Survival benefit of concurrent chemoradiotherapy for advanced ampulla of Vater cancer

BACKGROUND Currently,there is no standard adjuvant therapy for patients with resected ampulla of Vater(AoV)cancer.AIM To evaluate the effectiveness of adjuvant concurrent chemoradiotherapy(CCRT)in patients with advanced AoV cancer who underwent curative resection.METHODS This single-centered,retrospective study included 29 patients with advanced AoV cancer who underwent pancreaticoduodenectomy between 2006 and 2018.The impact of CCRT on advanced AoV cancer was analyzed.RESULTS The 1-,3-,and 5-yr recurrence-free survival(RFS)rates for patients with advanced AoV cancer were 82.8%,48.3%,and 40.8%,respectively,and the overall survival(OS)rates were 89.7%,62.1%,and 51.7%,respectively.Lymphovas-cular invasion was found to be a significant risk factor for RFS and OS in patients with advanced AoV cancer in the univariate analysis,whereas T stage and lymph node metastasis were significantly associated with OS in the multivariate analysis.Compared to the patients who did not receive adjuvant CCRT,those who received adjuvant CCRT did not show statistically significant improvements in the RFS and OS,although they had a significantly lower average age and significantly higher platelet-to-lymphocyte ratio.CONCLUSION Adjuvant CCRT did not improve survival outcomes in patients with advanced AoV cancer.These findings contribute to existing knowledge on the effectiveness of CCRT in this patient population and provide important insights for clinical decision-making.

Role of adjuvant chemotherapy on recurrence and survival in patients with resected ampulla of Vater carcinoma

BACKGROUND Owing to rarity of disease and lack of prospective studies, data supporting the role of adjuvant chemotherapy in ampulla of Vater(AoV) carcinoma is limited.AIM To evaluate whether adjuvant chemotherapy cases for AoV carcinoma had better disease-free survival(DFS) rates than cases of observation following curative surgery.METHODS We retrospectively analyzed the association between adjuvant chemotherapy and DFS and overall survival(OS) in patients with stage IB-Ⅲ AoV carcinoma who underwent curative surgical resection. Fluorouracil-based adjuvant chemotherapy was administered after surgery at the discretion of the physician. Adjusted multivariate regression models were used to evaluate the association between adjuvant chemotherapy and survival outcomes.RESULTS Of the total 104 patients who underwent curative surgery, 52 received adjuvant chemotherapy. Multivariate analysis revealed that higher histologic grade [hazard ratio(HR) = 2.24, P = 0.046], advanced tumor stage(HR = 1.85, P = 0.030), and vascular invasion(HR = 2.14, P = 0.010) were associated with shorter DFS. Adjuvant chemotherapy improved DFS compared to the observation group(HR =0.50, P = 0.015) and tended to be associated with a longer OS, although the difference was not statistically significant(HR = 0.58, P = 0.098).CONCLUSION Among patients with resected AoV carcinoma, the adjuvant chemotherapy group was not associated with a significant survival benefit compared to the observation group. However, on multivariate analysis adjusting for prognostic factors, adjuvant chemotherapy following surgery was an independent prognostic factor for DFS in patients with resected AoV carcinoma. Further studies are needed to investigate the effectiveness of adjuvant chemotherapy according to histologic phenotype.

