duodenal tumors are extremely rare , with only 0.1% prevalence according to upper gastrointestinal endoscopy screenings [ 1 , 2 ] .
duodenal tumors may be adenomas or adenocarcinomas ; however , most are adenomas in the descending portion .
patients with ampullary tumors typically present with jaundice or pancreatitis due to obstruction of the common bile duct , sometimes even in the early stages .
. they may present as an obstruction of the duodenum or bleeding at advanced stages .
it is , therefore , important to obtain biopsy specimens from portions of adenocarcinoma to ensure their accurate diagnosis .
we diagnosed a case of duodenal adenocarcinoma with a biopsy specimen obtained from a depressed lesion on the duodenal tumor .
the findings of our case suggest that depressed lesions may be suitable targets for biopsy .
an 82-year - old woman regularly visited national hospital organization shimoshizu hospital for rheumatoid arthritis .
she underwent abdominal ultrasonography screening ( ssa-700a ; toshiba medical systems , otawara , japan ) with a 3.75-mhz curved - array probe ( pvt-375bt ; toshiba medial systems ) .
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 .
a duodenoscopy ( jf-260v ; olympus , tokyo , japan ) revealed an elevated lesion around the papilla of vater ( fig .
upper gastrointestinal series showed that the lesion had an irregular surface and was located in the descending portion of the duodenum ( fig .
endoscopic ultrasonography ( gf - uct260 ; olympus ) was performed to investigate the depth of the tumor invasion of the common bile and pancreatic ducts .
a 20-mhz mini - probe ( um-3r-3 ; olympus ) was used to examine the depth of invasion of the wall of the duodenum .
the border between the mucosa and submucosa was not clear ; however , the border between the submucosa and muscularis propria was clear ( fig .
this finding suggested that the tumor was restricted to the mucosa and submucosa , and that the muscularis propria was intact .
a magnifying endoscopy was used to examine the surface of the tumor ( gif - h260z ; olympus ) .
another biopsy specimen obtained from a non - depressed portion of the elevated lesion ( fig .
no additional symptoms developed , such as jaundice , bleeding , or obstruction of the duodenum .
it is , however , difficult to target a particular portion of the adenocarcinoma with upper gastrointestinal endoscopy .
random biopsy of duodenal tumors is not practical for the efficient differentiation of adenomas and adenocarcinomas .
magnifying endoscopy narrow - band imaging has been proposed as a method to investigate duodenal tumors to diagnose adenomas or adenocarcinomas [ 12 , 13 ] .
reported that pinecone / leaf - shaped villi or irregular / non - structured duodenal tumor surfaces strongly correlate with adenomas or adenocarcinomas .
classified tumor surfaces as monotype or mixed - type on the basis of the presence of a single pattern .
however , despite these efforts , it remains difficult to differentiate adenomas from adenocarcinomas by observation with upper gastrointestinal endoscopies .
it is also difficult to target a portion of adenocarcinoma for biopsy . in our patient ,
a biopsy specimen from the depressed lesion on the tumor surface was diagnosed as an adenocarcinoma . however , a biopsy specimen from a non - depressed lesion was diagnosed as an adenoma .
however , they did not analyze the diagnoses of biopsy specimens obtained from depressed lesions of duodenal tumors .
to our knowledge , no reports have compared the diagnoses of biopsy specimens from depressed and non - depressed lesions . in our case , the depressed lesion was very clearly an adenocarcinoma .
our case also suggests that depressed lesions should be targeted for a biopsy for the diagnosis of adenocarcinomas .
based on the findings of this report , biopsy specimens should be obtained from depressed lesions on elevated lesions in the duodenum .
this report was approved by the ethics committee of the national hospital organization shimoshizu hospital .
the patient 's records were anonymously and retrospectively analyzed . written informed consent was obtained for magnetic resonance cholangiopancreatography , upper gastrointestinal endoscopy with duodenoscopy and magnifying endoscopy , endoscopic ultrasonography , and mini - probe .
 biopsies are necessary for the management of duodenal tumors . 
 however , the most suitable targets for biopsy are not known . an 82-year - old woman who regularly visited our hospital for rheumatoid arthritis underwent abdominal ultrasonography . 
 this screening revealed a dilated pancreatic duct . 
 magnetic resonance cholangiopancreatography was performed , and dilatation of the pancreatic duct was confirmed . 
 the patient underwent duodenoscopy to investigate the possibility of obstruction of the papilla of vater . 
 the examination revealed an elevated lesion around the papilla of vater . 
 endoscopic ultrasonography and a 20-mhz mini - probe were used to investigate the depth of the invasion . 
 the common bile and pancreatic ducts were intact . 
 the mucosal and submucosal borders were indistinct ; however , the border between the submucosa and muscularis propria was clear , suggesting that the muscularis propria was intact . 
 magnifying endoscopy was used to examine the surface of the elevated lesion , which revealed a depressed lesion . 
 a biopsy specimen of the depressed lesion was taken , and the tumor was diagnosed as an adenocarcinoma . another biopsy specimen from a non - depressed lesion was diagnosed as an adenoma . 
 the patient was diagnosed with duodenal adenocarcinoma , and was recommended surgery . 
 she declined surgery and was followed up for 34 months . because it is possible for depressed lesions of duodenal tumors to be adenocarcinomas , biopsy specimens should be obtained from depressed lesions of duodenal tumors . 
Introduction
Case Presentation
Discussion
Statement of Ethics
Disclosure Statement