Coexistent Ampullary Squamous Cell Carcinoma with Adenocarcinoma of the Pancreatic Duct

Primary squamous cell carcinoma (SCC) of ampulla has seldom been reported. However, metastatic SCC to ampulla of Vater is well known. We report a case of primary SCC of ampulla of Vater coexistent with well-differentiated adenocarcinoma of the distal pancreatic duct. A 50-year-old female presented with evidence of obstructive jaundice. Endoscopic retrograde cholangio-pancreatography revealed bulging papilla with ulcero-infiltrative growth at the ampulla of Vater. An initial endoscopic biopsy of the ampullary mass showed a well-differentiated SCC. The patient underwent Whipple''s operation. Thorough sampling of the dilated portion of the pancreatic duct showed presence of well-differentiated adenocarcinoma of the distal pancreatic duct. Immunohistochemical study with synaptophysin and chromogranin was done with negative result, ruling out neuroendocrine differentiation. Also, a detailed clinical, endoscopic and radiological examination was carried out, that excluded the presence of primary SCC elsewhere.     

Non-pancreatic periampullary adenocarcinomas: an explanation for favorable prognosis

BACKGROUND/AIMS: Our previous studies demonstrate that patients with non-pancreatic periampullary adenocarcinomas have a favorable prognosis relative to those with pancreatic adenocarcinoma. This study investigates histopathologic factors that contribute to the superior outcome of these patients. METHODOLOGY: A retrospective review of all patients explored for periampullary neoplasms at a single institution over a 20-year period. RESULTS: 291 patients with periampullary neoplasms underwent exploratory laparotomy, of which 185 had resectable tumors. Periampullary adenocarcinomas were resected in 120: pancreatic head (n=74), distal common bile duct (n=10), duodenum (n=5), and ampulla of Vater (n=31). The resection rate for non-pancreatic adenocarcinomas was 90%, while that of pancreatic cancers was 44% (p<0.01). Median survival for resected non-pancreatic adenocarcinomas was 38.8 months; that of pancreatic tumors was 15.3 months (p<0.01). Non-pancreatic adenocarcinomas were significantly smaller (p<0.001), better differentiated (p<0.001), and less likely to have involved nodes (p<0.001), margins (p<0.001), perineural invasion (p<0.001), or vascular invasion (p<0.2) than pancreatic adenocarcinomas. CONCLUSIONS: Histopathologic features of non-pancreatic periampullary adenocarcinomas significantly differentiate them from pancreatic adenocarcinoma and contribute to their relatively favorable long-term outcome following resection.     

Surgical technique for complete resection of the extrahepatic portion of the common bile duct and the ampulla of Vater for tumors of the ampulla of Vater

Background

Ampullary tumors have to be completely resected, but substantial morbidity and mortality rates are associated with pancreaticoduodenectomy (PD). Local resection can be the procedure of choice in selected ampullary lesions for high-risk patients.

Methods

Preoperative examination indicated that the ampullary tumor extended into the common bile duct without evidence of pancreatic duct involvement and no definite invasion into either the duodenum or the pancreas. We performed a complete resection of the extrahepatic bile duct and the ampulla of Vater, including the tumor, without performing PD by dissecting the intrapancreatic bile duct from the pancreas both downward towards the ampulla of Vater and upward using a transduodenal approach.

Results

The operation was successfully completed, and the postoperative course was uneventful, with the exception of a minor pancreatic fistula from retropancreatic dissection. The final pathological examination demonstrated well-differentiated tubular adenocarcinoma limited to the mucosa with negative surgical margins.

Conclusion

Complete resection of the extrahepatic bile duct and the ampulla of Vater through a transduodenal approach can be a feasible and safe surgical procedure for selected ampullary tumors in high-risk patients.     

