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Osama MA, Dhawan S, Rao S, Kumar A, Rawat S. Benign Lesion of the Common Bile Duct Mimicking a Malignant Tumor: an Entity Commonly Overdiagnosed Clinically. Indian J Surg Oncol 2024; 15:331-337. [PMID: 38818003 PMCID: PMC11133261 DOI: 10.1007/s13193-023-01860-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 11/29/2023] [Indexed: 06/01/2024] Open
Abstract
Adenomyomatous hyperplasia and adenomyoma are rare benign inflammatory pseudotumors of the gallbladder arising from Rokitansky-Aschoff sinuses. Occurrence of these hyperplastic conditions in the Vaterian and biliary system is extremely rare and is a concern for gastroenterologists and surgeons in distinguishing them from primary malignancies of the biliary system. Definitive diagnosis by imaging or cytopathological examination is difficult; thus, surgical resection becomes the only choice in such cases to relieve the obstruction. Here, we report two extremely rare cases of adenomyomatous hyperplasia of the extrahepatic bile duct after an extensive diagnostic workup, followed by Whipple's procedure.
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Affiliation(s)
- Md Ali Osama
- Department of Pathology, Lady Hardinge Medical College, New Delhi, India
| | - Shashi Dhawan
- Department of Pathology, Sir Gangaram Hospital, New Delhi, India
| | - Seema Rao
- Department of Pathology, Sir Gangaram Hospital, New Delhi, India
| | - Arvind Kumar
- Department of Surgical Oncology, Sir Gangaram Hospital, New Delhi, India
| | - Saumitra Rawat
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Gangaram Hospital, New Delhi, India
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Frutuoso L, Pereira AM, Carvalho L, Gonçalves G, Nora M. Adenomyomatous Hyperplasia of Ampulla of Vater and a Concomitant Renal Tumor: A Case Report. Cureus 2021; 13:e20258. [PMID: 35018260 PMCID: PMC8739335 DOI: 10.7759/cureus.20258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 11/05/2022] Open
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Gouveia C, Fidalgo C, Loureiro R, Oliveira H, Maio R, Cravo M. Adenomyomatosis of the Common Bile Duct and Ampulla of Vater. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 28:121-133. [PMID: 33791399 DOI: 10.1159/000507788] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 04/06/2020] [Indexed: 01/03/2023]
Abstract
Adenomyomatosis is a rare benign lesion that has been observed in different sites throughout the gastrointestinal tract, most frequently in the gallbladder. Few cases have been described in the stomach, small bowel, bile ducts, and ampullary region. Adenomyomas of the vaterian system (ampulla and common bile duct) have important clinical consequences, since the majority of these lesions present with biliary tract obstruction and mimic malignant behavior. As a consequence, considering the diagnostic difficulty of these lesions, patients are often treated with extensive surgery (pancreaticoduodenectomy). We report 2 cases of adenomyomatosis: one of the ampulla of Vater and the other of the common bile duct, as well as a review of reported cases in the literature. Both of our patients presented with epigastralgia and had laboratory or endoscopic evidence of biliary obstruction. Both patients underwent endoscopic ultrasound, one of them with fine-needle aspiration; however, it was not possible to exclude the possibility of cancer. The diagnosis of adenomyoma was only confirmed by the surgical specimen after pancreaticoduodenectomy.