Neuroendocrine carcinoma of the ampulla of Vater:a clinicopathologic evaluation

BACKGROUND:Only 105 cases of neuroendocrine tumor(NET)of the ampulla of Vater have been described, mostly as single case reports.The incidence of NET is rising.The changes in incidence may result from changes in detection.This study was to determine the relative incidence and clinicopathological characteristics of high- grade neuroendocrine carcinoma(small cell carcinoma and large cell carcinoma)of the ampulla of Vater at a single institution. METHODS:Sections from paraffin blocks of tumors of the ampulla of Vater taken from 45 patients who underwent Whipple’s procedure and 6 patients who underwent palliative bypass between September 2003 and January 2007 were subjected to immunohistochemical analysis.The clinical and pathological data from 5 patients diagnosed with NET of the ampulla of Vater were analyzed. RESULTS:The patients were 3 men and 2 women,ranging in age from 39 to 47 years(mean 44 years).Operative procedures included Whipple’s procedure in 4 patients and palliative bypass in 1 patient.Histopathological examination revealed large-cell neuroendocrine carcinoma in 2 patients,small cell carcinoma in 2,and carcinoid in 1.Three patients with high-grade neuroendocrine carcinoma who had undergone Whipple’s procedure died at postoperatively 7,11,and 13 months.The patient who had undergone palliative triple bypass died 3 months after surgery.CONCLUSIONS:The relative incidence of high-grade neuroendocrine carcinomas of the ampulla of Vater is higher than that generally expected.The tumors behave aggressively and have a dismal prognosis despite aggressive treatment.

Rare histological subtype of invasive micropapillary carcinoma in the ampulla of Vater: A case report

BACKGROUND Carcinoma of the ampulla of Vater is an uncommon ampullo-pancreatobiliary neoplasm,and the most common histological type is adenocarcinoma with a tubular growth pattern.Invasive micropapillary carcinoma(IMPC)is an aggressive variant of adenocarcinoma in several organs that is associated with lymph node metastasis and poor prognosis.IMPC was first described as a histological subtype of breast cancer;however,IMPC of the ampulla of Vater is extremely rare,with only three articles reported in the English literature.CASE SUMMARY We have reported a case of IMPC of the ampulla of Vater in an 80-year-old man.Microscopically,the surface area of the carcinoma was composed of tubulopapillary structures mimicking intra-ampullary papillary-tubular neoplasm,and the deep invasive front area exhibited a pattern of IMPC.The carcinoma showed lymphatic invasion and extensive lymph node metastasis.The immunohistochemical study revealed mixed intestinal and gastric/pancreatobiliary phenotypes.CONCLUSION This rare subtype tumor in the ampulla of Vater showed a histologically mixed phenotype and exhibited aggressive behavior.

Prognostic relevance of number and ratio of metastatic lymph nodes in resected carcinoma of the ampulla of Vater

Objectives： To explore the prognostic relevance of the number and ratio of metastatic lymph nodes in resected Carcinoma of the ampulla of Vater （CAV）. Methods： The clinical data of 155 patients who underwent pancreaticoduodenectomy （PD） for cancer of the ampulla of Vater between January 1990 and December 2010 were retrospectively analyzed. Kaplan- Meier method was used in survival analysis and Log rank method in comparison. Multivariate analysis was performed using Cox proportional hazards model. Results： Among these 155 patients, the in-hospital mortality rate was 4.5%, lymph node positive disease was 21.3%, and the 5-year survival rate was 51.6%. Patients with a lymph node ratio （LNR） 〉20% were more likely to have tumor differentiation, depth of duodenal involvement, depth of pancreatic invasion, T-stage and TNM-Stage. The number of the metastatic lymph nodes is important prognostic factors of the CAV. Univariate analysis showed that the factors associated with the prognosis included tumor size （P=0.036）, tumor differentiation （P=0.019）, LNR （P=0.032）, mtmber of metastatic lymph nodes （P=0.024）, lymph node metastasis （P=0.03）, depth of pancreatic invasion （P=0.001）, T-stage （P=0.002）, TNM stage （P=0.001）, elevated CA 19-9 （P=0.000）, and jaundice （P=0.021）. Multivariate analysis showed that the factors associated with the prognosis were the number of metastatic lymph nodes （P=0.032; RR： 1.283; 95% CI： 1.022-1.611）, tumor size （P=0.043; RR： 1.736; 95% CI： 1.017-2.963）, and elevated CA 19-9 （P=0.003; RR： 3.247; 95% CI： 1.504-7.010）. Conclusions： LNR is a useful factor for predicting the prognosis of the radical treatment for CAV,, whereas the number of metastatic lymph nodes is the most important factor. Further research on the locations, number, and LNR will be clinically meaningful to improve survival in patients with CAV.