A case of ampullary cancer with pancreas divisum treated by endoscopic papillectomy

A 60's man underwent a medical check-up and esophagogastroduodenoscopy revealed an exposed-type tumor at the ampulla of Vater. Endoscopic ultrasonography and intraductal ultrasonography showed a hypoechoic mass limited to the ampulla of Vater. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a slightly dilated ventral pancreatic duct not connected to the dorsal duct. Endoscopic papillectomy was performed without pancreatic stent placement and his postprocedural course was uneventful. The specimen was histologically diagnosed as well-differentiated adenocarcinoma limited to the mucosa of the ampulla of Vater. Endoscopic papillectomy without pancreatic stent placement can be performed without a risk of post-ERCP pancreatitis for ampullary tumor limited to the mucosa of the ampulla of Vater associated with pancreas divisum.     

Effect of cholecystectomy for gallstones on the surface of the papilla of Vater and the diameter of the common bile duct

BACKGROUND AND STUDY AIMS: To date, little is known about changes in the size of the papilla of Vater in patients with gallstones. Most of the research concerning these patients has investigated changes in the diameter of the common bile duct and pressure in the sphincter of Oddi region. The latest research has not confirmed the prevalent opinion that the common bile duct dilates after cholecystectomy; moreover, knowledge about changes in the form and size of the papilla of Vater remains poor. The aim of our research was to measure the surface of the papilla of Vater and the diameter of the periampullary pancreatic part of the common bile duct before surgery, then 3 months and 6 months after surgery, using endoscopic ultrasound. PATIENTS AND METHODS: In patients with symptomatic gallstones but with no evidence of cholestasis or stones in the common bile duct, the surface of the papilla of Vater and the diameter of the periampullary pancreatic part of the common bile duct were measured before surgery by endoscopic ultrasound. In the postoperative period, measurements were repeated in patients with an early occurrence of nausea, distension, bloating and pain in the upper abdomen and in patients without any symptoms in the same time period. The surface of the normal papilla of Vater and the diameter of the periampullary pancreatic part of the common bile duct were determined in healthy subjects. RESULTS: In all the patients included in our study, the surface of the papilla of Vater was enlarged before surgery and, after 3 months, was even larger. However, after 6 months, it was practically the same as before surgery. The diameter of the periampullary pancreatic part of the common bile duct before surgery and 6 months after surgery was within normal limits. However, a statistically significant and transient increase in the diameter was noticed in the third month after cholecystectomy. The results were almost the same for symptomatic and asymptomatic patients. CONCLUSION: In patients with symptomatic gallstones, the surface of the papilla of Vater is increased while the diameter of the periampullary pancreatic part of the common bile duct is normal. Cholecystectomy is an intervention that causes an additional transient increase in the surface of the papilla of Vater and a transient increase in the diameter of the periampullary pancreatic part of the common bile duct. The surface of the papilla of Vater does not reach normal values but the diameter of the periampullary pancreatic part of the common bile duct is normalized 6 months after surgery. There is no relation between clinical disorders and changes in the morphology of the papilla of Vater and the periampullary pancreatic part of the common bile duct after cholecystectomy.     

内镜下十二指肠乳头切除术在乳头部肿瘤诊断中的价值

目的:评价内镜下十二指肠乳头切除术(endos-copic papillectomy,EP)在乳头部肿瘤诊断中的临床价值.方法:分析2008-01/2012-03来我院的16例经病理检查确诊的十二指肠乳头部肿瘤患者的相关资料,评价EP在十二指肠乳头部肿瘤诊断中的临床价值.结果:16例患者中,内镜活检诊断为腺瘤者12例,慢性炎症改变者4例.EP将乳头部肿瘤组织切除后整体送检行病理学检查确诊为低分化腺癌者2例,高分化腺癌1例,腺瘤13例(其中1例腺瘤恶变,4例常规内镜活检诊断为慢性炎症改变者术后均确诊为腺瘤),EP术后准确率明显高于内镜活检法(P<0.05).超声内镜(endoscopic ultrasonography,EUS)检查提示病变均起源于黏膜层,胰胆管扩张者9例,未见黏膜下层连续性中断及胰胆管受累者,无腹膜后淋巴结肿大者;12例高回声病变者术后病理检查结果均为腺瘤,1例高回声病变局部见低回声区者术后病理检查结果为腺瘤恶变,3例低回声病变者术后病理检查结果均为腺癌.EP术后2例低分化腺癌者、1例腺瘤恶变者及1例腺瘤者胆管开口处见病变残留,提示胆管受累,但术前EUS检查均未提示胆管受累;1例高分化腺癌及11例腺瘤者病灶均完整切除,术后切缘阴性.EP术后除2例出现黑便外,无急性胰腺炎、穿孔及其他并发症发生,无患者死亡.结论:EP术将乳头部肿瘤组织切除后整体送检行病理学检查可提高诊断准确率,为治疗方法的抉择提供科学依据.     

