Carcinoid tumor of the ampulla of Vater presenting with biliary obstruction: report of four cases

Duodenal Epithelial Neoplasms Complicating von Recklinghausen's Disease: An Immunohistochemical Analysis in Two Patients

The authors report two patients with von Recklinghausen's disease and carcinoid tumors of the duodenum; one patient, in addition, also showed complications of an adenocarcinoma of the ampulla of Vater and multiple schwannomas, while the other patient was associated with an leiomyoblastoma of the duodenum. Histologically, both carcinoid tumors demonstrated glandular structures and psammoma bodies. Immunohistochemically, both carcinoid tumors stained diffusely positive against somatostatin. Duodenal carcinoid tumors associated with von Recklinghausen disease are characterized by originating in an ampullary lesion, by the presence of glandular structures, psammoma bodies, or both, and by being rich in somatostatin. A high prevalence of duodenal carcinoids has previously been recognized in patients with von Recklinghausen's disease, however, the association of adenocarcinoma of the small intestine and von Recklinghausen's disease is extremely rare.

[Von Recklinghausen type I neurofibromatosis and neuroendocrine tumor (somatostatinoma) in a 50-year-old woman]

HISTORY AND CLINICAL FINDINGS

A 50-year-old woman has had diffuse abdominal symptoms for approximately 2 weeks. For 30 years a von Recklinghausen's neurofibromatosis has been known.

INVESTIGATIONS

Clinically and chemically there was a cholestasis (alkaline phosphatase 244 U/l, gamma GT 83 U/l) with uneventful values for transaminases and bilirubin. The hepatitis serology (A, B, C) as well as the AMA were negative. Somatostatin with 73 ng/l was slightly increased. Ultrasonography revealed a low-grade intrahepatic cholestasis, the ductus pancreaticus was extended to 9 mm, while endoscopic retrograde cholangiopancreatography showed an extended pancreatic duct without inflamed changes as well as an extended intra- and extrahepatic gall duct system without detecting a stone. The oesophagogastroduodenoscopy showed a polypoid tumor 3 cm above the Papilla Vateri which is part of a neuroendocrine tumor of the carcinoid type, immunoreactive towards somatostatin.

TREATMENT AND COURSE

In the framework of the surgical intervention carried out by extirpation of the polypoid tumor above the Papilla Vateri by segment excision with a duodeno-duodenostomy. Within a period of 15 months, the patient was free from a tumor relapse or metastasis.

CONCLUSION

Carcinoid tumors should always be considered in patients who have von Recklinghausen's neurofibromatosis in combination with abdominal pain in the duodenal area, especially if cholestasis parameters and bilirubin are high or if gastrointestinal bleeding occurs.

Ampullary somatostatinoma associated with von Recklinghausen's neurofibromatosis presenting as obstructive jaundice

A case of von Recklinghausen's disease associated with a somatostatinoma of the pancreas causing obstructive jaundice is described. Discussion on the association of von Recklinghausen's disease with somatostatinoma is presented.

Carcinoid of the ampulla of Vater. Clinical characteristics and morphologic features

BACKGROUND

Carcinoid tumors of the gastrointestinal tract are most common localized in the appendix, followed by the small intestine, the rectum, and the stomach. The localization of these tumors at the ampulla of Vater is extremely seldom.

METHODS

In the present study the authors describe two patients with carcinoid tumors of the ampulla Vater and review 71 previously published cases.

RESULTS

Most patients presented with jaundice, but without carcinoid syndrome. Because the tumor grows submucosally, preoperative diagnosis was correct only in 15%. Most tumors were around 2 cm in size. Metastasis to lymph nodes and/or liver was present in 45%. Standard treatment is Whipple resection or local excision in small tumors.

CONCLUSIONS

Carcinoid tumors of the ampulla of Vater are an extremely rare clinical entity. Generally, the prognosis is good with a 5-year survival period of 90%.

Carcinoid of the ampulla of Vater. Local resection or pancreaticoduodenectomy

BACKGROUND

Carcinoid of the ampulla of Vater is a rare lesion that may produce obstructive jaundice. Analysis of nodal involvement as a function of primary tumor sizes indicated that metastases occur with tumors smaller than 2.0 cm. The case of a 36-year-old woman is presented and the literature reviewed in an attempt to define the treatment of choice.

METHODS

The English literature was reviewed, and 27 cases including the current one were identified. All cases were traced to the original case report. Clinical outcome data were tabulated.

RESULTS

The mean age of the sample group was 48.5 years, with 52% men and 48% women. Jaundice occurred in 60% of patients. Ampullary carcinoid developed in nine patients in association with von Recklinghausen disease. Treatment included pancreaticoduodenectomy, local excision, and biliary-enteric and endoscopic stenting. Seven patients had positive nodes. Four had metastatic disease at the time of surgical treatment. Long-term survivals of 5.5 years and 5 years were achieved after local excision and pancreaticoduodenectomy, respectively.

CONCLUSIONS

Long-term survival is possible after local excision or pancreaticoduodenectomy.

Clinical relevance of gastric and duodenal polyps

Gastric and duodenal epithelial polyps are almost always diagnosed incidentally and constitute a clinical problem for treatment and follow-up. All histologic types of these polyps are described, as are the clinical settings in which they are found. Endoscopy, often with snare polypectomy, is essential to obtain a certain histologic diagnosis. Guidelines are given for treatment and follow-up.