Long-term survival after pancreaticoduodenectomy for endocrine tumors of the ampulla of Vater and minor papilla

A case of neuroendocrine neoplasm of the minor duodenal papilla

A 61-year-old woman was referred to our hospital for intraductal papillary mucinous neoplasm with no symptoms. Magnetic resonance imaging (MRI) depicted a 15 mm nodular lesion at the descending portion of duodenum. Upper gastrointestinal endoscopy showed a submucosal tumor-like mass at the minor duodenal papilla. A boring biopsy of the tumor revealed a neuroendocrine neoplasm (NEN). Various blood hormone tests were all within normal limits, and the tumor was considered to be nonfunctional. Contrast-enhanced computed tomography showed no obvious distant metastasis, and subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) was performed. Histopathological examination revealed a dense cluster of spindle-shaped cells forming a sheet-like foci and areas showing glandular lumen formation, and immunohistochemistry showed synaptophysin ( + ), chromogranin ( + ). Mitotic rate was about 11 mitoses per 2 square millimeters, Ki-67 index was about 0.2%. She was pathologically diagnosed with NEN G2 at the minor duodenal papilla with regional lymph node metastasis according to the WHO2010 classification. The patient has been currently under outpatient observation with a good postoperative course. Review of the literature identified 43 cases of NENs of the minor duodenal papilla. NENs of the minor duodenal papilla have a high rate of lymph node metastasis, even if the tumor size is small.

Ampullary Neuroendocrine Neoplasms: Identification of Prognostic Factors in a Multicentric Series of 119 Cases

Neuroendocrine neoplasms (NENs) of the major and minor ampulla are rare diseases with clinico-pathologic features distinct from non-ampullary-duodenal NENs. However, they have been often combined and the knowledge on prognostic factors specific to ampullary NENs (Amp-NENs) is limited. The aim of this study was to identify factors associated with metastatic potential and patient prognosis in Amp-NENs. We clinically and histologically investigated an international series of 119 Amp-NENs, comprising 93 ampullary neuroendocrine tumors (Amp-NETs) and 26 neuroendocrine carcinomas (Amp-NECs). Somatostatin-producing tubulo-acinar NET represented the predominant Amp-NET histologic subtype (58 cases, 62%, 12 associated with type 1 neurofibromatosis). Compared to Amp-NETs, Amp-NECs arose in significantly older patients and showed a larger tumor size, a more frequent small vessel invasion, a deeper level of invasion and a higher rate of distant metastasis, and, importantly, a tremendously worse disease-specific patient survival. In Amp-NETs, the WHO grade proved to be a strong predictor of disease-specific survival (hazard ratio: 12.61, p < 0.001 for G2 vs G1), as well as patient age at diagnosis > 60 years, small vessel invasion, pancreatic invasion, and distant metastasis at diagnosis. Although nodal metastatic disease was not associated with survival by itself, patients with > 3 metastatic lymph nodes showed a worse outcome in comparison with the remaining Amp-NET cases with lymphadenectomy. Tumor epicenter in the major ampulla, small vessel invasion, and tumor size > 16 mm were independent predictors of nodal metastases in Amp-NETs. In conclusion, we identified prognostic factors, which may eventually help guide treatment decisions in Amp-NENs.

Neuroendocrine Tumors (NETs) of the Minor Papilla/Ampulla: Analysis of 16 Cases Underlines Homology With Major Ampulla NETs and Differences From Extra-Ampullary Duodenal NETs

Neuroendocrine tumors (NETs) of the minor papilla/ampulla (MIPA) are rare and poorly studied. Only individual case reports and no comprehensive analysis are available from the literature. We collected 16 MIPA NETs and investigated their clinicopathologic and immunohistochemical features, including markers such as somatostatin, pancreatic polypeptide, gastrin, serotonin, MUC1, cytokeratin 7, and somatostatin receptors type 2A and 5. The median age at diagnosis was 57.5 years, and the female-to-male ratio was 2.2:1. The median NET size was 1.45 cm, and most (94%) were low-grade (G1) tumors. Similarly to what was observed in the major ampulla, 3 histotypes were found: (i) ampullary-type somatostatin-producing tumors (ASTs, 10 cases), characterized by somatostatin expression in most tumor cells, focal-to-extensive tubulo-acinar structures, often with psammoma bodies, MUC1 reactivity, and no or rare membranous reactivity for somatostatin receptor type 2A; (ii) gangliocytic paragangliomas (3 cases), characterized by the coexistence of 3 tumor cell types: epithelioid, often reactive for pancreatic polypeptide, ganglion-like cells, and S100 reactive sustentacular/stromal cells; and (iii) ordinary nonfunctioning NETs (3 cases), resembling those more commonly observed in the extra-ampullary duodenum. Comparable histotypes could also be recognized among the 30 MIPA NETs from the literature. No NET-related patient death among MIPA cases was observed during a median follow-up of 38 months; however, MIPA ASTs showed lymph node metastases and invasion of the duodenal muscularis propria or beyond in 44% and 40% of cases, respectively. In conclusion, MIPA NETs closely resemble tumors arising in the major ampulla, with predominance of ASTs.

Endoscopic retrograde cholangiopancreatography for diagnosis and treatment of duodenal papillary carcinoma: Analysis of 39 cases

AIM: To assess the value of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of duodenal papillary carcinoma.

METHODS: Thirty-nine patients with duodenal papillary carcinoma underwent ERCP and histopathologic examination. After that, different endoscopic treatments were taken according to the patients' condition and their wishes, which included endoscopic metal biliary drainage (EMBD), endoscopic retrograde biliary drainage (ERBD), endoscopic naso-biliary drainage (ENBD) and so on.

RESULTS: All the 39 patients who were considered to have duodenal papillary carcinoma by endoscopic examination were precisely diagnosed with the disease by histopathologic examination, and the rate of accurate diagnosis was 100%. With a success rate of 82.1%, 32 patients accepted endoscopic biliary drainage (EBD) successfully, of whom 7 received EMBD, 15 adopted ERBD, 6 underwent ENBD, and the left 4 were treated by both ENBD and EMBD/ERBD. 1 wk after EBD, the discomforts such as abdominal pain and distension were evidently relieved compared with the condition before operation. The levels of serum total bilirubin (STB), direct bilirubin (DB), alkaline phosphatase (ALP), aspartate aminotransferase (AST), glutamyltranspetidase (GGT), and alanine aminotransferase (ALT) were significantly decreased compared with the values before EBD (P < 0.05).

CONCLUSION: ERCP is an effective method for the diagnosis and palliative treatment of duodenal papillary carcinoma.