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Affiliation(s)
- Catarina Gouveia
- Gastroenterology Department, Beatriz Ângelo Hospital, Loures, Portugal
| | - Catarina Fidalgo
- Gastroenterology Department, Beatriz Ângelo Hospital, Loures, Portugal
| | - Rui Loureiro
- Gastroenterology Department, Beatriz Ângelo Hospital, Loures, Portugal
| | - Helena Oliveira
- Pathology Department, Beatriz Ângelo Hospital, Loures, Portugal
| | - Rui Maio
- General Surgery Department, Beatriz Ângelo Hospital, Loures, Portugal
| | - Marília Cravo
- Gastroenterology Department, Beatriz Ângelo Hospital, Loures, Portugal
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Choi YH, Kim MJ, Han JH, Yoon SM, Chae HB, Youn SJ, Kang MH, Sung R, Choi JW, Park SM. Clinical, pathological, and immunohistochemical features of adenomyoma in the ampulla of vater. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2014; 62:352-8. [PMID: 24365734 DOI: 10.4166/kjg.2013.62.6.352] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND/AIMS Ampullary adenomyoma is a benign lesion whose malignant potential has yet to be confirmed. Despite its benign nature, adenomyoma is frequently misdiagnosed as a carcinoma or adenoma and is overtreated by extensive surgery. This study was performed to analyze the clinical, pathological, and immunohistochemical features of adenomyomas in the ampulla of Vater. METHODS Nine cases of adenomyoma in the ampulla of Vater, diagnosed in Chungbuk National University Hospital between 2008 and 2011, were enrolled in this study. We reviewed the clinical data on the symptoms, laboratory data, and radiologic findings of the abdominal computed tomography and endoscopic retrograde cholangiopancreatography. For pathological analysis, all the slides were reviewed by one pathologist, and immunohistochemical stainings with antibodies against cytokeratin 7 (CK7), cytokeratin 20 (CK20), α-smooth muscle actin (α-SMA), and Ki-67 antigen were performed. RESULTS All the cases were CK7 positive and CK20 negative. A strong cytoplasmic expression of α-SMA was confirmed in all cases. The Ki-67 index was less than 1% in eight cases and 5% in one case. Four cases underwent endoscopic papillectomy, and one case received surgical ampullectomy during colorectal cancer surgery. Five cases that underwent endoscopic or surgical treatment remained symptom-free for three years. Four cases that were closely observed with repeated endoscopic examinations exhibited no interval changes in the papillary lesions. CONCLUSIONS Endoscopic biopsy and immunohistochemistry can aid in the diagnosis of ampullary adenomyomas. Endoscopic papillectomy or surgical ampullectomy is adequate for the treatment of symptomatic ampullary adenomyomas.
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Affiliation(s)
- Yong Hyeok Choi
- Department of Internal Medicine, Chungbuk National University College of Medicine, 52 Naesudong-ro, Heungdeok-gu, Cheongju 361-711, Korea
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Rafiullah, Tanimu S. Adenomyomatous hyperplasia of the ampulla of Vater presenting as acute pancreatitis. BMJ Case Rep 2014; 2014:bcr-2013-203151. [PMID: 24604802 DOI: 10.1136/bcr-2013-203151] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
We report an interesting and rare case of a man with adenomyomatous hyperplasia of the ampulla of Vater presenting as acute pancreatitis, which to our knowledge, is only the second reported case in the English literature. The patient presented with an acute onset of abdominal pain, nausea and vomiting, without fever, chills or rigours. CT of the abdomen revealed changes of acute pancreatitis with a peripancreatic adenopathy, and abdominal ultrasound revealed a slightly hyperechoic and oedematous head of the pancreas, consistent with acute pancreatitis. Endoscopic retrograde cholangiopancreaticography revealed an ampullary lesion. Pathology of the ampullary lesion revealed an inflammatory polyp. Endoscopic ultrasound with endoscopic mucosal resection of the lesion revealed an adenomyomatous hyperplasia. The patient recovered well postendoscopic resection without recurrent pancreatitis or cholestasis.
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Affiliation(s)
- Rafiullah
- Department of Internal Medicine, Saint Clair's Hospital, Weston, Wisconsin, USA
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Abstract
A woman 80 years of age had diffuse adenomyosis in the wall of the choledochus, near to the papilla of Vater. The lesion caused icterus and was operated (partial pancreatoduodenectomy). Adenomyosis should be considered in the differential diagnosis of obstructive jaundice.
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Affiliation(s)
- Miklós Krutsay
- Magyar Imre Kórház Patológiai Osztály 8401 Ajka Korányi Frigyes u. 1.
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Iwaki K, Shibata K, Ohta M, Endo Y, Uchida H, Tominaga M, Okunaga R, Kai S, Kitano S. Adenomyomatous hyperplasia of the common bile duct: report of a case. Surg Today 2007; 38:85-9. [PMID: 18085373 DOI: 10.1007/s00595-007-3558-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2007] [Accepted: 04/27/2007] [Indexed: 12/14/2022]
Abstract
Adenomyomatous hyperplasia is most commonly found in the stomach, gallbladder, duodenum, and jejunum, while it is rarely found in the extrahepatic bile duct. A 62-year-old woman was referred to our institution with a diagnosis of common bile duct (CBD) stenosis which had been detected by endoscopic retrograde cholangiopancreatography (ERCP). Abdominal computed tomography with contrast medium revealed a thickening of the wall of the lower CBD, and this lesion was weakly enhanced by contrast medium in the arterial phase. ERCP revealed a 15-mm-long stenosis of the lower CBD, but no malignant cells were detected by either bile cytology or brush cytology. Because CBD cancer could not be ruled out, pylorus-preserving pancreatoduodenectomy was performed. Histopathologically, multiple hyperplastic glands without cellular atypia were present in the lower CBD wall. An immunohistochemical study showed fibroblasts with positive staining for alpha-smooth muscle actin surrounding the glands. The lesion was diagnosed to be adenomyomatous hyperplasia of the CBD. When a diagnosis of adenomyomatous hyperplasia of the CBD is difficult to make both preoperatively and intraoperatively, then a radical surgical procedure, such as a pancreatoduodenectomy, may be an effective treatment alternative.
