PMC4929374_01
An elevated lesion in the descending portion of the duodenum. Abdominal ultrasonography (a, arrow) and magnetic resonance cholangiopancreatography (b) show dilatation of the pancreatic duct. c Duodenoscopy shows an elevated lesion with a villous surface. d Upper gastrointestinal series shows an elevated lesion in the descending portion of the duodenum (arrowhead).
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F1
This examination revealed a dilated pancreatic duct (fig. 1a). To investigate the possibility that the pancreatic duct was stenotic or obstructed, she underwent magnetic resonance cholangiopancreatography (Achieva, software version 3.2.2.; Philips Medical Systems, Best, The Netherlands). This imaging indicated that the dilated pancreatic duct was not stenotic or obstructed (fig. 1b). A duodenoscopy (JF-260V; Olympus, Tokyo, Japan) revealed an elevated lesion around the papilla of Vater (fig. 1c). Upper gastrointestinal series showed that the lesion had an irregular surface and was located in the descending portion of the duodenum (fig. 1d).
Examination of the elevated lesion with endoscopic ultrasonography and mini-probe. a Endoscopic ultrasonography shows intact common bile and pancreatic ducts (arrow). CBD = Common bile duct. b A 20-MHz mini-probe indicates that the elevated lesion is limited to the mucosa and submucosa. The muscularis propria is intact (arrowhead).
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F2
Both ducts were intact (fig. 2a). The border between the mucosa and submucosa was not clear; however, the border between the submucosa and muscularis propria was clear (fig. 2b).
Biopsy of the elevated lesion with magnifying endoscopy. Magnifying endoscopy with white light (a) and narrow-band imaging (b) shows a depressed lesion on the surface of the elevated lesion. A clear demarcation line is visible (arrowheads). A biopsy specimen from the depressed lesion (c) was diagnosed as an adenocarcinoma. Another biopsy specimen obtained from the elevated lesion (e) was diagnosed as an adenoma (f). Original magnification: x400. Scale bars = 50 mum.
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F3
A depressed lesion was observed with white light (fig. 3a) and narrow-band imaging (fig. 3b). A biopsy specimen obtained from the depressed lesion (fig. 3c) revealed an adenocarcinoma (fig. 3d). Another biopsy specimen obtained from a non-depressed portion of the elevated lesion (fig. 3e) revealed an adenoma (fig. 3f).