Carcinoid of the Ampulla of Vater-Report of two Cases

Neuroendocrine tumor of the ampulla of Vater showing chronological endoscopic changes

We report a rare case of neuroendocrine tumor of the ampulla of Vater in a 53-year-old Japanese male. The patient was admitted to our institution for workup of presyncope secondary to anemia. Medical history was pertinent for coronary artery disease, for which he had drug eluting stents (DES) placed and was on aspirin and clopidogrel therapy. Upper endoscopic evaluation revealed bleeding from an erosion at the ampulla of Vater. Endoscopic therapy with epinephrine and thrombin injection allowed for successful hemostasis and repeat endoscopy 6 months later did not show any changes in lesion character. Repeat endoscopy at 1 year, however, revealed erythema and further erosion on the ampulla of Vater as the lesion had progressed. The patient was diagnosed with carcinoma of the ampulla of Vater. Abdominal computed tomography showed a 9-mm hypervascular tumor at the ampulla of Vater and the patient underwent open pancreatoduodenectomy and lymphadenectomy. Histologically, the tumor consisted of small-sized round cell proliferations with a solid nest pattern. Immunostaining results indicated that the tumor cells were positive for synaptophysin and 2.5% were positive for Ki-67. The final diagnosis was sporadic non-functional neuroendocrine tumor (NET) G1 of the ampulla of Vater. This case demonstrates that NET of the ampulla of Vater, while rare, can have significant changes and growth over time and highlights the importance of follow-up endoscopic evaluations.

Three Cases of Ampullary Neuroendocrine Tumor Treated by Endoscopic Papillectomy: A Case Report and Literature Review

We herein report three cases of patients with an ampullary neuroendocrine tumor (NET), who underwent endoscopic papillectomy (EP). No tumor recurrence or metastasis was detected in the patients for more than two years after EP. Generally, surgical resection is recommended for ampullary NETs by the European Neuroendocrine Tumor Society. However, as EP is less invasive than surgical resection, there are some reports of low-grade small ampullary NETs curatively treated by EP with long-term follow-up. We consider that EP may be a curative treatment for small and low-grade ampullary NETs without regional or distant metastasis.

Long-term survival after pancreaticoduodenectomy for endocrine tumors of the ampulla of Vater and minor papilla

OBJECTIVE

Endocrine tumors of the ampullary region are rare, and accurate indications for their management are lacking. We aimed to evaluate the outcome of surgical treatment in this indication.

METHOD

We reviewed all patients who submitted to a pancreaticoduodenectomy for ampullary endocrine tumors between 1982 and 2003 in our center.

RESULTS

Eight patients, 3 men and 5 women, with a mean age of 47.8 years (range, 37-57 years) were included. Two patients presented with Zollinger-Ellison syndrome, and 1 had neurofibromatosis. Operative mortality was nil. The mean size of the tumors was 17.4 mm (range, 5-40 mm). There were 7 well-differentiated and 1 poorly differentiated endocrine carcinomas. Seven patients had satellite lymph node metastases, and 1 had diffuse liver metastases. Median follow-up was 131 months (range, 17-315 months). At the end of the follow-up period, 5 patients were alive and disease-free; 1 patient was alive with stable liver metastases. Two patients died 17 months and 13 years after surgery, respectively, from metastasis and an unrelated cause.

CONCLUSION

This study demonstrates the high frequency of lymph node invasion in these uncommon tumors, even at an early clinical stage. Pancreaticoduodenectomy may result in prolonged survival of patients with well-differentiated tumors.

Endocrine carcinoma of the major papilla: report of two cases and review of the literature

To date, about 100 cases of ampullary NET are reported in International literature. These tumors can cause symptoms mainly secondary to their periampullary location. Up to 25% of patients have von Recklinghausen's disease. Carcinoid syndrome is uncommon, unless hepatic metastasis is present. Determination of histopathology is of utmost importance and involves specific immunohistochemical staining. The published data indicate that these tumors, metastasize in approximately half of cases irrespective of primary tumor size. Therefore, radical excision in the form of pancreaticoduodenectomy is recommended regardless of tumor size. Local excision should be confined to patients unable to tolerate more extensive surgery. We here report two case of ampullary neuroendocrine tumors presenting as melena and painless jaundice respectively in a 51-year old man and in a 54-year old man and review the relevant literature, giving special attention to the morphologic features, clinical characteristics, and treatment modalities associated with this disease process.