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Affiliation(s)
- Kentaro Iwaki
- Department of Surgery I, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Oita 879-5593, Japan
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Plard L, Leone S, Rod J, Chiche L. [Adenomyoma of the main biliary tract: a real diagnostic trap. Two cases and a review of the literature]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2007; 31:1005-1009. [PMID: 18166896 DOI: 10.1016/s0399-8320(07)78321-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Adenomyoma of the biliary tract is a benign neoplasm but its clinical, radiological and intraoperative features can mimic pancreatic or biliary cancer. These similarities may yield to useless pancreatoduodenectomy. We report here two cases of adenomyoma treated by pancreatoduodenectomy. The analysis of these two cases and the review of literature show that radiological and pathological knowledge of this disease, associated with pre and intraoperative evaluation (echoendoscopy-guided biopsy, brushing and intraoperative biopsy) can achieve diagnosis and thus may avoid inappropriate resection. For asymptomatic patient, simple follow-up seems to be the rule. For symptomatic patient endoscopic resection or surgical segmentary resection where appropriate is recommended.
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Affiliation(s)
- Laurent Plard
- Service de chirurgie hépatobiliaire et transplantation hépatique, CHU Caen, Caen
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Kwon TH, Park DH, Shim KY, Cho HD, Park JH, Lee SH, Chung IK, Kim HS, Park SH, Kim SJ. Ampullary adenomyoma presenting as acute recurrent pancreatitis. World J Gastroenterol 2007; 13:2892-4. [PMID: 17569131 PMCID: PMC4395647 DOI: 10.3748/wjg.v13.i20.2892] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Adenomyoma is a term generally applied to nodular lesions showing proliferation of both epithelial and smooth muscle components. Despite its benign nature, ampullary adenomyoma is usually presented as biliary obstruction. Most cases are misdiagnosed as carcinoma or adenoma by preoperative endoscopic or radiologic procedure. Therefore, it is frequently treated with extensive surgery. To our knowledge, this is the first reported case in English literature of adenomyoma located in the peripancreatic orifice resulting in intermittent pancreatic duct obstruction and recurrent pancreatitis diagnosed by the endoscopic piecemeal resection.
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Affiliation(s)
- Tae-Hee Kwon
- Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital 23-20 Bongmyung-dong, Cheonan, Choongnam 330-721, Korea
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Masoom S, Venkataraman G, Hammadeh R. Symptomatic adenomyoma of the Vaterian system: a pathologic curiosity with a potential for misdiagnosis. APMIS 2006; 114:559-61. [PMID: 16907862 DOI: 10.1111/j.1600-0463.2006.apm_476.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kahaleh M, Shami VM, Brock A, Conaway MR, Yoshida C, Moskaluk CA, Adams RB, Tokar J, Yeaton P. Factors predictive of malignancy and endoscopic resectability in ampullary neoplasia. Am J Gastroenterol 2004; 99:2335-9. [PMID: 15571579 DOI: 10.1111/j.1572-0241.2004.40391.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Endoscopic treatment of ampullary lesions has been well described, though it remains uncertain if specific features predict malignancy, and whether identifiable factors are associated with successful endoscopic resection of benign lesions. METHODS Fifty-six consecutive patients undergoing endoscopic evaluation of ampullary neoplasia between March 2000 and May 2004 were included in the study. Clinical presentation, underlying medical conditions, endoscopic treatment, endoscopic ultrasound (EUS) to define extent of local involvement, pathology results, and outcome were documented. Data elements for analysis included EUS findings, lesion lifting with submucosal injection, age, gender, tumor size, and endoscopic intervention. Analyses were performed to determine the ability to predict malignancy and the ability to extirpate benign lesions. RESULTS Thirty-one males and 25 females were included; mean age was 62 yr. Final diagnoses included 29 adenomas, 20 adenocarcinomas, 4 adenomyomas, 2 paragangliomas, and 1 neuroendocrine tumor. Thirty of 35 patients with benign lesions had extirpation with a mean of two endoscopic procedures. Complications of endoscopic resection included cholangitis (1), bleeding (2), and pancreatitis (4). The presence of malignancy was associated by multivariate analysis with the inability to obtain a cleavage plane with saline injection. Univariate analysis also identified EUS T stage as a predictor of malignancy. In benign lesions, none of the analyzed variables predicted successful endoscopic resection. CONCLUSION In ampullary lesions, failure to achieve a cleavage plane with submucosal injection is the strongest predictor of malignancy followed by EUS T stage. Endoscopic treatment of benign ampullary neoplasia is effective; no factor was predictive of successful extirpation.
