Duodenal Adenomas Research Articles

Sa1584 Efficacy and Safety of the Band and Slough Technique for Endoscopic Management of Non Ampullary Duodenal Adenomas: a Case Series

Duodenal adenomas are found in 0.3-4.6% of patients presenting for EGD. Standard polypectomy with the use of electrocautery is typically used to resect the adenoma. However, complications including bleeding, perforation and pain can occur in up to 5% due to the thin duodenal wall. Banding the adenoma without the use of electrocautery (band and slough) may decrease complication rates without adversely affecting the outcome.

Su1771 Ampullary Adenoma in Children With Familial Adenomatous Polyposis

Duodenal adenomas are found in the majority of adult patients with familial adenomatous polyposis (FAP) and contribute to a cumulative lifetime risk of duodenal cancer of approximately 5% (Vasen et al 1997). A much higher risk of 36% has been associated with Spigelman stage III and IV adenomatosis scored by size, number, histology, and grade of dysplasia of adenomas. While most of the duodenum can be examined by a forward-viewing endoscope (FVE), accurate inspection and biopsy of the ampulla requires use of a side-viewing endoscope (SVE). Ampullary disease does not correlate with the severity of non-ampullary duodenal involvement (Burke et al 1999) and ampullary cancers may represent approximately 50% of duodenal cancers in FAP patients (Latchford et al 2009). High-grade dysplasia and carcinoma of the ampulla has been reported in children with FAP (Attard et al 2004, Hinder et al 1980) but systematic examination of the ampulla using a SVE has not been reported. The primary aim of this study was to characterize the prevalence and stage of ampullary adenoma in children with FAP.

Mo1551 Management of Duodenal Adenomas by Endoscopic Resection: Adenoma Characteristics, Complication Rates and Patient Outcome in 75 Cases Treated in a Tertiary Western Academic Referral Center

Mo1551 Management of Duodenal Adenomas by Endoscopic Resection: Adenoma Characteristics, Complication Rates and Patient Outcome in 75 Cases Treated in a Tertiary Western Academic Referral Center

Duodenal Adenomas Coincide with Colorectal Neoplasia

Small case series have alluded to an association between sporadic duodenal adenomas and colorectal neoplasia. The strength of the association remains uncertain. This case-control study was designed to test this association in a large national pathology database. This study, performed at Miraca Life Sciences, a specialized pathology laboratory that receives gastrointestinal biopsy specimens from outpatient centers throughout the US, included all subjects who underwent a bidirectional endoscopy with biopsy results from both procedures between January 2008 and December 2011. The association between duodenal and colonic neoplasms was investigated using odds ratios (OR) and their 95 % confidence intervals (CIs) derived from univariate and multivariate analyses. There were 203,277 patients who underwent bidirectional procedures within the study period (mean age 58 years, 58 % females). Duodenal adenomas were present in 537 patients (median age 65 years, 51 % females; OR for male sex 1.34, 95 % CI 1.13-1.59). Hyperplastic colon polyps were present in 30,205 and colon adenomas in 85,801 patients. Hyperplastic polyps were more common in patients with duodenal adenomas (1.45, 1.07-1.95). Patients with duodenal adenomas also had a significantly greater prevalence of all types of colonic adenomas (2.65, 2.16-3.25), particularly of advanced adenomas (4.30, 3.24-5.70) and colorectal cancer (3.13, 1.38-7.12). Duodenal adenomas were associated with an equally increased risk for left and right colon adenomas. Patients with duodenal adenomas harbor an increased risk for any type of colonic neoplasm. This association may provide new insights into the general mechanisms underlying mucosal proliferation in the gastrointestinal tract.

