if a stent has been placed or endoscopic removal was attempted.

If some materials are missing, that is no reason to postpone the consultation: some examinations can be done on site.

The consultation is free of charge. How it goes and how long it takes is described on the page “Oncologist Consultation”.