Pseudotumors
A wide variation exists in the endoscopic appearance of normal major duodenal papillae. The only characteristic appearance distinguishing between benign and malignant disease is the presence of an ulcerative tumor mass, which was observed in 21% of patients with malignancy and in no patients with benign disease.
Leese et al reported that 49 patients of 2000 who underwent ERCP had the appearance of a periampullary carcinoma on duodenoscopy. Biopsies were taken both before and after duodenoscopy, and ERCP was attempted by the insertion of a catheter through the tumor mass. Thirty-eight patients had neoplasms and 11 had inflammatory nonneoplastic lesions that were termed pseudotumors. No statistical differences between these 2 groups were present with regard to any of the clinical features recorded, except that a higher proportion of patients with pseudotumors had epigastric pain. None of the patients with pseudotumors had a palpable gallbladder, whereas this finding was present in 16 patients with ampullary tumors.
Comparison of hematological and biochemical tests revealed significantly lower values for hemoglobin, total protein, albumin, and alanine transaminase in the group with tumors. Comparison of ERCP results disclosed that even though the diameter of the pancreatic duct tended to be larger in the group with tumors, no difference existed with respect to the CBD diameter, and the cholangiograms appeared similar in many cases. Gallstones were present significantly more often in the pseudotumor group.
Two of the 11 patients with pseudotumors were subjected to surgical excision because of the histological features on endoscopic biopsies that raised the suspicion of carcinoma. Thus, although certain clinical, laboratory, and endoscopic biopsies raised the suspicion of carcinoma, significant overlap with the findings in benign disease and malignant disease exists. When endoscopic biopsies are unequivocal for carcinoma and the suspicion of a pseudotumor exists, repeating duodenoscopy with biopsies in 2-4 weeks is indicated. A significant proportion of pseudotumors, especially those relating to gallstone disease, have resolved in this time period, thus preventing unnecessary surgery.
Benign Tumors
Although malignant tumors of the main papilla are more common, a number of benign neoplasms also may arise in this structure, including benign neoplasms (tubular and villous), lipomas, hamartomas, fibromas, and neurogenic tumors, including neurofibromas, granular cell tumors, leiomyomas, lymphangiomas, and hemangiomas.
The most common benign tumor of the ampulla is the villous adenoma. The incidence is lower than that of ampullary carcinomas, 0.04-0.12% in autopsy series.
No sexual predilection exists.
At diagnosis, the average person is aged 62 years (range of 4 mo to 79 y).
Location
In the series of Ryan et al, 16 of 19 patients with villous tumors of the duodenum had involvement of the main duodenal papilla.
Clinical presentation
Villous adenomas of the ampulla range in size from 4 mm to 7 cm in diameter. Small tumors of the main papilla can be asymptomatic, but symptoms were present in more than 75% of reported cases.
Signs and symptoms include the following:
- Nonspecific abdominal pain (75% of cases)
- Jaundice (70% of cases)
- Upper GI bleeding (50% of cases)
- Coexisting gallbladder or CBD stones (13-20% of cases)
Diagnosis
Laboratory studies are consistent with cholestatic jaundice (increased alkaline phosphatase [AP], gamma-GT, and direct bilirubin). Imaging studies occasionally reveal a filling defect in the duodenum.
Villous adenomas of the ampulla have a high incidence of coexisting malignancy. In a surgical series, the incidence of malignant change (both carcinoma in situ and invasive carcinoma) ranges from 26-63%. Any assessment of the prevalence of malignancy within ampullary villous adenomas must be based on histopathologic analysis of the entire specimen because endoscopic biopsies have an unacceptably high false-negative rate. In one series, endoscopic examination found the tumor in 9 of 10 patients, but endoscopic biopsies missed the rate of malignant change in 5 of 9 patients, or 56%.
