A 47-year-old woman was admitted because of epigastric pain. On duodenoscopy, the major duodenal papilla was enlarged with an uneven nodular appearance (A). Endoscopic biopsies revealed a tubulovillous adenoma with focal cancerous change. The patient was considered a poor candidate for surgery because of cirrhosis of the liver diagnosed 5 year earlier. Clinical evaluation and liver function tests were consistent with Child-Pugh class C cirrhosis. CT revealed no evidence of regional lymphadenopathy or metastasis. EUS showed that the neoplasm was confined to the mucosal layer. ERCP disclosed no evidence of intraluminal extension into the bile or pancreatic ducts and neither duct was dilated. Endoscopic snare papillectomy was performed by using blended electrosurgical current after submucosal injection of saline solution (B and C). There were no immediate complications such as bleeding, perforation, cholangitis, or pancreatitis. Histopathologic evaluation of the resection specimen (D, H&E, orig. mag. ×100) confirmed the diagnosis of adenocarcinoma without invasion of the muscularis mucosa arising in a tubulovillous adenoma with a clear margin of resection. At follow-up duodenoscopy 2 months later, there was no evidence, either macroscopically or microscopically, of recurrence of the tumor.
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