Endoscopic resection of large sporadic non-ampullary duodenal polyps: efficacy and long-term recurrence

Endoscopic resection is an alternative to surgery for removal of large duodenal polyps. There are limited data on the safety, efficacy, and long-term recurrence data after endoscopic resection of sporadic, non-ampullary, and large duodenal polyps. Our aim was to evaluate the safety and short-term outcomes of the endoscopic removal of the large sporadic duodenal polyps and to determine long-term risk of recurrence and factors predicting recurrence on follow-up. Patients with large (>10mm) sporadic non-ampullary duodenal polyps underwent endoscopic resection from 2001 to 2012 at the Cleveland Clinic. Patients underwent endoscopic polypectomy and argon plasma coagulation. The main outcome measurements were complete polypectomy, complications, short- and long-term recurrence. A total of 54 patients were included. The mean patient age was 66.4years. The mean polyp size was 15.1±5.4mm. Most polyps (N=48, 88.9%) were sessile polyps. The median follow-up time was 10.8 (range 0.5-120) months. Most lesions were located in the second part of the duodenum (N=41, 75.9%). Adenomas were found in 46 (85.2%) of lesions overall. Tubular adenoma was the most common histology type found in 33 cases (71.7%). Tubulovillous and villous were found in 12 (26.1%) and 1 (2.2%) cases, respectively. On follow-up, 50 (92.6%) achieved complete resection with tumor free margins post resection. The 30-day risk of major complications was 5.6% (N=3), 1 with perforation and 2 with delayed bleeding. Recurrence was documented in 29% (N=16) of patients. All recurrences were managed endoscopically except for one patient who required surgery. The recurrence rate was higher for patients who had villous component in their adenomas compared to those with tubular alone (p=0.03). Endoscopic resection is effective for treating large duodenal adenomas. Adenomas with villous features are more likely to recur. Almost all recurrences can be managed endoscopically.

Pancreas-preserving partial duodenectomy of the distal region for large duodenal adenoma: report of a case

For neoplasms in the third and fourth parts of the duodenum, a duodenectomy that preserves the pancreas may provide feasible tumor clearance while avoiding the additional dissection and pancreaticoduodenectomy. We herein describe the case of a 40-year-old male patient with an adenoma in the third part of the duodenum. The patient underwent a partial duodenectomy of the distal region, preserving the pancreas and Vater's papilla. The residual duodenum and jejunum were successfully reconstructed by an end-to-side anastomosis. We also present a review of the English literature regarding pancreas-preserving partial duodenectomy of the distal region.

Akutkomplikationen nach endoskopischer Resektion von Duodenaladenomen

With the increasing technological development of endoscopy in recent years the diagnosis of and endoscopic therapy for duodenal adenomas has gained in importance. Due to its potentially malignant transformation an effective and safe therapy is necessary. The endoscopic resection has been shown to be safe and effective, even in cases of resection of large duodenal adenomas. Several studies have supported this thesis but are based on relatively small numbers of patients. In our clinic we have performed endoscopic resections of 178 duodenal adenomas over a period of 14 years, including sporadic duodenal adenomas as well as adenomas in familial polyposis syndromes. The aim of this retrospective analysis was to determine the acute complications associated with this technique. The rate of severe complications such as major bleeding or perforations was 9%. Further complications were minor bleeding (15.7%), pain needing treatment with analgesia (6.7%), fever (2.8%) and pancreatitis (0.6%). Summing up our experience with the endoscopic resection of adenomas of the small bowel we also consider the endoscopic resection of duodenal adenomas in most cases as a safe and effective alternative to surgical therapy. Because of the potential complications and their management especially in the resection of large adenomas with a size more than 2 cm, the endoscopic resection should be performed on an inpatient basis in experienced centres.