Combination therapy of resection and intraoperative radiation for patients with carcinomas of extrahepatic bile duct and ampulla of Vater: prognostic advantage over resection alone?

BACKGROUND/AIMS: To investigate the therapeutic efficacy of intraoperative radiation for carcinomas of the bile duct and ampulla of Vater. METHODOLOGY: Postoperative morbidity, mortality and survival of patients undergoing surgical resection of ampullary cancer (n = 19) and bile duct cancer (n = 28) were retrospectively compared between two groups with and without intraoperative radiation. RESULTS: Background items (age, gender, preoperative laboratory data, operative time and bleeding volume, tumor stage) did not differ significantly between the two groups. The predominant postoperative complication was leakage of pancreatic juice, which occurred in similar rates in both groups. No significant differences were noted in the 3-year survival rates between the resection plus intraoperative radiation group and resection alone group (60.0% (n = 5) vs. 50.1% (n = 13) for ampullary cancer; 0% (n = 4) vs. 27.1% (n = 24) for bile duct cancer, respectively). The main causes of recurrence were distant metastasis for ampullary cancer and microscopic residue of carcinoma for bile duct cancer. CONCLUSIONS: The combination of intraoperative radiation and resection may add no significant benefit to patients with ampullary and bile duct cancer when compared with resection alone.     

Intraoperative fiberoptic choledochoscopy for malignant biliary tract obstruction

A prospective study to determine the safety and effectiveness of intraoperative fiberoptic choledochoscopy in the management of malignant obstruction of the biliary tree was conducted in 44 patients. There were 12 patients with cancer of the pancreatic head, 9 with adenocarcinoma of the distal common bile duct, 4 with adenocarcinoma of the ampulla of Vater, 8 with cholangiocarcinoma of the common hepatic duct, 9 with intrahepatic bile duct carcinoma, and 2 with hepatocellular carcinoma. Five patients with intrahepatic bile duct carcinoma and two with hepatocellular carcinoma were found during a search for intrahepatic duct stones in patients with recurrent cholangitis. In nine patients with bile duct carcinoma (seven extrahepatic and two intrahepatic), histopathological diagnosis was made at operative endoscopy. Treatment strategy was altered in seven patients based on findings at operative choledochoscopy. Complications were few with no mortality. Intraoperative fiberoptic choledochoscopy was safe and useful in the management of malignant obstruction of the biliary tree.     

Proposed indications for limited resection of early ampulla of Vater carcinoma: clinico-histopathological criteria to confirm cure

Background

Limited resection is reserved for patients with high operative risk or benign adenomas. We aimed to define indications for limited resection of early ampulla of Vater carcinoma with curative intent through detailed preoperative examinations and histopathological evaluations.

Methods

We performed a retrospective cohort study of all consecutive Japanese patients who underwent resection for ampulla of Vater neoplasms at our hospital from 1986 to 2010.

