Diagnosis of duodenal and ampullary epithelial neoplasms by endoscopic biopsy: a clinicopathologic and immunohistochemical study

Early Cancerous Lesions of the Pancreas and Ampulla: Current Concepts and Challenges

Owing to the increased use of advanced imaging techniques, mass-forming (cystic/intraductal) preinvasive neoplasms are being detected much more frequently and they have rapidly become one of the main focuses of interests in medical field. These neoplasms have very distinctive clinical and radiographic findings, exhibit a spectrum of dysplastic transformation, from low-grade dysplasia to high-grade dysplasia, and may be associated with an invasive carcinoma. Accounting for about 5% to 10% of pancreatic ductal adenocarcinomas, they provide a curable target subset in an otherwise biologically dismal pancreas cancer category.

Ampulla of Vater biopsies: A retrospective 10-year, single-institution study

Endoscopic biopsies from the ampulla of Vater are challenging due to specimen sampling limitation, small size, interventional artifacts, and the nature of local complex anatomy. We retrospectively reviewed 318 in-house ampulla of Vater biopsy specimens from 252 patients over a 10-year period. The biopsy findings were compared to those in subsequent biopsy and/or resection specimens. Of the 318 biopsy cases, 104 (32.7 %) cases were diagnosed as adenoma (96 with low-grade dysplasia; 8 with high-grade dysplasia), 19 (6.0 %) adenocarcinomas (ampullary-12, distal bile duct-6, pancreatic-1), 5 (1.6 %) other carcinomas/tumors, and the rest were benign findings (unremarkable, ulcer and acute inflammation, reactive changes, and rare atypical cells/gland). Of the 90 cases with follow-up specimens, 55 cases (61.1 %) had concordant results and 35 (38.9 %) were discordant. Eight (22.9 %) of the 35 discordant cases had major discrepancies (benign biopsy diagnosis with malignant resection diagnosis); 27 (77.1 %) cases had minor discrepancies (normal, reactive, atypical, and dysplastic). We found that vast majority of the false negative biopsy results were due to sampling limitations. Combined biopsy and cytology specimens may help decrease the false negative rate. Careful correlation with endoscopic/cytology/clinical findings and acknowledging the limitation of the biopsy material in the pathology report are important, when malignancy is suspected but cannot be established in a small ampullary biopsy.

Endoscopic management of non-ampullary duodenal adenomas

Duodenal polyps are found in 0.1 % to 0.8 % of all upper endoscopies. Duodenal adenomas account for 10 % to 20 % of these lesions. They can be sporadic or occur in the setting of a hereditary predisposition syndrome, mainly familial adenomatous polyposis. Endoscopy is the cornerstone of management of duodenal adenomas, allowing for diagnosis and treatment, primarily by endoscopic mucosal resection. The endoscopic treatment of duodenal adenomas has a high morbidity, reaching 15 % in a prospective study, consisting of bleeding and perforations, and should therefore be performed in expert centers. The local recurrence rate ranges from 9 % to 37 %, and is maximal for piecemeal resections of lesions > 20 mm. Surgical resection of the duodenum is flawed with major morbidity and considered a rescue procedure in cases of endoscopic treatment failures or severe endoscopic complications such as duodenal perforations. In this paper, we review the existing evidence on endoscopic diagnosis and treatment of non-ampullary duodenal adenomas.

MiR-186-5p Dysregulation Leads to Depression-like Behavior by De-repressing SERPINF1 in Hippocampus

Diagnosis of major depressive disorder (MDD) is perplexing due to its multifactorial etiologies. Here, we isolated exosomes from the peripheral blood of MDD patients and healthy control subjects for mass spectrometry-based label-free quantitative proteomics. We identified that SERPINF1 is significantly diminished in the peripheral blood-derived exosomes of MDD patients compared to the healthy control subjects. Through RNA immunoprecipitation and luciferase reporter assays, we validated that SERPINF1 is a target of miR-186-5p that is upregulated in MDD patients' blood. In vivo studies in the chronic unpredictable mild stress (CUMS) mice further demonstrated that SERPINF1 in hippocampus is suppressed by miR-186-5p. Inhibiting the microRNA significantly restores the hippocampal SERPINF1 mRNA and protein expression, and ameliorates the depressive-like behaviors including sucrose preference and extended immobility time in the forced swim test. Instead, overexpressing miR-186-5p through tail intravenous injection of the mimics molecularly and behaviorally phenocopies the CUMS mice in wild-type mice. Our results indicate that the exosomal SERPINF1 in peripheral blood could serve as a reliable biomarker indicating MDD development, and miR-186-5p is a potential therapeutic target for the disease.

Safety of Endoscopic Snare Ampullectomy for Adenomatous Ampullary Lesions: Focus on Pancreatic Stent Placement to Prevent Pancreatitis

BACKGROUND

Ampullary tumors, although relatively uncommon, are increasingly diagnosed due to ongoing progress in imaging technology and the diagnostic accuracy of endoscopic ultrasound and magnetic resonance cholangiopancreatography. Endoscopic ampullectomy (EA) has become the preferred treatment option over surgery due to its lower morbidity for benign ampullary adenomas. This study aims to evaluate the efficacy, safety, and outcome of EA in 30 patients with benign-appearing ampullary lesions with particular emphasis on the accuracy of preampullectomy histology and technical details of the pancreatic duct drainage to prevent postprocedural pancreatitis.