Melanoma in the ampulla of Vater

BACKGROUND:The most common tumors in the ampulla of Vater are adenocarcinomas.Although malignant melanoma usually occurs on the skin,it can also arise in the gastrointestinal and biliary tract.METHOD:We present a case of a 52-year-old,previously healthy man who presented with painless jaundice.RESULTS:Clinical examination revealed dilated intrahepatic and extrahepatic bile ducts and pancreatic duct due to the obstructive mass in the ampulla of Vater.The patient underwent pancreaticoduodenectomy and histopathological diagnosis of the resected tumor mass was malignant melanoma.Thorough clinical examination was preformed,but no other primary or metastatic site of melanoma could be found.In the next few months,the patient developed multiple liver metastases and died.CONCLUSION:An isolated amelanotic lesion in the ampulla of Vater can be a potential diagnostic pitfall,especially in patients who have had melanoma.

Large cell neuroendocrine carcinoma of the ampulla of Vater

BACKGROUND: Neuroendocrine tumors of the ampulla of Vater are extremely rare, and few cases of large cell neuroendocrine carcinoma (LCNEC) of the ampulla have been reported. METHODS: A 48-year-old male with obstructive jaundice was admitted to our hospital. On examination the patient was found to have a periampullary growth and subsequently underwent the Whipple's procedure. RESULTS: Histopathological examination and immunohistochemistry revealed features of LCNEC of the ampulla of Vater. The patient developed multiple liver metastases 6 months after Whipple's procedure. CONCLUSION: LCNEC of the ampulla of Vater is rare and highly aggressive, with a dismal prognosis.

Acute cholangitis detected ectopic ampulla of Vater in the antrum incidentally: A case report

BACKGROUND The ampulla of Vater is an opening at the confluence of the common bile duct and pancreatic duct.It is located in the second portion of the duodenum.An ectopic papilla of Vater is an anomalous termination.Few cases have been reported.We report the rare case of a man with an ectopic ampulla of Vater in the pylorus.CASE SUMMARY An 82-year-old man had experienced abdominal pain and fever with chills 1 d before his presentation.A computed tomography scan of the abdomen demonstrated dilatation of the common bile duct approximately 2.2 cm in width.Gas retention was found in his intrahepatic ducts.Acute cholangitis with pneumobilia was identified,and he was hospitalized.Esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography disclosed no ampulla of Vater in the second portion of the duodenum.Moreover,a capsule-like foreign body(pharmaceutical desiccant)approximately 1 cm×2 cm in size was found at the gastric antrum and peri-pyloric region.After the foreign body was removed,one orifice presented over the pyloric ring in the stomach,a suspected ectopic ampulla of Vater.Subsequently,sludge in the common bile duct was cleaned,and balloon dilatation was performed.The general condition improved daily.The patient was discharged in a stable condition and followed in our outpatient department.CONCLUSION This case involved an ampulla of Vater in an unusual location.Endoscopic retrograde cholangiopancreatography with balloon dilatation is the main treatment recommended and performed.

Ectopic pancreas at the ampulla of Vater diagnosed with endoscopic snare papillectomy: A case report and review of literature

BACKGROUND Ectopic pancreas is a rare developmental anomaly that results in a variety of clinical presentations.Patients with ectopic pancreas are mostly asymptomatic,and if symptomatic,symptoms are usually nonspecific and determined by the location of the lesion and the various complications arising from it.Ectopic pancreas at the ampulla of Vater(EPAV)is rare and typically diagnosed after highly morbid surgical procedures such as pancreaticoduodenectomy or ampullectomy.To our knowledge,we report the first case of confirmed EPAV with a minimally invasive intervention.CASE SUMMARY A 71-year-old male with coronary artery disease,presented to us with new-onset dyspepsia with imaging studies revealing a‘double duct sign’secondary to a small subepithelial ampullary lesion.His hematological and biochemical investigations were normal.His age,comorbidity,poor diagnostic accuracy of endoscopy,biopsies and imaging techniques for subepithelial ampullary lesions,and suspicion of malignancy made us acquire histological diagnosis before morbid surgical intervention.We performed balloon-catheter-assisted endoscopic snare papillectomy which aided us to achieve en bloc resection of the ampulla for histopathological diagnosis and staging.The patient’s post-procedure recovery was uneventful.The en bloc resected specimen revealed ectopic pancreatic tissue in the ampullary region.Thus,the benign histopathology avoided morbid surgical intervention in our patient.At 15 mo follow-up,the patient is asymptomatic.CONCLUSION EPAV is rare and remains challenging to diagnose.This rare entity should be included in the differential diagnosis of subepithelial ampullary lesions.Endoscopic en bloc resection of the papilla may play a vital role as a diagnostic and therapeutic option for preoperative histological diagnosis and staging to avoid morbid surgical procedures.