CpG island methylator phenotype and its association with malignancy in sporadic duodenal adenomas

CpG island methylator phenotype (CIMP) has been found in multiple precancerous and cancerous lesions, including colorectal adenomas, colorectal cancers, and duodenal adenocarcinomas. There are no reports in the literature of a relationship between CIMP status and clinicopathologic features of sporadic duodenal adenomas. This study sought to elucidate the role of methylation in duodenal adenomas and correlate it with KRAS and BRAF mutations. CIMP+ (with more than 2 markers methylated) was seen in 33.3% of duodenal adenomas; 61% of these CIMP+ adenomas were CIMP-high (with more than 3 markers methylated). Furthermore, CIMP+ status significantly correlated with older age of patients, larger size and villous type of tumor, coexistent dysplasia and periampullary location. MLH1 methylation was seen in 11.1% of duodenal adenomas and was significantly associated with CIMP+ tumors, while p16 methylation was an infrequent event. KRAS mutations were frequent and seen in 26.3% of adenomas; however, no BRAF mutations were detected. Furthermore, CIMP-high status was associated with larger size and villous type of tumor and race (non-white). These results suggest that CIMP+ duodenal adenomas may have a higher risk for developing malignancy and may require more aggressive management and surveillance.

Endoscopic resection of sporadic duodenal adenomas: comparison of endoscopic mucosal resection (EMR) with hybrid endoscopic submucosal dissection (ESD) techniques and the risks of late delayed bleeding

Endoscopic resection (ER) of sporadic duodenal adenomas (SDAs) is an alternative treatment strategy to surgical excision but carries substantial risks of bleeding. Endoscopic submucosal dissection (ESD) of SDAs has a high rate of perforation. This study aimed to examine the outcome for ER of SDAs in two large UK centers, both using a novel hybrid endoscopic mucosal resection (EMR) with ESD. Prospective endoscopy databases of ER cases were examined for the period January 2005 to December 2012. Records were analyzed for patient demographics, lesion size and morphology, staging investigations, procedural technique, outcomes, histology, complications, and follow-up assessments. The study included 34 patients. The mean adenoma size was 25 mm. Of the 34 cases, 21 (62 %) were managed by the traditional snare EMR technique, 12 (35 %) by the hybrid EMR-ESD technique, and 1 by full en bloc ESD. Successful resection was achieved in 33 (97 %) of the 34 cases. En bloc resection and recurrence rates did not differ significantly between the cases treated by EMR and those treated by hybrid EMR-ESD. Three episodes of significant delayed bleeding occurred 1-18 days after the procedure. No perforations or deaths occurred. The risk of delayed bleeding was higher for the lesions 30 mm in diameter or larger than for the lesions smaller than 30 mm (33% vs. 0 %; p = 0.003). The risk of delayed bleeding was not related to the ER technique used (EMR, 9.5 %; ESD/hybrid, 7.7 %; p = 0.855). Endoscopic resection is an effective treatment for SDAs and can avoid the need for open surgery. This is the first series to report the use of a hybrid EMR-ESD technique for the treatment of SDAs in a Western setting. However, this technique did not confer any major outcome benefits over EMR. The risk of delayed bleeding is substantial, and bleeding may occur up to 18 days after the procedure. The risk of delayed bleeding was increased with lesions larger than 30 mm but was not influenced by the endoscopic technique.

Treatment for superficial non-ampullary duodenal epithelial tumors.

Because of the low prevalence of non-ampullary duodenal epithelial tumors (NADETs), standardized clinical management of sporadic superficial NADETs, including diagnosis, treatment, and follow-up, has not yet been established. Retrospective studies have revealed certain endoscopic findings suggestive of malignancy. Duodenal adenoma with high-grade dysplasia and mucosal cancer are candidates for local resection by endoscopic or minimally invasive surgery. The use of endoscopic treatment including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), for the treatment for superficial NADETs is increasing. EMR requires multiple sessions to achieve complete remission and repetitive endoscopy is needed after resection. ESD provides an excellent complete resection rate, however it remains a challenging method, considering the high risk of intraoperative or delayed perforation. Minimally invasive surgery such as wedge resection and pancreas-sparing duodenectomy are beneficial for superficial NADETs that are technically difficult to remove by endoscopic treatment. Pancreaticoduodenectomy remains a standard surgical procedure for treatment of duodenal cancer with submucosal invasion, which presents a risk of lymph node metastasis. Endoscopic or surgical treatment outcomes of superficial NADETs without submucosal invasion are satisfactory. Establishing an endoscopic diagnostic tool to differentiate superficial NADETs between adenoma and cancer as well as between mucosal and submucosal cancer is required to select the most appropriate treatment.