MATERIALS AND METHODS

Data from a cohort of 30 patients who underwent EA were retrospectively analyzed. Histologic characteristics of the ampullomas, accuracy of histology of pre-EA biopsy specimen, safety of the procedure, recurrence rate, as well as the clinical outcome of all patients, are analyzed and discussed.

RESULTS

Endoscopic resection was successful as a definitive treatment in 25 patients (83.3%). Five patients required additional surgery. In 8 patients, a definitive histologic specimen revealed an adenocarcinoma (3 in situ and 5 invasive). The diagnostic accuracy obtained by preresection biopsy specimen was low (0.70). Pancreatic duct stent placement after snare resection was unsuccessful in 9 patients, and 3 of them developed pancreatitis after EA.

CONCLUSIONS

EA appears to be a relatively safe alternative to surgery as the first therapeutic option for selected patients with benign-appearing ampullary adenomas. A correct preoperative evaluation by endoscopic ultrasound and magnetic resonance cholangiopancreatography can help to define the anatomy of the pancreatic duct to improve the success rate of pancreatic stent placement which seems to offer a protective role in the prevention of postprocedural pancreatitis.

Prospective biomarkers of major depressive disorder: a systematic review and meta-analysis

Leading biological hypotheses propose that biological changes may underlie major depressive disorder onset and relapse/recurrence. Here, we investigate if there is prospective evidence for biomarkers derived from leading theories. We focus on neuroimaging, gastrointestinal factors, immunology, neurotrophic factors, neurotransmitters, hormones, and oxidative stress. Searches were performed in Pubmed, Embase and PsychInfo for articles published up to 06/2019. References and citations of included articles were screened to identify additional articles. Inclusion criteria were having an MDD diagnosis as outcome, a biomarker as predictor, and prospective design search terms were formulated accordingly. PRISMA guidelines were applied. Meta-analyses were performed using a random effect model when three or more comparable studies were identified, using a random effect model. Our search resulted in 67,464 articles, of which 75 prospective articles were identified on: Neuroimaging (N = 24), Gastrointestinal factors (N = 1), Immunology (N = 8), Neurotrophic (N = 2), Neurotransmitters (N = 1), Hormones (N = 39), Oxidative stress (N = 1). Meta-analyses on brain volumes and immunology markers were not significant. Only cortisol (N = 19, OR = 1.294, p = 0.024) showed a predictive effect on onset/relapse/recurrence of MDD, but not on time until MDD onset/relapse/recurrence. However, this effect disappeared when studies including participants with a baseline clinical diagnosis were removed from the analyses. Other studies were too heterogeneous to compare. Thus, there is a lack of evidence for leading biological theories for onset and maintenance of depression. Only cortisol was identified as potential predictor for MDD, but results are influenced by the disease state. High-quality (prospective) studies on MDD are needed to disentangle the etiology and maintenance of MDD.

Clinicopathological characteristics of non-ampullary duodenal tumors and their phenotypic classification

The tumorigenesis of non-ampullary duodenal epithelial tumors (NADETs) might be different between the oral and anal sides of Vater's papilla. We conducted an immunohistological review to elucidate the clinicopathological features according to the tumor location and phenotypic classification. A review of an institutional database identified 121 patients with 125 superficial NADETs. NADETs were histologically evaluated and classified into the intestinal or gastric type based on immunohistochemical analysis. Clinicopathological factors were compared based on the tumor location and phenotype. Logistic regression analysis was performed to identify independent predictors for gastric-type NADETs. According to location analysis, the mucin phenotype was significantly different (oral side, intestinal-type 64.8%, gastric-type 35.3%; anal side, intestinal-type 87.3%, gastric-type 12.7%; P < 0.01). Although the incidence of adenoma was significantly predominant in the intestinal type (75.3%), most gastric-type NADETs were cancerous (64.3%). Notably, most gastric-type NADETs were adenocarcinomas even when the tumor size was ≤0 mm. In multivariate analysis, tumor location on the oral side (odds ratio [OR], 4.42), villous structure (OR, 6.44), and low tumor gland density (OR, 9.49) were independent predictors of gastric-type tumors. Gastric-type NADETs significantly differ from intestinal-type NADETs in terms of tumor location, morphology, and biology.

The Prognostic Impact of the Carcinoembryonic Antigen in Ampullary Cancer - A Retrospective Single Center Study

Background: Carcinoembryonic antigen cell adhesion molecule (CEA) is a commonly immunohistochemically used antibody in pathological routine diagnostics with an overexpression in different cancers. We aimed to examine the immunohistochemically detectable CEA level in ampullary cancer and to correlate it with clinico-pathological data.

Methods: Shot-gun proteomics revealed CEA in undifferentiated ampullary cancer cell lines. Next, tumor tissue of 40 ampullary cancers of a retrospective single center cohort of 40 patients was stained immunohistochemically for CEA; CEA expression was determined and correlated with clinico-pathological data.

Results: Thirty-six patient specimens were included in statistical analysis. CEA expression and lymph node ratio (LNR) were the only independent predictors of overall survival in multivariate analysis.

