Presentation
Incidental finding in oncological follow up in woman with a history of breast cancer.
Patient Data
Enhancement of the distal common bile duct and of ampulla of Vater both with thickened walls. The bile ducts are not dilated. No liver metastasis. There are some calculi in both kidneys. Evaluation with magnetic resonance cholangiopancreatography (MRCP) is suggested.
Dilatation of the intrahepatic bile ducts and common bile duct with stenosis of its distal portion. There are no obstructing calculations.
Duodenoscopy with endoscopic retrograde cholangiopancreatography (ERCP) and forceps biopsies, and positioning biliary drainage with the distal stent across the ampulla into the duodenum. The gallbladder and the intra- and extra-hepatic biliary tracts are still moderately dilated.
Histological report
Carcinoma, with infiltration of the duodenal mucosa. Immunohistochemical study of tissue biopsy revealed strong estrogen receptor and progesterone receptor positivity, compatible with lobular breast carcinoma metastasis to ampulla of Vater.
Case Discussion
Ampulla of Vater metastatic lesion from breast cancer treated with a biliary stent. Biliary drainage is considered an effective method for diminution of obstructive jaundice by discharging bile from the intrahepatic or extrahepatic duct. Drainage tube usually is implanted via the nose, esophagus, stomach, and major duodenal papilla under endoscopy, or via a percutaneous transhepatic biliary approach. Secondary tumors of the ampulla of Vater are uncommon and malignant melanoma, renal and breast cancer are the most frequent primitive lesions. Patients may present jaundice or upper gastrointestinal bleeding. For lesions less than 10 mm, without endoscopic appearance of malignancy, endoscopic resection of the tumor is recommended.