Premalignant Conditions of the Small Bowel

Small intestinal dysplastic lesions are rare and difficult to detect before they progress to cancer. New investigative modalities, such as capsule endoscopy and doubleballoon enteroscopy, are very promising in search for premalignant lesions. Screening patients at high-risk for small bowel neoplasia is the only sensible approach. Duodenal adenoma represents the most easily accessible tumors with the possibility of curative endoscopic resection. Due to the strong association of the small bowel and colonic adenomas, it is always necessary to perform colonoscopy. In young patients, the exclusion of familial polyposis by genetic testing is always mandatory. Patients with celiac disease are especially at risk of developing nonHodgkins lymphomas and adenocarcinomas. There is a high-risk of ampuloma and other adenomas in patients with familial adenomatous polyposis. Patients with prolonged and complicated course of Crohns disease, Peutz Jeghers syndrome and patients with ileoanal pouch have higher risk of adenocarcinoma of the small intestine.

Giant villous duodenal adenoma with malignant change: an unusual cause of obstructive jaundice

Obstructive jaundice can have various causes, and both neoplastic and non-neoplastic lesions have to be considered. In cases of malignant disease, the tumors are usually located in the extrahepatic bile ducts, the pancreatic head, or the ampulla of Vater [1]. In rare cases, the causative lesion originates from the duodenum [2,3]. A 67-year-old man presented with nonspecific right upper quadrant pain and icterus. Laboratory analysis revealed marked cholestasis: alkaline phosphatase 607U/L (normal 35–129U/L), gamma glutamyltransferase 1595U/L (normal 0– 66U/L), and total bilirubin 27.2mg/dL (normal 0–1mg/dL). At endoscopy, a huge villous duodenal adenoma was detected, which covered almost the entire duodenal wall (● Fig.1). Intubation of the ampulla of Vater was impossible. A computed tomography (CT) scan showed an irregular, polypoid tumor that was protruding into theduodenal lumen, butwas confined to the bowelwall (● Fig.2). The pancreaticoduodenectomy specimen subsequently showed an intraduodenal villous tumor measuring 12.5cm in its largest diameter. The cut surface of the ampulla was firm, yellow–white, and suspicious of malignancy (● Fig.3). This area measured 1.5cm in its largest diameter. Histology revealed a villous adenoma (with low and high grade dysplasia) with progression to poorly differentiated ampullary adenocarcinoma that was invading both the pancreas and the peripancreatic soft tissue (● Fig.4). Seven regional lymph node metastases were identified. The patient’s postoperative course was uneventful and he was discharged in good condition 10 days after surgery. Villous adenomas of the duodenum have a predilection for the ampullary region, tend to present with obstructive jaundice, especially if malignancy is present, and Fig.1 Endoscopic view showing a circumferential villous adenoma carpeting almost the entire duodenal wall. Fig.2 Abdominal computed tomography (CT) scan showing an irregular polypoid tumor mass protruding into the duodenal lumen (arrows).

Duodenal mucosal risk markers in patients with familial adenomatous polyposis: effects of celecoxib/ursodeoxycholic acid co-treatment and comparison with patient controls