Results

A total of 75 patients were identified. Moderately/poorly differentiated histology, lympho-vascular/perineural invasion, and duodenal/pancreatic invasion were significant risk factors for lymph node metastases. Macroscopically, non-exposed protruded- or ulcerative-type disease did not correlate directly with lymph node metastases; however, these tumor types were associated with other invasive features. In a subset of early carcinomas fulfilling the conditions of exposed protruded adenoma or papillary/well-differentiated adenocarcinoma determined by endoscopic biopsy, negative duodenal invasion determined by endoscopic ultrasonography, no tumor infiltration into the pancreatic duct determined by intraductal ultrasound, and diameter of the pancreatic duct ≤3?mm determined by endoscopic retrograde cholangiopancreatography (N?=?11), the incidence of lymph node metastasis and tumor infiltration into the pancreatic duct was 0%.

Conclusion

Strictly selected patients with early ampulla of Vater carcinomas may benefit from limited resection if the resected specimen is evaluated to confirm all histopathological criteria.     

Can endoscopic resection be applied for early stage ampulla of Vater cancer?

BACKGROUND: Although endoscopic resection can provide a wide tumor resection with a negative resection margin, it is not yet recommended as a curative therapy for ampulla of Vater cancer. METHODS: To investigate the microinvasion rate and the diagnostic accuracy of endoscopic biopsy to properly judge the safety of endoscopic resection for ampulla of Vater cancer. DESIGN: Single-center, retrospective study. SETTING: Academic medical center. PATIENTS: One hundred fifty-nine patients who were finally diagnosed with ampulla of Vater cancer after curative surgical resection. INTERVENTIONS: We surveyed the pathologic concordance rate of endoscopic biopsy and the surgical pathology. For the 36 early stage (Tis or T1) cancers, we surveyed the presence of microlymphovascular invasion, gross appearance (intra-ampullary type, periampullary type, or mixed type), and pathologic subtype (intestinal type or pancreaticobiliary type). MAIN OUTCOME MEASUREMENTS: Presence of microinvasion in early staged ampulla of Vater cancer. RESULTS: Endoscopic biopsy failed to reveal malignancy in 15.9% of the 126 cases. Microlymphovascular invasion was present in 17 cases (56.7%) of the 30 T1 cancers but was absent in all cases of the 6 Tis cancers (P = .02). Neither the gross appearance (P = .51) nor the pathologic subtype (P = .28) could predict the microinvasion rate. LIMITATIONS: Single-center, retrospective study with small number of patients. CONCLUSIONS: Although endoscopic resection improves the low predictability of endoscopic biopsy, surgical resection should be performed for the T1 stage ampulla of Vater cancer because of the high lymphovascular invasion rate. On the other hand, the safety of endoscopic resection should be evaluated by a large-scale study on Tis cancers to consider the absence of microinvasion.     

Ampullary somatostatinoma in a patient with von Recklinghausen's disease

We report a case of somatostatinoma of the ampulla of Vater associated with von Recklinghausen's disease in a 44-year-old woman. On admission the patient was jaundiced, and percutaneous Cholangiodrainage was performed. Cholangiography revealed stenosis of the common bile duct at the lower end Duodenoscopy showed a yellowish tumor of the ampulla of Vater, and the biopsy specimens showed no malignant cells. Pylorus-preserving pancreaticoduodenectomy was performed. Histologically, the tumor was composed of small round cells with a solid or trabecular pattern and with multiple psammoma bodies. Immunohistochemical examination showed that the tumor cells stained for somatostatin. Genomic examination showed neither K-ras nor p53 gene mutations of the resected specimen.     

Autofluorescence endoscopy images of pancreas cancer: report of a case

This is the first report of the observation of pancreas cancer with an autofluorescence endoscopic imaging system (excitation: 437 nm). A case of intraductal papillary adenocarcinoma of pancreas was presented. After pancreatectomy, the resected pancreas was used to test the endoscope (16Fr) in the pancreatic duct. The normal pancreatic duct was seen as light blue and the protruding cancerous lesion was observed as a dark red image. In previous studies, cancerous lesions of the gastrointestinal tract, bronchial tree and bile duct also appeared dark red when examined by autofluorescence endoscopy. In the pancreatic duct, the cancer lesion was also detected as dark red color.     

