Ampullary adenocarcinoma

Case contributed by Dr Jan Frank Gerstenmaier

Presentation

Intermittent colicky RUQ pain. Suspected gallstones

Patient Data

Age: 78
Gender: Female

CT IVC

Modality: CT

CTIVC demonstrates a soft tissue density at the ampullary region extending into the distal CBD over a short distance, causing biliary obstruction. No stone disease.

Modality: CT

 

An ill-defined ampullary mass is seen, measuring 1.6 x 1.6 x 2.2 cm. This is associated with increased distension of the intra and extra hepatic bile ducts, with the common bile duct measuring up to 17 mm in diameter. This has reduced from the pre-ERCP imaging, where the common bile duct measured at 22 mm in diameter. Intrahepatic pneumobilia is now present. There is pancreatic duct dilation, which measures up to 5 mm.

The lesion is well clear of the superior mesenteric vessels and portal vein. No further pancreatic lesions are identified.

An enlarged lymph node is seen in the porta hepatis, inferior to the neck of gallbladder, measuring 11 x 16 mm. No further abdominal or pelvic lymphadenopathy is demonstrated.

No focal liver lesions. 9 mm left renal cyst, otherwise the kidneys are unremarkable. No abnormality of the spleen, adrenals, bladder or bowel. The lung bases show minor atelectasis and incidental cysts. No airspace consolidation or lesions. No suspicious osseous lesions.

Conclusion:

Ampullary lesion, with biliary obstruction. The appearance is consistent with a pancreatic or ampullary carcinoma. Solitary borderline enlarged porta hepatis lymph node. No other evidence of regional or distant spread.

Modality: Fluoroscopy

ERCP AND BIOPSY

Modality: Pathology

CLINICAL NOTES:
Ampullary mass.

MACROSCOPIC DESCRIPTION:
"Ampullar mass Bx": Multiple pieces of tan tissue 5mm in aggregate.
A1. (TWR)

MICROSCOPIC DESCRIPTION:
Sections show fragments of small bowel mucosa, some including
muscularis mucosae. Several fragments include infiltrating cords of
cells and small nests within fibromuscular stroma. Tumour cells show
large hyperchromatic pleomorphic nuclei and mitotic figures are
present. There is some luminal necrosis. In a few fragments the
surface epithelium shows features of low and high grade intestinal
dysplasia.

DIAGNOSIS:
Ampullary mass, biopsies: Adenocarcinoma arising from a duodenal
tubulovillous adenoma.
 

Case Discussion

There are no features on imaging to indicate that this is a malignant lesion. Differential diagnosis would be between an adenoma and adenocarcinoma primarily.

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Case Information

rID: 34013
Case created: 2nd Feb 2015
Last edited: 7th Sep 2016
Inclusion in quiz mode: Included

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