BackgroundFamilial adenomatous polyposis (FAP) is a disease characterized by the development of hundreds to thousands of adenomatous polyps in the colorectum early in life. Virtually all patients with FAP will develop colorectal cancer before the age of 40 to 50 years, unless prophylactic colectomy is performed, which significantly improves their prognosis. The mortality pattern has changed and duodenal cancer now is one of the main cancer-related causes of death in these patients. Practically all patients with FAP develop premalignant duodenal adenomas, which may develop to duodenal cancer in approximately 3-7% of patients. Duodenal cancer in patients with FAP has a poor prognosis. The clinical challenge is to identify patients at high-risk for duodenal carcinoma. Chemoprevention would be desirable to avoid duodenectomy. The main goal of this study is to identify risk markers in normal duodenal mucosa of patients with FAP, that could help identify patients at increased risk for malignant transformation.MethodsMessenger RNA (mRNA) levels of glutathione S-transferase A1 (GSTA1), glutathione S-transferase P1 (GSTP1), KIAA1199, E-cadherin, peroxisome proliferative activated receptor δ (PPARδ), caspase-3, cyclin D1, β-catenin, and cyclooxygenase-2 (COX-2) were measured in duodenal mucosa, using the QuantiGene 2.0 Plex assay. Levels in normal appearing mucosa of patients with FAP (n = 37) were compared with levels in non-FAP patient controls (n = 16). In addition, levels before and after treatment with either celecoxib & ursodeoxycholic acid (UDCA, n = 14) or celecoxib & placebo (n = 13) were evaluated in patients with FAP.ResultsmRNA levels of glutathione S-transferase A1 (28.16% vs. 38.24%, p = 0.008) and caspase-3 (3.30% vs. 5.31%, p = 0.001) were significantly lower in patients with FAP vs. non-FAP patient controls, respectively. COX-2 mRNA levels in normal duodenal mucosa of patients with FAP were found to be unexpectedly low. None of the potential risk markers was influenced by celecoxib or celecoxib & UDCA.ConclusionsProtection against toxins and carcinogens (GSTA1) and apoptosis (caspase-3) is low in patients with FAP, which could contribute to increased susceptibility for malignant transformation of duodenal mucosa.Trial registrationhttp://ClinicalTrials.gov number NCT00808743

Familial risk-colorectal cancer: ESMO Clinical Practice Guidelines

J. Balmana1, F. Balaguer2, A. Cervantes3 & D. Arnold4, on behalf of the ESMO Guidelines Working Group* Department of Medical Oncology, Hospital Vall d’Hebron, Vall d’Hebron Institute of Oncology (VHIO), Universitat Autonoma de Barcelona, Barcelona; Department of Gastroenterology, Hospital Clinic, CIBERehd, IDIBAPS, University of Barcelona, Barcelona; Department of Hematology and Medical Oncology, INCLIVA, University of Valencia, Valencia, Spain; Department of Medical Oncology, Tumor Biology Clinic, Albert Ludwigs University, Freiburg, Germany;

Submucosal tunnel dissection through the pyloric ring for removal of a sessile duodenal adenoma adjacent to a scar

Submucosal tunnel dissection through the pyloric ring for removal of a sessile duodenal adenoma adjacent to a scar

Hypogranular Platelets in a 78-Year-Old Man

Patient: 78-year-old white man Chief Complaint : Abdominal aortic aneurysm with thrombocytopenia History of Present Illness: The patient has had a mildly decreased platelet count since 2004, which had become progressively lower. He had started taking a new oral hypoglycemic agent, sitagliptin phosphate (Januvia; Merck and Co, Inc, Whitehouse Station, NJ), in 2006 for his type-2 diabetes; there was speculation at the time that the decrease in platelets (Table 1) was related to the addition of this new medication to his regimen. No increased mucocutaneous bleeding was noted. No serious hemostatic challenges such as major surgery were recorded. Medical History: The patient has multiple comorbidities, including hypertension, hyperlipidemia, chronic renal insufficiency, coronary artery disease, post-myocardial infarction, atrial fibrillation, diabetes mellitus, congestive heart failure, erosive gastritis, and duodenal adenomas. Medications: The patient takes multiple medications, including warfarin sodium (Coumadin; Bristol-Myers Squibb Company, New York, NY), furosemide (Lasix; Sanofi-Aventis LLC, Paris, France), simvastatin (Zocor; Merck and Co, Inc), sitagliptin phosphate (Januvia), glimepiride (Amaryl; Sanofi-Aventis LLC), pioglitazone (Actos; Takeda Pharmaceutical Co Ltd, Osaka, Japan), lisinopril, colesevelam (Welchol; Daiichi Sankyo Co Ltd, Tokyo, Japan), and cholestyramine. Family History: No family history of abnormal bleeding or clotting is noted. Physical Examination: The patient was alert and oriented to person, place, and time without acute distress. No purpura, petechiae, or ecchymoses were observed. No lymphadenopathy, hepatomegaly, or splenomegaly was present. The patient reported no fevers, night sweats, or unexplained weight loss. The review of systems revealed no other pertinent hematologic findings. Laboratory Findings: The bone marrow was slightly to moderately hypercellular, and all 3 cell lineages were present. The bone marrow contained an adequate number of megakaryocytes with normal morphology and without clusters or dysplastic features. The immunohistochemical stain for factor VIII–related antigen helped to enhance visualization of megakaryocytes, platelets, and endothelial cells. Granulopoiesis was increased …

