Ampulla of Vater

From Libre Pathology
Revision as of 10:37, 18 October 2012 by Michael (talk | contribs) (tweak)
Jump to navigation Jump to search
The printable version is no longer supported and may have rendering errors. Please update your browser bookmarks and please use the default browser print function instead.

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, when duodenal pathology is considered.

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:

Sign out

See tubular adenoma.

Ampullary carcinoma

  • AKA ampullary adenocarcinoma.

General

Gross

  • Ampullary carcinomas are classified by site.
  • Modest differences exist in survival between the sites.

Classification

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

Subtype Prevalence Origin/definition Notes
Intra-ampullary papillary-tubular carcinoma ~25% of cases arises from intra-ampullary epithelium and/or distal end of CBD or pancreatic duct generalized category intra-ampullary papillary-tubular neoplasm -- the ampullary counterpart of the IPMN of the pancreas
Ampullary-ductal carcinoma ~15% of cases arises from intra-ampullary ducts
Peri-ampullary duodenal carcinoma ~5% of cases primarily in the duodenum; ampullary orfice must be clearly within lesion
Ampullary carcinoma not otherwise specified ~55% of cases arise from papillary projection into duodenum - from foveolar-like epithelium with goblet cells

Microscopic

Dependent on histologic subtype:[1][6]

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

Notes:

  • May lack desmoplastic stroma.[3]

DDx:

Intestinal ampullary carcinoma

Features:[1]

  • Pseudostratified columnar epithelium with hyperchromatic, ellipsoid nuclei.
    • Glands usually tightly packed, i.e. high gland-to-stroma ratio; often >2:1.

Note:

Pancreatobiliary ampullary carcinoma

Features:[1]

  • Tubular arrangements consisting of cuboidal cells in one or two layers.
    • Tubules usually spaced; ~1:3 gland-to-stroma ratio.

Other

Features - any of the following characteristics:[1]

  • Non-tubular morphology/poorly-differentiated.
  • Micropapillary architecture.
  • Medullary.
  • Signet ring cells.
  • Mucin:
    1. Colloid.
    2. Mixed-mucinous.
    3. Mucinous-signet-ring.

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]
  • p53 +ve ~55% of cases.[9][10]
  • E-cadherin +ve ~40% of cases.[11]
  • Beta-catenin +ve ~65% of cases.[11]

Sign out

  • Separate CAP protocol.[12]

See also

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 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. Takashima, M.; Ueki, T.; Nagai, E.; Yao, T.; Yamaguchi, K.; Tanaka, M.; Tsuneyoshi, M. (Dec 2000). "Carcinoma of the ampulla of Vater associated with or without adenoma: a clinicopathologic analysis of 198 cases with reference to p53 and Ki-67 immunohistochemical expressions.". Mod Pathol 13 (12): 1300-7. doi:10.1038/modpathol.3880238. PMID 11144926.
  10. Park, SH.; Kim, YI.; Park, YH.; Kim, SW.; Kim, KW.; Kim, YT.; Kim, WH. (Jan 2000). "Clinicopathologic correlation of p53 protein overexpression in adenoma and carcinoma of the ampulla of Vater.". World J Surg 24 (1): 54-9. PMID 10594204.
  11. 11.0 11.1 Park, S.; Kim, SW.; Lee, BL.; Jung, EJ.; Kim, WH.. "Expression of E-cadherin and beta-catenin in the adenoma-carcinoma sequence of ampulla of Vater cancer.". Hepatogastroenterology 53 (67): 28-32. PMID 16506371.
  12. URL: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2012/Ampulla_12protocol_3101.pdf. Accessed on: 12 September 2012.