Evaluation and management of periampullary tumors

Bile duct metastasis of duodenal bulb carcinoma misdiagnosed as postoperative cholangitis: A case report

Duodenal bulb carcinoma is very rare, and its metastasis to the bile duct is even extremely rare. As a result, both tend to be misdiagnosed or have a missed diagnosis. Here we report a case of bile duct metastasis of duodenal bulb carcinoma after surgery, which was initially misdiagnosed as cholangitis. A definite diagnosis was made by postoperative pathology after biliary intestinal anastomosis. Our case suggests that clinicians should enhance their awareness of duodenal adenocarcinoma and its metastasis to the bile duct to reduce or avoid missed diagnosis and misdiagnosis and improve patients' survival rate.

15-year experience with surgical treatment of duodenal carcinoma: a comparison of periampullary and extra-ampullary duodenal carcinomas

BACKGROUND

The aim of our study was to compare the outcomes of periampullary and extra-ampullary duodenal adenocarcinomas and segmental duodenal resection versus pancreatoduodenectomy and to evaluate prognostic factors.

METHODS

We performed a retrospective review of all adults treated for duodenal adenocarcinoma by operative resection at a large tertiary referral center from 1994 to 2009.

RESULTS

One hundred twenty-four patients had an operation for duodenal adenocarcinoma over a 15-year period (periampullary, n = 25, and extra-ampullary, n = 99). Ninety-nine patients (80%) underwent curative resection, including 24 (96%) with periampullary and 75 (76%) with extra-ampullary carcinomas. The average number of lymph nodes sampled was eight with segmental resection and 12 with pancreatoduodenectomy (p < 0.001). Five-year overall survivals were 37% for the entire cohort (n = 124), 37% in the extra-ampullary group, and 38% in the periampullary group. Tumor size (p = 0.20), positive nodes (p = 0.60), segmental resection versus pancreatoduodenectomy (p = 0.55), adjuvant therapy (p = 0.23), and R(1) versus R(0) resection (p = 0.21) were not associated with survival. In contrast, advanced T stage and pathologic grade were associated with poor survival.

CONCLUSION

Extra-ampullary and periampullary duodenal adenocarcinomas have similar survival after resection. For distal duodenal tumors, survival is improved by curative resection without being compromised by limited resection. The number of lymph nodes sampled was significantly less with segmental resection than pancreatoduodenectomy.

Linear endoscopic ultrasonography vs magnetic resonance imaging in ampullary tumors

AIM: To assess linear endoscopic ultrasound (L-EUS) and magnetic resonance imaging (MRI) in biliary tract dilation and suspect small ampullary tumor.

METHODS: L-EUS and MRI data were compared in 24 patients with small ampullary tumors; all with subsequent histological confirmation. Data were collected prospectively and the accuracy of detection, histological characterization and N staging were assessed retrospectively using the results of surgical or endoscopic treatment as a benchmark.

RESULTS: A suspicion of ampullary tumor was present in 75% of MRI and all L-EUS examinations, with 80% agreement between EUS and histological findings at endoscopy. However, L-EUS and histological TN staging at surgery showed moderate agreement (κ = 0.54).

CONCLUSION: L-EUS could be a useful adjunct as a diagnostic tool in the evaluation of patients with suspected ampullary tumors.

Immunocytochemical assessment of p53 protein to detect malignancy in increased cell-yield brush cytology from the biliopancreatic tree

BACKGROUND

Malignancies arising from the biliopancreatic tree are often diagnostic challenges for the gastroenterologist and the pathologist, especially when strictures without masses are present.

AIM

To evaluate the diagnostic yield of p53 immunocytology for the detection of malignancies in material obtained by biliopancreatic tree brushing by means of an increased cell-yield procedure.

PATIENTS AND METHODS

Cytologic specimens obtained from biliary and pancreatic tree brushing in 24 patients with biliary strictures suspected for malignancy were assessed by conventional Papanicolau staining and p53 immunocytochemistry.

RESULTS

Papanicolau staining detected 67% and p53 87% of the malignancies in the study group. p53 immunocytology displayed excellent sensitivity, specificity, and diagnostic accuracy.

CONCLUSIONS

p53 immunocytology may represent a useful diagnostic tool in the detection of malignancies from biliary and pancreatic tree brushing, especially when using an increasing cell-yield procedure.