Conclusion: To our knowledge, cell line and patient cohorts are the largest and characterized cohorts examined for CEA so far. Hereby, CEA expression in ampullary cancer cells permits an estimation of outcome and suggests an opportunity for individualized CEA-directed therapy. Further trials with larger cohorts are needed to verify our results and to integrate CEA immunohistochemistry into clinical routine.

Preoperative endoscopic diagnosis of superficial non-ampullary duodenal epithelial tumors, including magnifying endoscopy

Superficial non-ampullary duodenal epithelial tumor (SNADET) is defined as a sporadic tumor that is confined to the mucosa or submucosa that does not arise from Vater's papilla, and it includes adenoma and adenocarcinoma. Recent developments in endoscopic technology, such as high-resolution endoscopy and image-enhanced endoscopy, may increase the chances of detecting SNADET lesions. However, because SNADET is rare, little is known about its preoperative endoscopic diagnosis. The use of endoscopic resection for SNADET, which has no risk of metastasis, is increasing, but the incidence of complications, such as perforation, is significantly higher than in any other part of the digestive tract. A preoperative diagnosis is required to distinguish between lesions that should be followed up and those that require treatment. Retrospective studies have revealed certain endoscopic findings that suggest malignancy. In recent years, several new imaging modalities have been developed and explored for real-time diagnosis of these lesion types. Establishing an endoscopic diagnostic tool to differentiate between adenoma and adenocarcinoma in SNADET lesions is required to select the most appropriate treatment. This review describes the current state of knowledge about preoperative endoscopic diagnosis of SNADETs, such as duodenal adenoma and duodenal adenocarcinoma. Newer endoscopic techniques, including magnifying endoscopy, may help to guide these diagnostics, but their additional advantages remain unclear, and further studies are required to clarify these issues.

Diagnostic values of dual focus narrow band imaging and probe-based confocal laser endomicroscopy in FAP-related duodenal adenoma

BACKGROUND AND STUDY AIMS

Familial adenomatous polyposis (FAP) is associated with an increased risk of development of periampullary and nonampullary adenoma. Either routine biopsy or endoscopic removal of the lesion is generally required to identify the presence of adenoma. Because the risk of tissue sampling from the ampulla is high and nonampullary polyps are sometimes numerous, resection of all the lesions is time-consuming. This study aimed to evaluate the diagnostic values of duodenal adenoma by dual focus NBI (dNBI) and probe-based confocal endomicroscopy (pCLE) in FAP patients.

PATIENTS AND METHODS

The authors conducted a diagnostic study in a single tertiary-care referral center. Surveillance esophagogastroduodenoscopy with dNBI and pCLE was performed on 26 patients with FAP for real-time adenoma diagnosis by two different endoscopists; one used dNBI and the other pCLE. Histology from the matched lesion was used as the gold standard.

RESULTS

A total of 55 matched biopsies (25 ampullas, 30 nonampullas) were performed. The sensitivity, specificity, post predictive value (PPV), negative predictive value (NPV), and accuracy of dNBI vs. pCLE from all duodenal lesions were 96.9 % vs. 93.8 %, 78.3 % vs. 81 %, 86.1 % vs. 88.2 %, 94.7 vs. 89.5 %, and 92.4 % vs. 88.6 %, respectively.

CONCLUSIONS

For surveillance of periampullary and nonampullary adenoma in patients with FAP, the real-time readings provided a high degree of diagnostic value when histology was used as the gold standard. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT02162173).

Management of ampullary neoplasms: A tailored approach between endoscopy and surgery

Ampullary neoplasms, although rare, present distinctive clinical and pathological features from other neoplastic lesions of the periampullary region. No specific guidelines about their management are available, and they are often assimilated either to biliary tract or to pancreatic carcinomas. Due to their location, they tend to become symptomatic at an earlier stage compared to pancreatic malignancies. This behaviour results in a higher resectability rate at diagnosis. From a pathological point of view they arise in a zone of transition between two different epithelia, and, according to their origin, may be divided into pancreatobiliary or intestinal type. This classification has a substantial impact on prognosis. In most cases, pancreaticoduodenectomy represents the treatment of choice when there is an overt or highly suspicious malignant behaviour. The rate of potentially curative resection is as high as 90% and in high-volume centres an acceptable rate of complications is reported. In selected situations less invasive approaches, such as ampullectomy, have been advocated, although there are some concerns mainly because of a higher recurrence rate associated with limited resections for invasive carcinomas. Importantly, these methods have the drawback of not including an appropriate lymphadenectomy, while nodal involvement has been shown to be frequently present also in apparently low-risk carcinomas. Endoscopic ampullectomy is now the procedure of choice in case of low up to high-grade dysplasia providing a proper assessment of the T status by endoscopic ultrasound. In the present paper the evidence currently available is reviewed, with the aim of offering an updated framework for diagnosis and management of this specific type of disease.

Diagnostic Accuracy of the Initial Endoscopy for Ampullary Tumors

Background/Aims

Ampullary tumors come in a wide variety of malignant forms. We evaluated the diagnostic accuracy of endoscopy for ampullary tumors, and analyzed the causes of misdiagnosis.

Methods

We compared endoscopic imaging and biopsy results to final diagnoses. Types of endoscope, numbers of biopsy specimens taken, and final diagnoses were evaluated as possible factors influencing diagnostic accuracy.