Treatment of Nonampullary Sporadic Duodenal Adenomas with Endoscopic Mucosal Resection or Ablation

Malignant neoplasms of the small intestine are rare; US annual incidence and mortality are 8,810 and 1,170, respectively [1]. Duodenal adenocarcinoma is even rarer, accounting for \0.5 % of all gastrointestinal malignancies but up to *60 % of all small bowel cancers [2]. One proposed mechanism of duodenal carcinogenesis invokes the adenoma–carcinoma sequence, analogous to colorectal adenocarcinoma. Duodenal adenomas, regarded as potential premalignant lesions, are prevalent among patients with familial adenomatous polyposis, but sporadic adenomas among the general population are uncommon [3]. Given concern over malignant transformation, the traditional standard of care has been radical surgical excision. Nevertheless, surgery is associated with significant perioperative mortality and morbidity, lengthy hospital courses, and long-term complications, which diminish the quality and quantity of life [4]. Endoscopic intervention is a promising alternative therapeutic option. Duodenal adenomas are classified as either ampullary (adenomas of the major duodenal papilla) or non-ampullary. Successful endoscopic treatment of conventional ampullary adenomas and wide excision of laterally spreading ampullary adenomas is well-described [5]. Endoscopic management of non-ampullary adenomas has been reported, although data are sparse in comparison with those for ampullary adenomas. Notably, many duodenal adenomas can exist for years, particularly in familial polyposis patients, without malignant transformation. Recent data from Okada et al. [6] reveal that non-ampullary sporadic duodenal adenomas (NSDAs) with low-grade dysplasia progress infrequently to adenocarcinoma, although with some risk of progression to high-grade dysplasia, warranting surveillance biopsies at 6–12 months. Highgrade dysplasia lesions and large NSDAs ([2 cm) more often progress to adenocarcinoma, warranting immediate intervention. Endoscopic intervention in the duodenum is associated with a higher risk of complications than intervention elsewhere in the gastrointestinal tract. Perforation of the relatively thin duodenal wall is a particular concern. Perforations can be difficult to manage, and contribute to patient morbidity and mortality, average length of stay, and healthcare cost. Polypectomy in the duodenum also carries a higher risk of bleeding than in the colon; this is likely to be associated with the rich vascular supply of the proximal small intestine [4]. Duodenal polypectomy can also cause pancreatitis, particularly when the adenoma involves the major papilla, necessitating endoscopic ampullectomy [7]. Sepsis from endoscopic ampullectomy has also been reported [8]. The therapeutic techniques used to treat duodenal adenomas encompass several endoscopic modalities, including polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and ablation (e.g. argon plasma coagulation). ESD involves en-bloc resection with clear margins but is, unfortunately, timeconsuming, technically difficult, and associated with a high risk of perforation [9]. R. Perumpail Department of Medicine, Stanford University, Stanford, CA, USA

