Difference between revisions of "Ampulla of Vater"

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(→‎IHC: tweak)
(→‎Ampullary adenocarcinoma: rename, add subclassification)
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:''See [[tubular adenoma of the gastrointestinal tract|tubular adenoma]]''.
:''See [[tubular adenoma of the gastrointestinal tract|tubular adenoma]]''.


==Ampullary adenocarcinoma==
==Ampullary carcinoma==
*[[AKA]] ''ampullary carcinoma''.
*[[AKA]] ''ampullary adenocarcinoma''.
===General===
===General===
*Uncommon.  
*Uncommon.  
*Textbook association: [[familial adenomatous polyposis]].<ref name=pmid15756395>{{Cite journal  | last1 = Tran | first1 = TC. | last2 = Vitale | first2 = GC. | title = Ampullary tumors: endoscopic versus operative management. | journal = Surg Innov | volume = 11 | issue = 4 | pages = 255-63 | month = Dec | year = 2004 | doi =  | PMID = 15756395 }}</ref><ref name=pmid9834381>{{Cite journal  | last1 = Soravia | first1 = C. | last2 = Berk | first2 = T. | last3 = Haber | first3 = G. | last4 = Cohen | first4 = Z. | last5 = Gallinger | first5 = S. | title = Management of advanced duodenal polyposis in familial adenomatous polyposis. | journal = J Gastrointest Surg | volume = 1 | issue = 5 | pages = 474-8 | month =  | year =  | doi =  | PMID = 9834381 }}</ref>
*Textbook association: [[familial adenomatous polyposis]].<ref name=pmid15756395>{{Cite journal  | last1 = Tran | first1 = TC. | last2 = Vitale | first2 = GC. | title = Ampullary tumors: endoscopic versus operative management. | journal = Surg Innov | volume = 11 | issue = 4 | pages = 255-63 | month = Dec | year = 2004 | doi =  | PMID = 15756395 }}</ref><ref name=pmid9834381>{{Cite journal  | last1 = Soravia | first1 = C. | last2 = Berk | first2 = T. | last3 = Haber | first3 = G. | last4 = Cohen | first4 = Z. | last5 = Gallinger | first5 = S. | title = Management of advanced duodenal polyposis in familial adenomatous polyposis. | journal = J Gastrointest Surg | volume = 1 | issue = 5 | pages = 474-8 | month =  | year =  | doi =  | PMID = 9834381 }}</ref>
====Classification====
Adsay ''et al.'' proposed a four subtype classification system:<ref name=pmid23026934>{{Cite journal  | last1 = Adsay | first1 = V. | last2 = Ohike | first2 = N. | last3 = Tajiri | first3 = T. | last4 = Kim | first4 = GE. | last5 = Krasinskas | first5 = A. | last6 = Balci | first6 = S. | last7 = Bagci | first7 = P. | last8 = Basturk | first8 = O. | last9 = Bandyopadhyay | first9 = S. | title = Ampullary Region Carcinomas: Definition and Site Specific Classification with Delineation of Four Clinicopathologically and Prognostically Distinct Subsets in an Analysis of 249 Cases. | journal = Am J Surg Pathol | volume =  | issue =  | pages =  | month = Sep | year = 2012 | doi = 10.1097/PAS.0b013e31826399d8 | PMID = 23026934 }}</ref>
{| class="wikitable sortable"
! Subtype
! Prevalence
! Definition
! Subclassification
|-
| Intra-ampullary carcinoma
| ~25% of cases
| intra-ampullary epithelium and/or distal end of CBD or pancreatic duct
|
|-
| Ampullary-ductal carcinoma
| ~15% of cases
| arise from intra-ampullary ducts
|
|-
| Peri-ampullary duodenal carcinoma
| ~5% of cases
| primary duodenal, ampullary orficie must be clearly within lesion
| (1) intestinal type, (2) mixed mucinous-intestinal type
|-
| Ampullary carcinoma not otherwise specified
| ~55% of cases
| arise from papillary projection into duodenum - from foveolar-like epithelium with goblet cells
|
|}


===Microscopic===
===Microscopic===
Features:
Features:
*Dependent on subtype.
*Dependent on subtype:<ref name=pmid15549428/><ref name=pmid23026934>
*#Intestinal ampullary carcinoma.
*#Pancreaticobiliary ampullary carcinoma.
*#Other.


Notes:
Notes:
*May lack desmoplastic stroma.<ref name=Ref_Sternberg5_1640>{{Ref Sternberg5|1640}}</ref>
*May lack desmoplastic stroma.<ref name=Ref_Sternberg5_1640>{{Ref Sternberg5|1640}}</ref>
Main subtypes:<ref name=pmid15549428/>
*Intestinal ampullary carcinoma.
*Pancreatobiliary ampullary carcinoma.