Results

Final diagnoses were 19 adenocarcinomas, 18 normal or papillitis, 11 adenomas, two adenomyomas, one paraganglioma, and one neuroendocrine tumor. The diagnostic accuracy of endoscopic imaging or the initial biopsy was identical (67.3%). At least one test was concordant with the final diagnosis in all except two cases. Compared with the final diagnosis, endoscopic imaging tended to show more advanced tumors, whereas the initial biopsy revealed less advanced lesions. The diagnostic accuracy of the initial biopsy was influenced by the type of endoscope used and the final diagnosis, but not by the number of biopsies taken.

Conclusions

Endoscopy has limited accuracy in the diagnosis of ampullary tumors. However, most cases with concordant endoscopic imaging and biopsy results are identical to the final diagnosis. Therefore, in cases where both of these tests disagree, re-evaluation with a side-viewing endoscope after resolution of papillitis is required.

Advances in diagnostic endoscopy for duodenal, including ampullary, adenoma

Currently, the strategy for real-time endoscopic diagnosis of duodenal, including ampullary, adenoma is still unclear. In the era of high-definition and magnification endoscopy, using this modality for the detection and diagnosis of these neoplasms is very challenging for endoscopists. Over the past 10 years, many instruments have been developed to improve the detection rate of duodenal and ampullary polyps and to distinguish between adenoma and non-adenoma. The present review will focus on these novel methods and their usefulness in the diagnosis of ampullary and non-ampullary adenoma.

Factors predicting survival and pathological subtype in patients with ampullary adenocarcinoma

BACKGROUND

Carcinoma of the ampulla of Vater is uncommon. This study aimed to clarify predictors of survival for ampullary adenocarcinoma and to identify characteristics of its two major pathological subtypes.

METHODS

Medical records were reviewed for 86 patients who underwent curative resection for ampullary adenocarcinoma between 2000 and 2012 at 12 principal hospitals in Kagawa, Japan.

RESULTS

Resection was most common among 75-79-year-old patients. Actuarial 1-, 3-, and 5-year postoperative survival rates for ampullary adenocarcinoma were 90%, 72.3%, and 69.1%, respectively. Preoperative biliary drainage; serum CA19-9 and total bilirubin levels; pathological grade; perineural, vascular, pancreatic, and duodenal invasion; nodal metastasis; UICC-T stage; and pancreatobiliary subtype were predictors of poor survival. An elevated serum CA19-9 level; an elevated total bilirubin level; lymphatic, vascular, perineural, and pancreatic invasion; and advanced overall tumor stage were more common in patients with pancreatobiliary-type tumors than in patients with intestinal-type tumors. Additionally, pathologic subtype analysis showed that each subtype had distinct prognostic factors.

CONCLUSIONS

Preoperative elevated serum CA19-9 and total bilirubin levels are prognostic factors for ampullary adenocarcinoma, and are both associated with pancreatobiliary-type tumors. Surgeons should be aware of these factors because pancreatobiliary-type adenocarcinoma is aggressively invasive and is associated with poor survival.

Diagnosis and management of ampullary adenoma: The expanding role of endoscopy

Ampullary adenoma is a pre-cancerous lesion arising from the duodenal papilla that is often asymptomatic. It is important to distinguish whether the adenoma is sporadic or arises in the setting of familial adenomatous polyposis as this has important implications with respect to management and surveillance. Multiple modalities are available for staging of these lesions to help guide the most appropriate therapy. Those that are used most commonly include computed tomography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography. In recent years, endoscopy has become the primary modality for therapeutic management of the majority of ampullary adenomas. Surgery remains the standard curative procedure for confirmed or suspected adenocarcinoma. This review will provide the framework for the diagnosis and management of ampullary adenomas from the perspective of the practicing gastroenterologist.

The assessment of specimens procured by endoscopic ampullectomy

Endoscopic ampullectomy (EA) is increasingly used in the management of ampullary neoplasia. Although studies on the safety and efficacy of this procedure exist, no study has specifically addressed the histopathologic features of the specimens. We review our experience with 45 EA specimens assessed for the following: diagnosis, high-grade dysplasia (HGD), submucosal ampullary gland/ductule involvement, specimen integrity, and margin status. Familial adenomatous polyposis (FAP) status and the endoscopist's impression of completeness of removal were also ascertained. Previous biopsy diagnoses were compared with ampullectomy diagnoses, and histologic and clinical features were correlated with disease persistence. The histologic features of the ampullectomy specimens were as follows: diagnosis (no diagnostic abnormality, 3; reactive, 8; adenoma, 26; adenocarcinoma, 7; other, 1); HGD, 1; submucosal ampullary gland/ductule involvement, 20; specimen integrity (intact, 22; fragmented, 23); and margin status (positive, 20; negative, 2; could not be assessed, 12). Five patients had FAP, and EA was deemed complete in 21 (47%). The diagnostic agreement between preampullectomy biopsy and ampullectomy was 64%. Of the patients, 33 (73%) had documented persistent disease. None of the histologic or clinical features had a statistically significant relationship with disease persistence.

A survey of ampullectomy practices

AIM: To investigate the endoscopic ampullectomy practices of expert biliary endoscopists.