Gallstones in the pancreatic duct: endoscopic retrograde pancreatographic demonstration

A gallstone blocking the ampulla of Vater or the common bile duct is the usual cause of gallstone pancreatitis. A gallstone in the pancreatic duct itself, leading to pancreatitis, has rarely been documented. We describe such a case and show what seems to have been the obstructing stone by endoscopic retrograde cholangiopancreatography (ERCP).     

Pancreaticobiliary involvement in familial polyposis coli/Gardner's syndrome

Adenomatous lesions and carcinoma of the upper gastrointestinal tract, biliary tree, and gallbladder are being reported with increasing frequency in patients with familial polyposis coli or Gardner's syndrome (FPC/GS). A patient with FPC/GS who developed polyps with carcinoma in situ of the common bile duct and ampulla of Vater, along with extensive adenomatous changes in the duodenum, gallbladder, extrahepatic bile ducts, and main pancreatic duct is presented. Proliferative lesions, adenomas, and carcinomas should always be considered in the differential in patients with FPC/GS who have symptoms of upper gastrointestinal, biliary or pancreatic disease.     

Pancreatic calculus impacted at Ampulla of Vater causing severe cholangitis and septic shock.

Patients with chronic pancreatitis may have varied complications including common bile duct stenosis, cholangitis, pseudocyst or fistula formation and secondary biliary cirrhosis. Common bile duct obstruction due to disimpaction of a pancreatic calculus into the ampulla of Vater leading to severe cholangitis and septic shock is a rare phenomenon. We are reporting such a case here.     

A case of triple synchronous cancers occurring in the gallbladder,common bile duct,and pancreas

We report a 74-year-old man with triple synchronous cancers occurring in the gallbladder, common bile duct, and pancreas. The patient had consulted a nearby physician because of epigastralgia and icterus. On September 30, 1997, the patient was admitted to our department for further evaluation and treatment. Abdominal computed tomography (CT) showed dilatation of the common bile duct, cystic duct, and intrahepatic bile duct, and swelling of the gallbladder. On CT, the wall of the distal common bile duct was thick and a low-density mass was detected on the left side. Cholangiography, performed via percutaneous transhepatic cholangiodrainage (PTCD), revealed stenosis of the distal common bile duct. Endoscopic retrograde pancreatography (ERP) showed marked dilatation of the main pancreatic duct. On October 17, 1997, pancreatoduodenectomy was performed under the diagnosis of carcinoma of common bile duct and pancreas. Histopathological examination revealed poorly differentiated tubular adenocarcinoma of the common bile duct, well-differentiated tubular adenocarcinoma of the gallbladder, and mucinous cystadenocarcinoma of the pancreas. These three tumors were histopathologically different. Moreover, p53-positive nuclei were recognized only in the pancreas tumor. These findings suggested that the oncogenic mechanisms of multiple synchronous cancers were not the result of only abnormal DNA reparative mechanisms. Received: March 15, 2001 / Accepted: December 14, 2001 Reprint requests to: K. Sato     

Periampullary choledochoduodenal fistula in ampullary carcinoma

Most patients with ampullary carcinoma have obstructive jaundice without cholangitis. We experienced a patient with ampullary carcinoma who presented with obstructive jaundice and cholangitis, probably because of an accompanying periampullary choledochoduodenal fistula. A 77-year-old Japanese man had jaundice, high fever, and upper abdominal pain and was diagnosed, at another hospital, with obstructive cholangitis. On admission to our hospital, his symptoms and signs had subsided spontaneously. Abdominal ultrasonography showed cholecystolithiasis and dilatation of the common bile duct. Duodenoscopy showed an ulcerating tumor at the oral prominence of the ampulla of Vater and a periampullary choledochoduodenal fistula at the bottom of the ulcer. Biopsy from the fistula showed well differentiated adenocarcinoma. With a diagnosis of ampullary carcinoma with fistula formation, the patient underwent pylorus-preserving pancreatoduodenectomy. The diagnosis was confirmed by histology. This communication presents a unique case of ampullary carcinoma that caused obstructive jaundice, which subsided spontaneously but was associated with cholangitis caused by the divergent effects of the periampullary choledochoduodenal fistula formed by the carcinoma.     

