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DOI: 10.1055/s-0030-1257031
© Georg Thieme Verlag KG Stuttgart · New York
Ampullary carcinoid tumors diagnosed by endoscopic ultrasound-guided fine needle aspiration in two patients with biliary and pancreatic duct obstruction
M. Al-HaddadMD
Assistant Professor of Clinical Medicine
Division of
Gastroenterology & Hepatology
Indiana University School of
Medicine
550 N. University Blvd, UH
4100
Indianapolis
Indiana 46202
USA
Fax: +1-317-278-8145
Email: moalhadd@iupui.edu
Publication History
Publication Date:
24 January 2012 (online)
We present two cases of ampullary carcinoid tumors diagnosed and appropriately staged by EUS-FNA.
In case 1, a 46-year-old man presented with anemia and a 4.5-kg weight loss. Laboratory analysis showed: hemoglobin 11.2 mg/dL, total bilirubin 1.4 mg/dL, alkaline phosphatase 324 U/L, aspartate aminotransferase (AST) 221 U/L, and alanine aminotransferase (ALT) 205 U/L. Colonoscopy was unremarkable.
Upper endoscopy showed an enlarged and ulcerated ampulla ([Fig. 1]).
Mucosal biopsies showed non-specific inflammatory changes. Abdominal computed tomography (CT) disclosed dilation of the main pancreatic duct and the intrahepatic and extrahepatic biliary ducts. Endoscopic ultrasound (EUS) revealed a round hypoechoic 26-mm ampullary subepithelial mass, staged as T2N1Mx ([Fig. 2]).
The pancreatic duct and bile duct were dilated up to 4 mm and 8 mm respectively. Fine needle aspiration (FNA) showed atypical cells with round, eccentric nuclei, suggestive of a low grade neuroendocrine tumor. Immunostains for synaptophysin and chromogranin A were positive.
The patient underwent pancreaticoduodenectomy. Surgical pathology confirmed a T2N1M0 carcinoid tumor ([Fig. 3]). Imaging and clinical follow-up at 6 months were unremarkable.
In case 2, a 53-year-old woman presented with painless jaundice and a 9-kg weight loss. Physical examination revealed scleral icterus and mild non-tender hepatomegaly. Laboratory analysis showed: total bilirubin 5.9 mg/dL, alkaline phosphatase 405 U/L, AST 96 U/L, and ALT 190 U/L.
Abdominal CT showed a dilated pancreatic duct and intrahepatic and extrahepatic biliary ducts. Endoscopy revealed an 18-mm ampullary subepithelial lesion, staged on EUS as T3N1Mx ([Fig. 4] and [Fig. 5]).
The pancreatic duct and common bile duct were dilated up to 5 mm and 13 mm respectively. FNA showed malignant pleomorphic cells with round, eccentric nuclei, suggestive of high grade neuroendocrine tumor ([Fig. 6]). Immunostains for cytokeratin, synaptophysin, and chromogranin A were positive.
The patient underwent pancreaticoduodenectomy. Histological examination confirmed a T3N1M0 high grade carcinoid tumor ([Fig. 7]). Imaging and clinical follow-up at 3 months were unremarkable.
Ampullary carcinoid tumors compromise 2 % of ampullary malignancies and account for 0.3 % of all gastrointestinal neuroendocrine tumors [1]. To date, approximately 100 cases of ampullary carcinoid tumor have been reported in worldwide literature [2]. Endoscopic diagnosis is usually limited by the subepithelial nature of the tumor. EUS-FNA provides accurate diagnosis and staging of ampullary malignancies in general [3]. In a series of 41 patients with ampullary tumors, the accuracy of EUS was found to be superior to that of CT and equivalent to that of magnetic resonance imaging (MRI) for T staging (EUS 73 %, CT 26 %, MRI 54 %) and N staging (EUS 67 %, CT 44 %, MRI 77 %) [4]. The role of EUS-FNA in the early diagnosis and staging of ampullary carcinoid tumors has been described only once before in the literature in English [5].
Endoscopy_UCTN_Code_CCL_1AF_2AD
Competing interests: None
#References
- 1 Godwin J D. Carcinoid tumors. An analysis of 2,837 cases. Cancer. 1975; 36 560-569
- 2 Hartel M, Wente M N, Sido B. et al . Carcinoid of the ampulla of Vater. J Gastroenterol Hepatol. 2005; 20 676-681
- 3 Krishna S G, Lamps L W, Rego R F. Ampullary carcinoid: diagnostic challenges and update on management. Clinical Gastroenterol Hepatol. 2010; 8 e5-6
- 4 Chen C, Yang C, Yeh Y. et al . Reappraisal of endosonography of ampullary tumors: correlation with transabdominal sonography, CT, and MRI. J Clin Ultrasound. 2009; 37 18-25
- 5 Defrain C, Chang C Y, Srikureja W. et al . Cytologic features and diagnostic pitfalls of primary ampullary tumors by endoscopic ultrasound-guided fine-needle aspiration biopsy. Cancer. 2005; 105 289-297
M. Al-HaddadMD
Assistant Professor of Clinical Medicine
Division of
Gastroenterology & Hepatology
Indiana University School of
Medicine
550 N. University Blvd, UH
4100
Indianapolis
Indiana 46202
USA
Fax: +1-317-278-8145
Email: moalhadd@iupui.edu
References
- 1 Godwin J D. Carcinoid tumors. An analysis of 2,837 cases. Cancer. 1975; 36 560-569
- 2 Hartel M, Wente M N, Sido B. et al . Carcinoid of the ampulla of Vater. J Gastroenterol Hepatol. 2005; 20 676-681
- 3 Krishna S G, Lamps L W, Rego R F. Ampullary carcinoid: diagnostic challenges and update on management. Clinical Gastroenterol Hepatol. 2010; 8 e5-6
- 4 Chen C, Yang C, Yeh Y. et al . Reappraisal of endosonography of ampullary tumors: correlation with transabdominal sonography, CT, and MRI. J Clin Ultrasound. 2009; 37 18-25
- 5 Defrain C, Chang C Y, Srikureja W. et al . Cytologic features and diagnostic pitfalls of primary ampullary tumors by endoscopic ultrasound-guided fine-needle aspiration biopsy. Cancer. 2005; 105 289-297
M. Al-HaddadMD
Assistant Professor of Clinical Medicine
Division of
Gastroenterology & Hepatology
Indiana University School of
Medicine
550 N. University Blvd, UH
4100
Indianapolis
Indiana 46202
USA
Fax: +1-317-278-8145
Email: moalhadd@iupui.edu