METHODS: An anonymous survey was mailed to 79 expert biliary endoscopists to assess ampullectomy practices.

RESULTS: Forty six (58%) biliary endoscopists returned the questionnaire. Of these, 63% were in academia and in practice for an average of 16.4 years (± 8.6). Endoscopists performed an average of 1.1 (± 0.8) ampullectomies per month. Prior to ampullectomy, endoscopic ultrasound was “always” utilized by 67% of respondents vs“sometimes” in 31% of respondents. Empiric biliary sphincterotomy was not utilized uniformly, only 26% “always” and 37% “sometimes” performed it prior to resection. Fifty three percent reported “never” performing empiric pancreatic sphincterotomy prior to ampullectomy. Practitioners with high endoscopic retrograde cholangiopancreatography volumes were the most likely to perform a pancreatic sphincterotomy (OR = 10.9; P = 0.09). Participants overwhelmingly favored “always” placing a prophylactic pancreatic stent, with 86% placing it after ampullectomy rather than prior to resection (23%). Argon plasma coagulation was the favored adjunct modality (83%) for removal of residual adenomatous tissue. Practitioners uniformly (100%) preferred follow-up examination to be within 6 mo post-ampullectomy.

CONCLUSION: Among biliary experts, there is less variation in ampullectomy practices than is reflected in the literature.

Increased prevalance of colorectal adenoma in patients with sporadic duodenal adenoma

OBJECTIVES

Duodenal adenomas are common in familial adenomatous polyposis (FAP). It is, however, not known whether patients with duodenal adenomas without FAP should undergo routine colonoscopy for detection of colorectal neoplasia. The aim of this study was to evaluate the correlation between the incidence of sporadic duodenal adenomas and colorectal neoplasias.

METHODS

Patients with sporadic duodenal adenomas and without FAP were retrospectively evaluated for the existence of colorectal neoplasia. Each patient was compared with three randomly selected age and sex-matched controls.

RESULTS

Sporadic duodenal adenomas were diagnosed by endoscopy in 51 patients, of whom 48 underwent additional colonoscopy. The mean age of the 48 analysed patients was 66 (40-83) years (women:men=23 : 25). Colorectal neoplasia was significantly more common among patients with duodenal adenomas (75% vs. 27.7%; P<0.05; odds ratio=7.80 [95% confidence interval 3.48-17.72]).

CONCLUSION

In this case control study, the prevalence of colorectal adenomas in patients with sporadic duodenal adenomas without FAP was significantly increased compared with the average population. Therefore, patients with duodenal adenomas should be screened for the occurrence of colorectal adenomas.

Endocrine cells in ampullary carcinoma

BACKGROUND/PURPOSE

As ampullary carcinoma originates from four anatomical regions, it may have different behaviors depending on its origin. We documented the presence of endocrine cells found in ampullary carcinoma, and we studied the clinicopathological implications of their presence.

METHODS

We immunohistochemically examined the presence of an endocrine component in 62 surgically resected specimens of ampullary carcinoma, and we studied the clinicopathological differences between endocrine component-positive cases and endocrine component-negative cases.

RESULTS

Endocrine cells were detected in 16 cases (26%); 11 cases had many endocrine cells, and five cases had scattered endocrine cells. Serotonin-positive cells were detected in all 16 cases, in which six cases had many positive cells. Several somatostatin-positive cells were detected in three cases. Endocrine cells were detected in ampulloduodenal polypoid lesions (two cases) and ampullopancreaticobiliary ducts (14 cases). The histology of 15 of the 16 endocrine component-positive ampullary carcinomas was the intestinal type. Pancreatic invasion and lymph node involvement were observed less frequently in endocrine component-positive cases (P < 0.01). There were no significant differences with respect to immunoreactivity for carbohydrate antigen (CA) 19.9, carcinembryonic antigen (CEA), and p53 overexpression, and K-ras mutations.

CONCLUSIONS

Endocrine component-positive ampullary carcinoma seemed to be derived from the ampullopancreaticobiliary common duct or the ampulloduodenum, and to behave less aggressively than endocrine component-negative carcinoma.

New approach to diagnosing ampullary tumors by magnifying endoscopy combined with a narrow-band imaging system

BACKGROUND

A newly developed narrow-band imaging (NBI) system, which uses modified optical filters, can yield clear images of microvessels and surface structure in gastric and colonic diseases. In the present study, we investigated the ability of magnifying endoscopy with NBI (MENBI) to diagnose and differentiate between benign and malignant ampullary tumors.

METHODS

Fourteen patients, whose ampullas were noted to be significantly enlarged or protruding with conventional endoscopy, were enrolled in the study. Specimens, which were obtained by forceps biopsy, endoscopic papillectomy, and/or surgery, were retrieved for histopathological examination. The correlation between MENBI images and histopathological findings was investigated. MENBI findings were classified as I, oval-shaped villi; II, pinecone/leaf-shaped villi; or III, irregular/nonstructured. In addition, tortuous, dilated, and network-like vessels noted on the ampullary lesions with MENBI were defined as abnormal vessels.