Comparison of mismatch repair and immune checkpoint protein profile with histopathological parameters in pancreatic,periampullary/ampullary,and choledochal adenocarcinomas

BACKGROUND Pancreatic,periampullary/ampullary,and choledochal adenocarcinomas are aggressive malignancies with a poor prognosis.Immune checkpoint blockade is a promising treatment option for several tumor types.H long terminal repeatassociating 2(HHLA2),which is analogous to programmed death-ligand 1(PDL1),is a recently discovered member of the B7/cluster of differentiation 28 family and is expressed in many malignancies.AIM To analyze the expression of HHLA2 and its association with the pathologic biomarkers that predict sensitivity to immunotherapy.METHODS Ninety-two adenocarcinoma cases located in the pancreas,ampulla,and distal common bile duct were identified.This study assessed 106 pancreaticoduodenectomy and distal/total pancreatectomy samples that were delivered to Ankara City Hospital between 2019 and 2021.Immunohistochemistry was conducted to examine the expression of DNA mismatch repair(MMR),PD-L1,and HHLA2 proteins.RESULTS Patients with high HHLA2 expression had a higher mean age than those with low expression.Low HHLA2 expression was associated with high perineural invasion.HHLA2 expression was low in pathological stage T3(pT)3 cases and high in pathological stage T1,T2,and T4 cases.There was no correlation between HHLA2 expression and the expression of MMR proteins and PD-L1.CONCLUSION Evaluation of HHLA2 expression in microsatellite stable and PD-L1-negative tumors may be useful for predicting the response of individuals to immunotherapy and may serve as a novel therapeutic target for immunotherapy in advanced-stage disease.

Jaundice as a prognostic factor in patients undergoing radical treatment for carcinomas of the ampulla of Vater

Background Carcinomas of the ampulla of Vater （CAV） is a relatively rare malignant gastrointestinal tumor,and its postoperative prognostic factors have been well studied.However,as its first symptom,the impact of jaundice on the prognosis of CAV is not so clear.This study aims to explore the role of jaundice as a prognostic factor in patients undergoing radical treatment for CAV.Methods The clinical data of 195 patients with CAV who were treated in the Cancer Hospital,Chinese Academy of Medical Sciences ＆ Peking Union Medical College,from January 1989 to January 2013 were retrospectively analyzed.Among them,170 patients with pathologically confirmed CAV entered the statistical analysis.Jaundice was defined as a total bilirubin serum concentration of ≥3 mg/dl.Result Of these 170 patients,99 （58.20％） had jaundice at presentation.Jaundice showed significant correlations with tumor differentiation （P=0.002）,lymph node metastasis （P=0.016）,pancreatic invasion （P=0.000）,elevated preoperative CA199 （P=0.000）,depth of invasion （P=0.000）,and tumor stage （P=0.000）.There were more patients with pancreatic invasion in the jaundice group than in the non-jaundice group.Also,lymph node metastasis was more common in the jaundice group （n=26） than in the non-jaundice group （n=8）.The non-jaundice group had significant better overall 5-year disease-free survival （72.6％） than the jaundice group （41.2％,P=0.013）.Jaundice was not significantly correlated with the postoperative bleeding （P=-0.050）.Conclusions Jaundice in patients with CAV often predicts more advanced stages and poorer prognoses.Pancreatic invasion and lymph node metastasis are more common in CAV patients with jaundice.Jaundice is not a risk factor for postoperative bleeding and preoperative biliary drainage cannot reduce the incidence of postoperative complications.

