Clinical, pathological, and immunohistochemical features of adenomyoma in the ampulla of vater

When Aunt Minnie turns out to be a Zebra: distal bile duct adenomyoma stimulating pancreas head tumor

A 55-year-old female patient with a history of ethyl and nicotine abuse presented with chronic diarrhoea, significant weight loss and abnormal liver tests. Ultrasound examination revealed dilatation of the bile ducts and computed tomography scan with IV contrast further established simultaneous dilatation of the common bile duct and pancreatic duct (double duct sign). The dilatation abruptly stopped at the level of the pancreatic head which demonstrated a small irregular hypovascular zone (1.2 cm), suspected for malignancy. The following week, a radical pancreaticoduodenectomy was performed. Anatomopathological analysis revealed an adenomyoma (12 mm) located distal to the common bile duct, without arguments for malignancy.

Differentiation of Adenomyoma from Localized Adenocarcinoma of the Ampulla of Vater Using Multidetector CT

Purpose

To determine the multidetector CT (MDCT) findings that differentiate adenomyoma of the ampulla of Vater (AOV) from localized adenocarcinoma of the AOV.

Materials and Methods

Sixteen and 30 patients with adenomyoma and localized adenocarcinoma of the AOV, respectively, were evaluated using MDCT. We analyzed the size and attenuation value and presence of uniform enhancement of the lesions, diameters of the extrahepatic bile duct (EHD) and main pancreatic duct, presence of regional lymph node enlargement, and laboratory findings. We determined the independent findings for differentiating adenomyoma from localized adenocarcinoma of the AOV using multivariate analysis.

Results

The size of the lesion and diameter of the EHD were significantly smaller for adenomyoma than those for localized adenocarcinoma of the AOV (all p < 0.001). In multivariate analyses, a lesion size of ≤ 1.3 cm, an EHD diameter of ≤ 1.3 cm, and an alanine transaminase level of ≤ 31 IU/L significantly differentiated adenomyoma from localized adenocarcinoma of the AOV. When all of these three findings were met, the specificity for adenomyoma of the AOV was 93.3%.

Conclusion

MDCT imaging may facilitate the differential diagnosis of adenomyoma and localized adenocarcinoma of the AOV based on the size of the lesion and diameter of the EHD.

Adenomyomatosis of the Common Bile Duct and Ampulla of Vater

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.

Combination of Adenomyoma and Adenomyomatous Hyperplasia of the Ampullary System: A First Case Report

Adenomyoma and adenomyomatous hyperplasia are benign tumor-like lesions that rarely involve the major or minor duodenal papilla. We report the case of a 73-year-old patient who underwent a cephalic duodenopancreatectomy due to clinical and radiological evidence of underlying malignant neoplasm. The histopathology results revealed the unusual association of a major duodenal papilla adenomyoma and an adenomyomatous hyperplasia of the minor papilla. Because of their resemblance to pancreatic malignancy, the diagnosis of these lesions is particularly challenging. In most cases, it is established postoperatively, after histopathological examination of the surgical specimen.

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.