RESULTS

In 6 of 14 patients, the ampullary changes were proven to be inflammatory in forceps biopsy specimens, without any evidence of malignancy after more than 1 year of follow-up. In five patients, ampullary lesions were treated by endoscopic papillectomy, and in three, by pancreatoduodenectomy. All adenomas and adenocarcinomas had type II and/or type III surface structures, and patients whose ampulla had a type I surface structure had only inflammatory or hyperplastic changes. In addition, abnormal vessels were seen only in adenocarcinomas and never in adenomas.

CONCLUSIONS

MENBI has the ability and potential to predict histological characteristics of ampullary lesions.

Cytologic features and diagnostic pitfalls of primary ampullary tumors by endoscopic ultrasound-guided fine-needle aspiration biopsy

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-guided FNAB) is highly sensitive and specific in cytologic diagnosis and clinical staging of malignant neoplasms of the gastrointestinal tract, pancreas, liver, and lymph nodes. However, no study has been performed to evaluate its accuracy, sensitivity, specificity, and the cytomorphologic features of suspected primary ampullary tumors.

METHODS

All EUS-guided FNABs of suspected primary ampullary lesions at the University of California Irvine Medical Center (Orange, CA) from January 1998 to September 2004 were retrospectively retrieved. The number of passes necessary to arrive at a preliminary diagnosis during adequacy assessment was documented. The cytologic features were analyzed with endosonographic correlation. Follow-up information was also collected.

RESULTS

Thirty-five patients were found, 17 men and 18 women. The mean age of the patients was 68.9 years (range, 34-87 yrs). Adenocarcinoma was diagnosed in 13 patients. Atypical cells were found in six patients, four of which were suspicious for adenocarcinoma and two of which were consistent with reactive atypia. Adenoma was diagnosed in two patients and carcinoid tumor in one. Thirteen patients had a diagnosis that was negative for malignant cells. The average number of aspiration passes was 2.4 (range, 1-6 passes). Follow-up information was available in 27 patients. There were three false-negative results and no false-positive results. The sensitivity, specificity, and the positive and the negative predictive values were 82.4%, 100%, 100%, and 76.9%, respectively. The diagnostic accuracy was 88.8%. The consistent cytologic features in specimens that were positive or suspicious for adenocarcinoma included high cellularity, single cells, 3-dimensional cell balls, high nuclear-to-cytoplasmic ratio, prominent nucleoli, coarse/uneven distribution of chromatin, and necrosis.

CONCLUSIONS

EUS-guided FNAB was accurate, sensitive, and specific in the assessment of suspected primary ampullary masses. Adenoma presented a diagnostic challenge and endosonographic correlation was instrumental to increase the diagnostic accuracy.

High frequency of colorectal adenoma in patients with duodenal adenoma but without familial adenomatous polyposis

BACKGROUND

Duodenal adenomas are extremely common in patients with familial adenomatous polyposis. However, it is uncertain whether patients with duodenal adenomas without familial adenomatous polyposis are at greater risk for colorectal neoplasia and, therefore, should routinely undergo surveillance colonoscopy. The aim of this study was to determine whether there is a correlation between non-papillary duodenal adenoma without familial adenomatous polyposis and colorectal adenoma.

METHODS

Twenty-five patients with non-papillary duodenal adenomas without familial adenomatous polyposis, seen from January 1990 to April 2003, were retrospectively evaluated.

RESULTS

Non-papillary duodenal polyps were diagnosed by endoscopy in the 25 patients. Of these, 21 underwent colonoscopy and one underwent proctoscopy. The mean age of these 22 patients (12 women, 10 men) was 69 years (range 50-83 years). Sixteen of the 22 patients (72.7%) with duodenal adenomas had associated colorectal adenomas. A total of 38 adenomas and one colorectal cancer were detected. The mean size of the polyps was 6.2 mm (range 3-15 mm). The adenomas were removed by snare excision or with a biopsy forceps.

CONCLUSIONS

Based on the results of this uncontrolled, retrospective study, the frequency of colorectal adenomas in patients with duodenal polyps without familial adenomatous polyposis appears to be increased compared with the general population. All patients with duodenal polyps should undergo surveillance colonoscopy for colorectal adenomas. A prospective study to definitively establish the frequency of colorectal adenomas in these patients is warranted.

Role of the DPC4 tumor suppressor gene in adenocarcinoma of the ampulla of Vater: analysis of 140 cases

The K-ras oncogene is activated in approximately 90% of pancreatic adenocarcinomas, and the DPC4 (MADH4/SMAD4) tumor suppressor gene is inactivated in approximately 55% of pancreatic adenocarcinomas. The contributions of these genetic alterations to the development of adenocarcinoma of the ampulla of Vater have not been fully established. One hundred forty surgically resected ampullary adenocarcinomas (76 with associated adenomas with high-grade dysplasia) were immunohistochemically labeled for the DPC4 gene product, and in 85 cases the results were correlated with the status of the K-ras oncogene from previously reported data. The results were correlated with clinical outcome and with other pathologic predictors of prognosis. Complete loss of Dpc4 labeling was identified in 34% (95% confidence interval [CI]: 26%, 43%) of the invasive carcinomas and in none (upper 95% CI: 6%) of the associated adenomas. Focal loss of Dpc4 was seen in three (4%; 95% CI: 1%, 14%) of the areas of high-grade dysplasia. Complete loss of Dpc4 expression was seen in 28/77 intestinal-type tumors, in 17/46 pancreaticobiliary-type tumors, and in 0/10 colloid carcinomas. Activating point mutations in the K-ras gene were identified in 40% of the invasive cancers. There was no correlation between K-ras gene mutations and Dpc4 expression and no correlation between these variables and survival. The overall 5-year survival rate was 38%. Lymph node metastases were associated with shorter survival (P =.03). Loss of Dpc4 expression occurs in approximately one third of invasive ampullary cancers but is not seen in adenomas; thus, loss of Dpc4 expression occurs late in ampullary carcinogenesis. Although ampullary and pancreatic adenocarcinomas share histologic and molecular features, ampullary carcinomas are less likely to show loss of Dpc4 expression or K-ras gene mutations.