Can pathologists reliably establish ampulla of Vater carcinoma histologic subtype on H&E alone?Concordance of subtype and comparison to immunohistochemistry-established subtype

Histologic subtyping of ampulla of Vater carcinoma(ampullary carcinoma,AC)may guide choice of adjuvant chemotherapy for advanced disease,as intestinal(INT)subtype may have a better treatment response and survival as compared to the pancreatobiliary(PB)and mixed(MIX)subtypes.However,ambiguous morphologic features can result in inconsistent subtyping among pathologists.Recently immunohistochemistry(IHC)for cytokeratin(CK)7,CK20,CDX2,and the Mucin(MUC)family proteins had been used to aid in the subtyping.It is important to determine if accurate subtyping can be achieved based on hematoxylin and eosin(H&E)evaluation alone,or if IHC is required.In this study,5 gastrointestinal pathologists evaluated 34 cases of AC for histologic subtype(PB,INT,or MIX)based on H&E stain alone.IHC studies(CK7,CK20,and CDX2)were used to determine a gold standard subtyping for comparison(strong CK7 with weak CK20 and CDX2=PB;strong CK20 or CDX2 and weak CK7=INT;strong CK7 and CK20 or CDX2=MIX).Interobserver concordance(kappa)was calculated.Percent correctness of subtyping was calculated in relation to IHC-established subtype gold standard.Interobserver concordance for subtype was fair(kappa 0.31).Percent correctness for subtype against IHC-established subtype was 50%for a majority(3 or more)of pathologists.In all 11 cases with 4 or 5 pathologists being concordant,the subtype was also correctly identified.In addition,data on chemotherapy regimen and overall survival was gathered from the electronic medical record.Patients who were assigned a subtype at time of diagnosis tended to receive gemcitabine for PB subtype,and FOLFOX-based therapy for INT subtype,with some cases diagnosed as"not-otherwise specified"typically also receiving gemcitabine.Survival data were limited by loss to follow-up.In conclusion,despite 11 cases with strong concordance and correctness,overall subtyping concordance was only fair,and a majority of the 5 pathologists correctly identified the subtype in only 50%of cases.Thus,while some AC cases yield clear-cut subtyping,significant discrepancy among pathologists remains.It appears that utilization of IHC to identify subtype in AC cases is necessary to provide accurate,reliable prognostic and therapeutic information.

Impact of periampullary diverticula on the outcome and fluoroscopy time in endoscopic retrograde cholangiopancreatography

BACKGROUND: It is unclear whether the presence of periampullary diverticula (PAD) affects technical success and complication rates during endoscopic retrograde cholangio- pancreatography (ERCP). Moreover, the impact of PAD on fluoroscopy duration is still unknown. The present study aimed to investigate the success rate and difficulty of common bile duct (CBD) cannulation, post-procedure complications and fluoroscopy duration in patients with and without PAD. METHODS: Patients from January 2008 to December 2010 with PAD (group A) and without PAD (group B) and similar indications for therapeutic ERCP were prospectively compared. The comparison included patient characteristics, findings of ERCP, and details of procedure and fluoroscopy time. The influence of papilla’s location with respect to the diverticulum on procedure was also investigated. RESULTS: A total of 428 consecutive patients who had undergone therapeutic ERCP for similar indications were divided in two groups according to the presence (group A, 107 patients) or absence (group B, 321 patients) of PAD. The mean age and ASA score of the patients with PAD were significantly higher than those patients without PAD. The main indication was choledocholithiasis. Successful final CBD cannulation was achieved in 97.20% of the patients in group A vs 99.69% in group B (P=0.05). CBD diameter, number of stones and the largest stone size were significantly higher in group A thangroup B (P【0.001). Complete clearance of the CBD after the first attempt was achieved in 85.86% and 94.75% of the patients in groups A and B, respectively (P=0.03). In both groups, the time needed to complete the procedure and fluoroscopy time was significantly longer in patients with PAD (22.87 vs 18.99 minutes, P【0.001; 76.51 vs 47.42 seconds, P【0.001). There was no significant difference between the two groups in the complication rate. The type of papilla’s location with respect to the diverticulum did not influence the total cannulation rate and post-procedure complications. CONCLUSION: The presence of a PAD does not affect the success rate and complications of therapeutic ERCP in expert hands; however, the fluoroscopy time is significantly longer in patients with PAD.