Leucine-rich Repeat and Immunoglobulin Domain-containing Protein-1 (Lrig1) Negative Regulatory Action toward ErbB Receptor Tyrosine Kinases Is Opposed by Leucine-rich Repeat and Immunoglobulin Domain-containing Protein 3 (Lrig3)

Lrig1 is the founding member of the Lrig family of transmembrane leucine-rich repeat proteins, which also includes Lrig2 and Lrig3. Lrig1 is a negative regulator of oncogenic receptor tyrosine kinases, including ErbB and Met receptors, and promotes receptor degradation. Lrig1 has recently emerged as both a tumor suppressor and a key regulator of epidermal and epithelial stem cell quiescence. Despite this, little is known of the mechanisms by which Lrig1 is regulated. Lrig3 was recently reported to increase ErbB receptor expression suggesting that it may function in a manner opposite to Lrig1. In this study, we explore the interaction between Lrig1 and Lrig3 and demonstrate that Lrig1 and Lrig3 functionally oppose one another. Lrig3 opposes Lrig1 negative regulatory activity and stabilizes ErbB receptors. Conversely, Lrig1 destabilizes Lrig3, limiting Lrig3's positive effects on receptors and identifying Lrig3 as a new target of Lrig1. These studies provide new insight into the regulation of Lrig1 and uncover a complex cross-talk between Lrig1 and Lrig3.

Endoscope ultrasonography with micro-probe in diagnosis duodenal lesions

Objective To evaluate the diagnosis and application values of endoscopic uhrasonography （EUS） with micro-probe in duodenal lesions. Methods Clinical data of 37 patients with duodenal lesions and underwent EUS with micro-probe were analyzed retrospectively. All lesions were treated with endoscopic mucosal resection or surgical resection to get the pathological diagnosis. The diagnostic accuracy of EUS with microprobe and endoscopic biopsy was analyzed respectively. Results The overall diagnosis accuracy of EUS with micro-probe on duodenal lesions was 78.38% （29/37）, with a higher diagnostic rate in duodenal lipoma 4/4 and duodenal adenomas 10/12 than in early duodenal cancer 2/4 or inflammatory hyperplasia 3/8. The overall diagnostic accuracy of biopsy on duodenal lesions was 40. 54% （ 15/37）, with a higher diagnosis rate on duodenal carcinoid 1/1 and adenoma 7/12 than on duodenal stromal tumor 1/10 and lipema 1/4. Conclusion Pathological evaluation of endoscopic biopsy sample is not a golden standard for the diagnosis of duodenal lesions, while EUS with micro-probe has better diagnostic and application value. Key words: Endoscopic ultrasonography; Duodenum; Micro-probe ; Diagnose accordance rate

SOX9 Is Highly Expressed in Nonampullary Duodenal Adenoma and Adenocarcinoma in Humans

Background/AimsSOX9 is a marker for stem cells in the intestine, and overexpression of SOX9 is found in gastric and colon cancer; however, the expression of SOX9 in nonampullary duodenal adenoma and adenocarcinoma has not yet been evaluated. This study aimed to investigate SOX9 expression in nonampullary duodenal adenoma and adenocarcinoma by immunohistochemistry.MethodsWe evaluated SOX9 expression in 43 clinical samples (nonampullary duodenal adenoma in 22 lesions and nonampullary duodenal adenocarcinoma in 21 lesions) resected under endoscopic mucosal resection or endoscopic submucosal dissection.ResultsSOX9 was expressed in part of the base of the normal duodenal mucosa surrounding adenomas and adenocarcinomas. In contrast, SOX9-positive cells were found in more than half of the crypts from the bottom part of the crypt in all of the 43 samples. Moreover, in 15 adenoma samples (68.2%) and 19 carcinoma samples (90.5%), SOX9 was expressed in more than three-quarters of the crypts from the bottom part of the crypt.ConclusionsSOX9 is overexpressed in nonampullary duodenal adenoma and adenocarcinoma in humans.