Primary duodenal carcinoma

Eight cases of primary duodenal carcinoma in a district general hospital are presented. The cases highlight the advanced state of the disease at presentation, the difficulty in diagnosis, and its poor prognosis. Duodenal carcinoma occurs in both sexes worldwide with no predisposing factors in the majority of cases. There is an increased risk in patients with familial adenomatous polyposis and adenomas of the duodenum. Duodenal carcinoma occurs about 22 years from the diagnosis of familial adenomatous polyposis in about 2% of patients, forming over 50% of upper gastrointestinal cancers occurring in these patients. Carcinomatous changes occur in 30 to 60% of duodenal villous adenomas and much less in tubulo-villous and tubular adenomas. These categories of patients should be screened and adequately followed up. Aggressive and radical surgery, even in the presence of locally advanced disease and lymph node involvement, gives a better outcome. When curative surgery is not possible, chemotherapy must accompany palliation with or without radiotherapy. Pre-operative chemotherapy may facilitate a curative radical resection. The general five-year survival is 17-33% but some centres have achieved a five-year survival of 40-60% with aggressive management of these patients.

Sphincter of Oddi dysfunction caused by an ampullary neoplasm

The case of a 50-year-old man with abdominal pain and abnormal liver test results is described. Endoscopic retrograde cholangiopancreatography with manometric studies showed biliary dilatation, poor ductal drainage, and sphincter of Oddi dysfunction. Clinical and radiographic clues suggested the possibility of an ampullary lesion; a small ampullary adenoma was detected after endoscopic sphincterotomy, and ampullary carcinoma was found in the operative specimen. Malignancy can cause sphincter dysfunction not only in the esophagus (as pseudoachalasia) but in the ampulla of Vater as well.

Adenoma of the ampulla of Vater: putative precancerous lesion

The histopathology of 12 patients with adenoma of the ampulla of Vater was examined to trace the adenoma-carcinoma sequence of the ampulla of Vater. Immunohistochemistry for carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 was also performed. Four large adenomas with mild dysplasia also had foci of moderate dysplasia while another one contained foci of severe dysplasia (intramucosal carcinoma). Immunohistochemically, adenomas of mild to moderate dysplasia had either linear CEA and CA19-9 immunoreactants at the apical portions, or fine granular immunoreactants in the cytoplasm of adenoma cells. In addition, adenomas of severe dysplasia (intramucosal carcinoma) showed a more diffuse or dense immunoreactivity for these two substances in the cytoplasm. These results are consistent with the adenoma-carcinoma sequence for the ampulla of Vater. The immunohistochemistry for CEA and CA19-9 was representative of the degree of dysplasia in the adenoma cells, but the relationship was not conclusive.

Villous adenomas of the duodenum and an unusual variant

We report two cases of villous adenoma of the duodenum, one arising from the main papilla and the other from the accessory papilla. Both were managed by local resection. In one case endoscopic biopsies and intraoperative frozen sections were negative for carcinoma but histology of the locally resected specimen revealed a focus of invasive adenocarcinoma. Villous adenomas of the duodenum have a high risk of malignant change and foci of carcinoma can be missed on endoscopic biopsy. The literature is reviewed and the clinical, diagnostic, pathological and therapeutic aspects of villous adenomas of the duodenum are discussed.

Endoscopic biopsy has limited accuracy in diagnosis of ampullary tumors

Endoscopic biopsy specimens and surgically resected specimens in a collective series of 78 Japanese patients with ampullary tumor were retrospectively reviewed to investigate the clinical implications of endoscopic biopsy. Endoscopic biopsy specimens were classified into five groups based on the degree of epithelial atypia: group 1 (no atypia), group 2 (mild atypia), group 3 (moderate atypia or adenoma), group 4 (severe atypia or carcinoma in situ), and group 5 (invasive carcinoma). Final diagnosis of the 78 resected ampullary tumors was adenoma in five cases, carcinoma in 27 cases, and both adenoma and carcinoma in 46 cases. Biopsy accuracy of carcinoma (group 4 or 5) was 70% (51 of 73) overall in 73 carcinoma cases. Biopsy accuracy was 50% (7 of 14) in the intramural protruding type, 64% (21 of 33) in the exposed protruding type, and 88% (23 of 26) in the ulcerating type. The diagnostic accuracy of adenoma (group 3) was 80% (4 of 5) in five cases of ampullary adenoma. In 18 (25%) of the 73 carcinoma cases, biopsy diagnosis was adenoma (group 3), whereas carcinoma was found in the deeper layers of surgically resected specimens. Biopsy diagnosis of adenoma does not rule out the possibility of deeper carcinoma in ampullary tumors.