A rare synchrony of adenocarcinoma of the ampulla with an ileal gastrointestinal stromal tumor: A case report

BACKGROUND This is a unique case of a patient who was found to have two extremely rare primary malignancies synchronously,i.e.,an ampullary adenocarcinoma arising from a high-grade dysplastic tubulovillous adenoma of the ampulla of Vater(TVAoA)with a high-grade ileal gastrointestinal stromal tumor(GIST).Based on a literature review and to the best of our knowledge,this is the first report of this synchronicity.Primary ampullary tumors are extremely rare,with an incidence of four cases per million population,which is approximately 0.0004%.Distal duodenal polyps are uncommon and have a preponderance of occurring around the ampulla of Vater.An adenoma of the ampulla(AoA)may occur sporadically or with a familial inheritance pattern,as in hereditary genetic polyposis syndrome such as familial adenomatous polyposis syndrome(FAPS).We report a case of a 77-year-old male who was admitted for painless obstructive jaundice with a 40-pound weight loss over a two-month period and who was subsequently diagnosed with two extremely rare primary malignancies,i.e.,an adenocarcinoma of the ampulla arising from a high-grade TVAoA and a high-grade ileal GIST found synch-ronously.CASE SUMMARY A 77-year-old male was admitted for generalized weakness with an associated weight loss of 40 pounds in the previous two months and was noted to have painless obstructive jaundice.The physical examination was benign except for bilateral scleral and palmar icterus.Lab results were significant for an obstructive pattern on liver enzymes.Serum lipase and carbohydrate antigen-19-9 levels were elevated.Computed tomography(CT)of the abdomen and pelvis and magnetic resonance cholangiopancreatography were consistent with a polypoid mass at the level of the common bile duct(CBD)and the ampulla of Vater with CBD dilatation.The same lesions were visualized with endoscopic retrograde cholangiopancreatography.Histopathology of endoscopic forceps biopsy showed TVAoA.Histopathology of the surgical specimen of the resected ampulla showed an adenocarcinoma arising from the TVAoA.Abdominal and pelvic CT also showed a coexisting heterogeneously enhancing,lobulated mass in the posterior pelvis originating from the ileum.The patient underwent ampullectomy and resection of the mass and ileo-ileal side-to-side anastomosis followed by chemoradiation.Histopathology of the resected mass confirmed it as a high-grade,spindle cell GIST.The patient is currently on imatinib,and a recent follow-up positron emission tomography(PET)scan showed a complete metabolic response.CONCLUSION This case is distinctive because the patient was diagnosed with two synchronous and extremely rare high-grade primary malignancies,i.e.,an ampullary adenocarcinoma arising from a highgrade dysplastic TVAoA with a high-grade ileal GIST.An AoA can occur sporadically and in a familial inheritance pattern in the setting of FAPS.We emphasize screening and surveillance colonoscopy when one encounters an AoA in upper endoscopy to check for FAPS.An AoA is a premalignant lesion,particularly in the setting of FAPS that carries a high risk of metamorphism to an ampullary adenocarcinoma.Final diagnosis should be based on a histopathologic study of the surgically resected ampullary specimen and not on endoscopic forceps biopsy.The diagnosis of AoA is usually incidental on upper endoscopy.However,patients can present with constitutional symptoms such as significant weight loss and obstructive symptoms such as painless jaundice,both of which occurred in our patient.Patient underwent ampullectomy with clear margins and ileal GIST resection.Patient is currently on imatinib adjuvant therapy and showed complete metabolic response on follow up PET scan.