Long-term survival with carcinoma arising from a congenital choledochal cyst

We report a case of 11-year survival with carcinoma arising from a congenital choledochal cyst. A 34-year-old Japanese woman was admitted due to epigastric discomfort. Ultrasonography revealed a choledochal cyst involving a polypoid tumor. Endoscopic retrograde cholangiopancreatography revealed pancreaticobiliary maljunction in which the main pancreatic duct joined the dilated common bile duct 2 cm above the papilla of Vater. A choledochal cyst containing a polypoid tumor was resected with the regional lymph nodes. Grossly, a 2×2-cm papillary tumor was noted in the posterior wall of the choledochal cyst. Microscopically, the tumor was well-differentiated tubular adenocarcinoma invading the mucosa and fibromuscular layer. Neither anticancer chemotherapy nor radiotherapy was performed. The patient recovered uneventfully after the operation and has been well for 11 years without evidence of recurrent cancer. The good results in this patient may have been due to the early stage of the cancer.     

胰腺癌的不典型64排螺旋CT影像表现

目的 分析胰腺癌的64排螺旋CT的不典型表现,以提高对该肿瘤的CT征象的认识水平.方法 回顾性分析经手术病理证实的缺乏典型CT征象的12例胰腺导管腺癌的64排螺旋CT资料.结果 12例均为胰腺导管腺癌.其中,中分化导管腺癌7例,中高分化导管腺癌1例;黏液腺癌1例;腺鳞癌3例.8例导管腺癌病灶中位于胰头及(或)钩突部7例,胰颈部1例,表现为等、低密度或囊实性肿块,增强后无明显强化;5例肿瘤呈明显外生性或有外生倾向;5例肿瘤远端胰管无扩张,2例出现胆总管和肝内胆管扩张,仅1例出现肿瘤远端胰腺萎缩.1例黏液腺癌CT平扫示胰头部5 cm囊性病灶,增强后仅囊性病灶下方少许实性部分轻度强化,体尾部胰管中度扩张(7 mmn),胆总管及邻近血管未受侵犯.3例腺鳞癌病灶中位于胰头2例,胰体部1例,肿块最大径3.0～4.5 cm,CT增强扫描胰腺实质期示3例病灶内均见液化坏死区,病灶远端胰管均轻度扩张(4～5 mm),胆总管和肝内胆管均未见扩张.结论 胰腺癌可出现不典型的CT影像表现,要注意与易混淆疾病进行鉴别诊断.     

Suspected malignant cancer of the pancreas associated with pseudo-invasive duodenal hamartomas in a patient with Peutz-Jeghers syndrome

A 29-year-old man with a previously known Peutz-Jeghers syndrome (PJS) was admitted for epigastric pain, emesis and weight loss due to both intestinal intussusception causing bowel obstruction and obstructive pancreatitis. The patient had cholestasis with an enlarged common bile duct on imaging. Because duodenal and/or pancreatic cancer was suspected due to weight loss, the pancreatic and bile duct obstruction, and the increased risk of small intestine and pancreatic adenocarcinoma in patients with PSJ, a pancreatoduodenectomy was performed. Pathological examination revealed a duodenal polyp with epithelial misplacement invading the ampulla and compressing the main bile duct. Twenty months after surgery, there was no relapse of symptoms or cholestasis. This is the first case showing a direct role of pseudo-invasive duodenal harmatomas in the development of biliary obstruction and chronic obstructive pancreatitis.