Management of Minor Papilla Adenomas in Patients with Familial Adenomatous Polyposis and Pancreas Divisum

Abstract

Purpose: Tumors of the minor papilla are uncommon and to date endoscopic management of these tumors in patients with FAP and associated pancreas divisum has not been reported. We describe two cases of endoscopic treatment of minor papillary adenomas in patients with familial adenomatous polyposis (FAP) and associated pancreas divisum. Case 1: A 36-year-old woman with history of FAP, was found to have a 1 cm adenoma involving her minor papilla at routine surveillance endoscopy. A biopsy of this polyp was consistent with a tubular adenoma without dysplasia. At EUS the lesion was confined to the mucosal layers and was without ductal or duodenal wall involvement. A suspicion of pancreas divisum at EUS prompted a non-invasive MRCP, which confirmed pancreas divisum anatomy. During ERCP a pancreatic sphincterotomy was performed followed by endoscopic snare resection of the duodenal lesion. A 5-F × 5 cm stent placed in the pancreatic duct. The remaining area of adenomatous appearing tissue was fulgated with APC. At follow-up endoscopy, biopsies were negative for adenomatous tissue. Case 2: A 32-year-old man with history of FAP was found during surveillance endoscopy to have a periampullary adenoma positioned between the major and minor papilla. Biopsies of this lesion were consistent with a tubular adenoma without dysplasia. At EUS no evidence of duodenal wall or ductal involvement was appreciated. MRCP performed prior to EUS evaluation revealing pancreas divisum. Side-viewing endoscopic examination failed to demonstrate minor or major papillary involvement and ERCP was deemed unnecessary. A saline lift polypectomy was performed removing a 2.5 × 2.0 cm duodenal polyp. The patient developed mild post-polypectomy bleeding controlled with epinephrine and clip placement. A small amount of residual adenomatous appearing tissue was fulgated with APC. No pancreatic stent was placed given lack of the minor papilla disruption directly. The patient was discharged from the endoscopy unit the same day and had no complications. Histopathology revealed duodenal adenoma with high-grade dysplasia and tumor-free margins. Follow-up endoscopy with biopsy was negative for residual adenomatous tissue. Based on our experience in addition to EUS examination of the ampulla to exclude ductal involvement MRI/MRCP seems a prudent, non-invasive cross-sectional imaging procedure given the high degree of potential complications involving the major and minor papilla and endoscopic papillectomy. These cases illustrate endoscopic resection of minor papillary adenomas in patients with FAP and pancreas divisum anatomy to be a safe and feasible option.