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Affiliation(s)
- Michel Kahaleh
- Departments of Surgery, University of Virginia Health System, Charlottesville, Virginia 22908-0708, USA
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Handra-Luca A, Terris B, Couvelard A, Bonte H, Flejou JF. Adenomyoma and adenomyomatous hyperplasia of the Vaterian system: clinical, pathological, and new immunohistochemical features of 13 cases. Mod Pathol 2003; 16:530-6. [PMID: 12808057 DOI: 10.1097/01.mp.0000073525.71096.8f] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Adenomyoma and adenomyomatous hyperplasia of the Vaterian system are consistently benign lesions. Clinically, adenomyoma mimics frequently ampullary adenoma or carcinoma, and biopsy analysis is often difficult. The histogenesis of ampullary adenomyoma and adenomyomatous hyperplasia is still subject to debate. We present a retrospective study of clinicopathological features of 13 cases of surgically resected ampullary adenomyoma. The age of our patients was between 38 and 78 years (mean: 63 y). The preoperative diagnosis was ampullary tumor or tumor of the head of the pancreas. On macroscopy, a white, firm lesion of the ampullary wall was observed; its size ranged between 10 and 30 mm. Histologically the lesion consisted of multiple glandular structures surrounded by a fibroblastic/myofibroblastic proliferation, resulting in a "pseudo-hypertrophy" of the Vaterian system. The immunophenotype of the epithelial component was cytokeratin 7+/cytokeratin 20-, similar to that of the normal biliary and pancreatic duct system. The epithelial cells exhibited low proliferative activity. The hyperplastic myofibroblastic cells expressed smooth muscle actin. A complete pancreatic heterotopy contiguous with the adenomyoma was noted in three cases. Adenomyoma and adenomyomatous hyperplasia of the Vaterian system are benign lesions frequently treated by extensive surgery because of long-term biliary obstruction. The clinicopathological characteristics suggest either a reactive and/or a malformative, nonneoplastic nature for this lesion, which could, in some cases, develop from heterotopic pancreas. The immunophenotype of epithelial cells may be a useful tool for differentiating it from ampullary adenoma on biopsy specimens.
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Park JS, Kim MH, Lee SK, Seo DW, Lee SS, Chang HS, Han J, Kim JS, Min YI. The clinical significance of papillitis of the major duodenal papilla. Gastrointest Endosc 2002; 55:877-82. [PMID: 12024144 DOI: 10.1067/mge.2002.124559] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND This study investigated the clinical significance of papillitis of the major duodenal papilla and analyzed the correlation between endoscopic and histologic papillitis in patients with biliary or pancreatic disorders. METHODS Eighty-seven patients and 12 healthy control subjects were enrolled. The endoscopic appearance of papillitis was classified by two blinded endoscopists, and biopsy specimens were taken of the papilla. Various factors were prospectively analyzed to identify any relationship with the endoscopic severity of the papillitis. RESULTS By univariate analysis, a clinically acute inflammatory condition and elevation of serum transaminase levels were significantly associated with moderate and severe endoscopic papillitis (p < 0.05). However, by multivariate analysis, only a clinically acute inflammatory condition was significantly associated with moderate and severe endoscopic papillitis (p < 0.001). The endoscopic severity of papillitis was poorly correlated with monocyte infiltration, but there was a good correlation with neutrophil infiltration. Moderate and severe papillitis were not observed in healthy volunteers. CONCLUSIONS Moderate and severe endoscopic papillitis were significantly more common in patients with biliary or pancreatic disorders plus a clinically acute inflammatory condition, whereas moderate and severe papillitis were not observed in healthy volunteers. Moderate and severe endoscopic papillitis are characteristic of biliary or pancreatic disorders.
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Affiliation(s)
- Ju Sang Park
- Department of Internal Medicine and Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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