DDx:
DDx:
*[[Invasive ductal carcinoma of the pancreas]].
*[[Invasive ductal carcinoma of the pancreas]] - has a much worse prognosis.
*Ectopic pancreas.<ref name=pmid18304504>{{Cite journal  | last1 = Hsu | first1 = SD. | last2 = Chan | first2 = DC. | last3 = Hsieh | first3 = HF. | last4 = Chen | first4 = TW. | last5 = Yu | first5 = JC. | last6 = Chou | first6 = SJ. | title = Ectopic pancreas presenting as ampulla of Vater tumor. | journal = Am J Surg | volume = 195 | issue = 4 | pages = 498-500 | month = Apr | year = 2008 | doi = 10.1016/j.amjsurg.2007.01.043 | PMID = 18304504 }}
*Ectopic pancreas.<ref name=pmid18304504>{{Cite journal  | last1 = Hsu | first1 = SD. | last2 = Chan | first2 = DC. | last3 = Hsieh | first3 = HF. | last4 = Chen | first4 = TW. | last5 = Yu | first5 = JC. | last6 = Chou | first6 = SJ. | title = Ectopic pancreas presenting as ampulla of Vater tumor. | journal = Am J Surg | volume = 195 | issue = 4 | pages = 498-500 | month = Apr | year = 2008 | doi = 10.1016/j.amjsurg.2007.01.043 | PMID = 18304504 }}
</ref>
</ref>

Revision as of 23:44, 16 October 2012

The ampulla of Vater, also hepatopancreatic ampulla, is found in the duodenum. It has a unique histology and is a relatively common site of disease.

Normal histology

Features:[1]

  • Complex folding of epithelium - may for papillae.
  • +/-Pancreatic heterotopia - common.
  • +/-Gastric heterotopia - not common.

Ampullary tumours

  • AKA tumours of the ampulla of Vater.
  • AKA tumours of the hepatopancreatic ampulla.

Ampullary adenoma

General

Microscopic

Features:

  • +/-Paneth cells - may be prominent.[2]
  • Similar to adenoma of colon - with:
    • Less pseudostratification.
    • Finer chromatin pattern.

DDx:

Sign out

See tubular adenoma.

Ampullary carcinoma

  • AKA ampullary adenocarcinoma.

General

Classification

Adsay et al. proposed a four subtype classification system:[5]

Subtype Prevalence Definition Subclassification
Intra-ampullary carcinoma ~25% of cases intra-ampullary epithelium and/or distal end of CBD or pancreatic duct
Ampullary-ductal carcinoma ~15% of cases arise from intra-ampullary ducts
Peri-ampullary duodenal carcinoma ~5% of cases primary duodenal, ampullary orficie must be clearly within lesion (1) intestinal type, (2) mixed mucinous-intestinal type
Ampullary carcinoma not otherwise specified ~55% of cases arise from papillary projection into duodenum - from foveolar-like epithelium with goblet cells

Microscopic

Features:

  • Dependent on subtype:[6]Cite error: Closing </ref> missing for <ref> tag

DDx:

IHC

Features:[6]

  • CK7 +ve.
  • CK20 +ve.
  • MUC2 +ve.

Others:

  • SMAD4 +ve/-ve.
    • Lost in pancreatic neoplasia ~90% of cases vs. ~35% of ampullary tumours.[8]

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  • Separate CAP protocol.[9]

See also

References

  1. ↑ Mills, Stacey E; Carter, Darryl; Greenson, Joel K; Reuter, Victor E; Stoler, Mark H (2009). Sternberg's Diagnostic Surgical Pathology (5th ed.). Lippincott Williams & Wilkins. pp. 1639. ISBN 978-0781779425.
  2. ↑ Mills, Stacey E; Carter, Darryl; Greenson, Joel K; Reuter, Victor E; Stoler, Mark H (2009). Sternberg's Diagnostic Surgical Pathology (5th ed.). Lippincott Williams & Wilkins. pp. 1640. ISBN 978-0781779425.
  3. ↑ Tran, TC.; Vitale, GC. (Dec 2004). "Ampullary tumors: endoscopic versus operative management.". Surg Innov 11 (4): 255-63. PMID 15756395.
  4. ↑ Soravia, C.; Berk, T.; Haber, G.; Cohen, Z.; Gallinger, S.. "Management of advanced duodenal polyposis in familial adenomatous polyposis.". J Gastrointest Surg 1 (5): 474-8. PMID 9834381.
  5. ↑ Adsay, V.; Ohike, N.; Tajiri, T.; Kim, GE.; Krasinskas, A.; Balci, S.; Bagci, P.; Basturk, O. et al. (Sep 2012). "Ampullary Region Carcinomas: Definition and Site Specific Classification with Delineation of Four Clinicopathologically and Prognostically Distinct Subsets in an Analysis of 249 Cases.". Am J Surg Pathol. doi:10.1097/PAS.0b013e31826399d8. PMID 23026934.
  6. ↑ 6.0 6.1 Fischer, HP.; Zhou, H. (2004). "Pathogenesis of carcinoma of the papilla of Vater.". J Hepatobiliary Pancreat Surg 11 (5): 301-9. doi:10.1007/s00534-004-0898-3. PMID 15549428.
  7. ↑ Hsu, SD.; Chan, DC.; Hsieh, HF.; Chen, TW.; Yu, JC.; Chou, SJ. (Apr 2008). "Ectopic pancreas presenting as ampulla of Vater tumor.". Am J Surg 195 (4): 498-500. doi:10.1016/j.amjsurg.2007.01.043. PMID 18304504.
  8. ↑ McCarthy, DM.; Hruban, RH.; Argani, P.; Howe, JR.; Conlon, KC.; Brennan, MF.; Zahurak, M.; Wilentz, RE. et al. (Mar 2003). "Role of the DPC4 tumor suppressor gene in adenocarcinoma of the ampulla of Vater: analysis of 140 cases.". Mod Pathol 16 (3): 272-8. doi:10.1097/01.MP.0000057246.03448.26. PMID 12640108.
  9. ↑ URL: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2012/Ampulla_12protocol_3101.pdf. Accessed on: 12 September 2012.
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