Comparison of clinicopathological characteristics between resected ampullary carcinoma and carcinoma of the second portion of the duodenum

BACKGROUND Few studies compared the oncological and biological characteristics between ampullary carcinoma(AC) and cancer of the second portion of the duodenum(DC-Ⅱ), although both tumors arise from anatomically close locations.AIM To elucidate differences in clinicopathological characteristics, especially the patterns of lymph node metastasis(LNM), between AC and DC-Ⅱ.METHODS This was a retrospective cohort study of 80 patients with AC and 27 patients with DC-Ⅱ who underwent pancreaticoduodenectomy between January 1998 and December 2018 in two institutions. Clinicopathological factors, LNM patterns, and prognosis were compared between the two groups.RESULTS The patients with AC and DC-Ⅱ did not exhibit significant differences in 5-year overall survival(66.0% and 67.1%, respectively) and 5-year relapse-free survival(63.5% and 62.2%, respectively). Compared to the patients with DC-Ⅱ, the rate of preoperative biliary drainage was higher(P = 0.042) and the rates of digestive symptoms(P = 0.0158), ulcerative-type cancer(P < 0.0001), large tumor diameter(P < 0.0001), and advanced tumor stage(P = 0.0019) were lower in the patients with AC. The LNM rates were 27.5% and 40.7% in patients with AC and DC-Ⅱ,respectively, without significant difference(P = 0.23). The rates of LNM to hepatic nodes(N-He)and pyloric nodes(N-Py) were significantly higher in patients with DC-Ⅱ than in those with AC(metastasis to N-HE: 18.5% and 5% in patients with DC-Ⅱ and AC, respectively;P = 0.0432;metastasis to N-Py: 11.1% and 0% in patients with DC-Ⅱ and AC, respectively;P = 0.0186)CONCLUSION Although there were no significant differences in the prognosis and recurrence rates between the two groups, metastases to N-He and N-Py were more frequent in patients with DC-Ⅱ than in those with AC.

Acute pancreatitis following endoscopic ampullary biopsy:A case report

BACKGROUND Endoscopic biopsy is mandatory for the diagnosis of malignant and premalignant ampullary tumours.The commonly reported inadvertent complications following routine mucosal biopsy include perforation and haemorrhage.Acute pancreatitis is an extremely rare complication following this procedure.CASE SUMMARY This report details the case of a 59-year-old man who underwent biopsy of the ampulla for a suspected periampullary tumour.Following the procedure,the patient presented with symptoms of acute pancreatitis which was substantiated by laboratory and radiological investigations.He was conservatively managed and discharged following complete resolution of symptoms.CONCLUSION This case report serves to highlight the importance of this potential complication following routine endoscopic biopsy of the ampulla.

Amiodarone hepatotoxicity complicating obstructive jaundice due to ampullary cancer

BACKGROUND:The presence of dual pathology can cause diagnostic dilemmas. We present a case of adenocarcinoma of the ampulla of Vater with concurrent amiodarone hepatotoxicity. METHODS:Painless jaundice associated with a palpable gallbladder was investigated clinically,radiologically endoscopically and via liver biopsy. RESULTS:Liver biopsy showed amiodarone hepatotoxicity Endoscopic biopsy identified an ampullary adenoma However,the endoscopic ultrasound and intra-operative findings suggested a malignancy,which was confirmed postoperatively. CONCLUSIONS:While the classic findings of Courvoisier’s Law are borne out in this case,the etiology of jaundice is twofold. Although dual pathology is uncommon it should always be considered.

miR-215 overexpression distinguishes ampullary carcinomas from pancreatic carcinomas

Distinguishing ampullary carcinoma from pancreatic carcinoma is important because of their different prognoses. microRNAs are differentially expressed according to the tissue of origin. However, there is rare research on the differential diagnosis between the two types of cancers by microRNA in periampullary cancers. The present study was undertaken to compare microRNA profiles between ampullary and pan- creatic carcinomas using microarrays, miR-215 was most significantly overexpressed in ampullary carcinomas; whereas the expressions of miR-134 and miR-214 were significantly lower in ampuUary carcinomas than in pancreatic carcino- mas. When these discriminatory microRNAs were applied to liver metastases, they were correctly predicted for the tissue of origin. Although this study is limited by small sample size, striking difference in microRNA expression and concordant expression of discriminating microRNAs in primary tumors and metastases suggest that these novel discriminatory mi- croRNAs warrant future validation.

