Difference between revisions of "Ampulla of Vater"

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DDx:
 
DDx:
 
*[[Ampullary carcinoma]].
 
*[[Ampullary carcinoma]].
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*[[Duodenal carcinoma]] secondarily involving the ampulla.
 +
*[[Pancreatic adenocarcinoma]] secondarily involving the ampulla.
  
 
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Revision as of 23:53, 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

Periampullary:[1]

  • Intestinal epithelium with goblet cells.

Papilla of Vater (the projection into the duodenal lumen):[1]

  • Goblet cells in foveolar-like epithelium.

Note about heterotopias:[2]

  • +/-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.[3]
  • Similar to adenoma of colon - with:
    • Less pseudostratification.
    • Finer chromatin pattern.

DDx:

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See tubular adenoma.

Ampullary carcinoma

  • AKA ampullary adenocarcinoma.

General

Classification

Adsay et al. proposed a four subtype classification system:[1]

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][1]
    1. Intestinal ampullary carcinoma.
    2. Pancreaticobiliary ampullary carcinoma.
    3. Other.

Notes:

  • May lack desmoplastic stroma.[3]

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. 1.0 1.1 1.2 1.3 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.
  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. 1639. ISBN 978-0781779425.
  3. 3.0 3.1 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. 1640. ISBN 978-0781779425.
  4. Tran, TC.; Vitale, GC. (Dec 2004). "Ampullary tumors: endoscopic versus operative management.". Surg Innov 11 (4): 255-63. PMID 15756395.
  5. 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.
  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.