Investigations on the significance of the adenoma-carcinoma sequence in the small bowel

In view of the rarity of small-bowel epithelial neoplasms as compared with the case for the large bowel, evidence for an adenoma-carcinoma sequence in the small bowel was studied based on a search for data in the medical literature for the years 1927 through 1986. Sufficiently defined data were found for comparison of 185 benign adenomas, 76 adenoma-with-carcinomas, and 1333 carcinomas in patients without familial polyposis disease and for 63, five, and 30, respectively, in patients with disease. For patients without polyposis, it was found that (1) 29.8% of all small-bowel adenomas (33.6% if those at Vater's ampulla are excluded) showed malignancy; (2) the mean and median ages were lower for benign adenoma than for adenoma-with-carcinoma and carcinoma, although the ratios by sex were the same; (3) there is a nearly identical spatial distribution of the three types of epithelial neoplasms within the small bowel; and (4) both the frequency of finding adenomatous residues existing in continuity with carcinoma and the life history of the adenoma-carcinoma sequence are similar in the small bowel as in the large. In comparing these results with those from patients with familial polyposis disease, it was particularly noted that (1) the only difference was that adenomas in familial polyposis occurred earlier and multiply, and (2) the spatial distributions of adenomas and carcinomas for both cases were closely similar. It is therefore postulated that the adenoma-carcinoma sequence is as significant in the small bowels as in the large. A hypothesis regarding the relationship of epithelial neoplasms in people with and without familial polyposis disease is suggested.

Incidence, sites of origin, and immunohistochemical and histochemical characteristics of atypical epithelium and minute carcinoma of the papilla of Vater

To elucidate the relationship between atypical epithelial growth and cancer of the papilla of Vater, histologic, histochemical, and immunohistochemical observations were made of the autopsy cases of mainly elderly people. The atypical grades of the epithelium were histologically classified into five groups: normal epithelium, Group 1; mild atypism, nonmalignant, Group 2; moderate atypism, borderline, Group 3; severe atypism, possibly malignant, Group 4; and apparent carcinoma, Group 5. The incidences of each group in 576 autopsy cases were 65.8%, 30.0%, 3.1%, 0.9%, and 0.2, respectively. The atypical epithelia were observed with the highest incidence in the common pancreaticobiliary channel. The immunohistochemical stainings for cancer-associated antigens (carcinoembryonic antigen [CEA] and carbohydrate antigen 19-9 [CA 19-9]) and histochemical stainings for mucin (periodic acid-Schiff [PAS] and alcian blue [AB], pH 2.5 and pH 1.0) revealed that most of the Group 1 and 2 epithelia were negative for CEA and positive for AB, pH 2.5. Group 3 and 4 epithelia were negative for both CEA and AB, and Group 5 epithelia were positive for CEA but negative for AB (chi-square test, P less than 0.01). A combination of CEA and AB pH 2.5 stainings may be helpful in the histologic diagnosis of normal epithelium to mild atypism, moderate to severe atypism, and carcinoma. The study on the relationships between atypical epithelia showed that some carcinomas of the papilla of Vater may arise from atypical epithelia.

Long-term survival after resection of ampullary carcinoma is associated independently with tumor grade and a new staging classification that assesses local invasiveness

Long-term survival characteristics after resection for ampullary carcinoma are documented poorly. We have reviewed the clinical and histopathologic features of 23 long-term survivors who underwent resections between 1972 and 1984 (5-year survival rate, 52.1%). Twenty patients (87%) had intestinal type tumors and only two (9%) had papillary tumors. Associated adenomata were present in eight cases (35%) and distant ductular dysplasia was present in nine cases (39%). Long-term survival was correlated independently with tumor grade (P = 0.0031) and a new staging system that assesses local invasiveness (P = 0.0055). No correlation was found between survival and sex, tumor size, or presence of adenoma. Age was significant in univariate analysis (P = 0.0322) but not in multivariate analysis. A simple scoring system based on the grade and stage increased the predictability of survival (P = 0.0004). Application of this scoring system may allow an objective comparison of long-term survival results after resection from different series.

The histopathology and staging of carcinoma of the ampulla of Vater

Review of 26 resected ampullary carcinomas revealed intestinal type adenocarcinoma in all but one and overtly papillary carcinoma in only one case. Co-existing adenoma of the ampulla was present in 11 cases, over half of which were low-grade carcinomas. Flat duct epithelial dysplasia was present in a further eight cases, the adenocarcinoma in only two of these being well differentiated. The estimated 5 year survival rate, overall, was 52% and, with well differentiated adenocarcinoma, 75%. We recommend a new staging system, based on extent of local and lymph node spread: I = invasion confined to wall of common bile duct; II = infiltration of duodenal or retroperitoneal tissues, excluding pancreas; III = infiltration of pancreas; IV = metastasis to nearby lymph nodes. Long-term survival correlates inversely with stage, both by univariate analysis and independently of grade, so that a simple scoring system, based on a combination of both grade and stage, is an excellent predictor of the long-term outcome, defining two groups, with 5 year survival rates of 79% and 0% (P less than 0.001).