Intra-ampullary papillary-tubular neoplasm combined with ampullary neuroendocrine carcinoma:A case report

BACKGROUND The ampulla of Vater is an anatomically and histologically complex region giving rise to a heterogenous group of tumors.This is,to the best of our knowledge,the first case of intra-ampullary papillary-tubular neoplasm combined with ampullary neuroendocrine carcinoma reported in the literature.CASE SUMMARY A 61-year-old woman presented to the emergency department for evaluation of painless jaundice.Contrast-enhanced computed tomography(CT)of the abdomen and chest showed a periampullary tumor mass measuring 15 mm×12 mm×14 mm,with no evidence of locoregional and distant metastases,for which she underwent pancreatoduodenectomy.Histopathologic examination of a resected specimen revealed an intra-ampullary papillary tubular neoplasm with highgrade dysplasia in combination with poorly differentiated grade 3 neuroendocrine carcinoma with a mitotic count of more than 20 mitoses per 10 high power fields and Ki-67 index of 100%.No positive lymph nodes were identified.Her postoperative course was uneventful.Postoperatively,she remained under close surveillance.Multiple liver metastases were observed on follow-up CT 8 mo after the surgery,so systemic therapy with cisplatin and etoposide was initiated.CONCLUSION The simultaneous occurrence of neuroendocrine and non-neuroendocrine tumors in the ampulla of Vater is rare and the pathogenesis of such tumors is largely unknown.Due to unpredictable clinical behavior and lack of solid evidence on optimal treatment strategy,close patient surveillance is advised after radical resection of the primary tumor.

Surgical ampullectomy:A comprehensive review

Tumours of the ampulla of Vater are relatively uncommon lesions of the digestive system.They are typically diagnosed at an earlier stage than other types of tumours in this region,due to their tendency to invoke symptoms by obstructing the bile duct or pancreatic duct.Consequently,many are potentially curable by excision.Surgical ampullectomy(SA)(or transduodenal ampullectomy)for an ampullary tumour was first described in 1899,but was soon surpassed by pancreatoduodenectomy(PD),which offered a more extensive resection resulting in a lower risk of recurrence.Ongoing innovation in endoscopic techniques over recent decades has led to the popularization of endoscopic papillectomy(EP),particularly for adenomas and even early cancers.The vast majority of resectable ampullary tumours are now treated using either PD or EP.However,SA continues to play a role in specific circumstances.Many authors have suggested specific indications for SA based on their own data,practices,or interpretations of the literature.However,certain issues have attracted controversy,such as its use for early ampullary cancers.Consequently,there has been a lack of clarity regarding indications for SA,and no evidence-based consensus guidelines have been produced.All studies reporting SA have employed observational designs,and have been heterogeneous in their methodologies.Accordingly,characteristics of patients and their tumours have differed substantially across treatment groups.Therefore,meaningful comparisons of clinical outcomes between SA,PD and EP have been elusive.Nevertheless,it appears that suitably selected cases of ampullary tumours subjected to SA may benefit from favourable peri-operative and long-term outcomes with very low mortality and significantly long survival,hence its role in this setting warrants further clarification,while it can also be useful in the management of specific benign entities.Whilst the commissioning of a randomised controlled trial seems unlikely,well-designed observational studies incorporating adjustments for confounding variables may become the best available comparative evidence for SA,potentially informing the eventual development of consensus guidelines.In this comprehensive review,we explore the role of SA in the modern management of ampullary lesions.