Surgical treatment
Given the high false-negative rate for endoscopic biopsy in detecting foci of malignancy, local surgical excision and pancreaticoduodenectomy have been the mainstays of treatment of villous adenomas of the main duodenal papilla. The selection of a surgical procedure primarily depends on the results of endoscopy and intraoperative frozen-section biopsies. For tumors without evidence of malignancy, submucosal excision is the procedure of choice, and this is combined with sphincterotomy or sphincteroplasty if the tumor is growing within the ampullary orifice. More than 85% of patients with benign villous adenomas treated with local excision do well clinically and remain free of recurrence.
If intraoperative frozen sections or examination of the local excision specimen reveals carcinoma in situ, most authorities recommend radical pancreaticoduodenectomy, though others, especially in older reports, have recommended a conservative approach with local excision alone. For lesions that contain invasive carcinoma, the operation of choice is pancreaticoduodenectomy.
Laser therapy
Endoscopic therapy for benign adenomas of the papilla is assuming a larger role. Lambert et al attempted the use of a neodymium:yttrium-aluminum-garnet (Nd:YAG) laser in 7 patients with papillary adenomas and 1 patient with an adenoma that contained a malignant focus. In 3 of these 8 patients, a previous snare resection had been performed, with incomplete removal of the tumor. Complete tumor destruction was achieved in 7 of the 8 cases; follow-up ranged from 14-53 months. Recurrence of the villous adenoma was observed after 24 months in only 1 patient. No complications were noted. In this study, argon laser photoablation seemed to be much less effective in destroying adenomatous tissue residue than the Nd:YAG laser.
In the series of 52 patients with ampullary tumors performed by Ponchon et al, 11 patients underwent attempted adenoma ablation by snare resection, laser photocoagulation, or both, after sphincterotomies. Adenomatous tissue was completely ablated in 10 patients, with a mean duration follow-up of 39 months. Five other patients with comorbid illness or metastatic malignancy underwent successful palliative treatment with sphincterotomy alone (4 patients) or with a transhepatically placed stent (1 patient). Four of these patients died of cardiac disease at a mean of 45 months after the procedure, and 1 was alive at 15 months after the sphincterotomy.
Diathermic fulguration
Shemesh et al reported 5 patients with adenomas of the papilla who presented with obstructive jaundice and underwent successful drainage via endoscopic sphincterotomy. Four of these patients underwent local surgical excision with subsequent adenoma recurrence in all 4 within 6-18 months after the operation. The recurrent adenomas were eradicated by endoscopic diathermic fulguration using the tip of a polypectomy snare or a hot biopsy forceps; no recurrences were noted during follow-up that ranged from 12-24 months. One patient with a sessile adenoma of the papilla refused surgery and, therefore, underwent incomplete piecemeal resection of the adenoma by snare polypectomy; an adenocarcinoma at the head of the pancreas developed 40 months later.
Snare papillectomy
Binmoeller et al described 25 patients with adenomatous tumors of the main papilla who underwent radical endoscopic resection by snare papillectomy. The 3 criteria for inclusion in this study were tumor size less than 4 cm, benign endoscopic appearance, and benign histological results on at least 6 forceps biopsies. Twenty-three patients had de novo tumors, and 2 had recurrent adenomas after local surgical excision.
Endoscopic excision was performed with a pure-cutting current to the level of the muscularis propria. Residual tissue was fulgurated using a monopolar current. ERCP was performed after the papillectomies; then biliary or pancreatic duct papillotomies, or both, were performed, as well as endoprosthesis placement in some patients as satisfactory drainage was needed. Surveillance duodenoscopy was performed at 1, 6, and 12 months after the papillectomies and yearly thereafter. Immediate complications included postpapillectomy bleeding in 2 patients, necessitating local injection of epinephrine (1:20,000), and self-limited pancreatitis in 3 patients. No procedure-related deaths occurred.
Two patients had evidence of intraductal tumor extension by ERCP and were referred for surgery. The remaining 23 patients were observed for a median of 37 months. Six patients had benign recurrences (26%), usually within the first year of follow-up. Of the 6 patients with recurrences, 1 patient had tumor extension into the distal CBD and later succumbed to complications of a Whipple procedure. The remaining 5 patients with recurrence of adenomas were treated endoscopically with snare resection (1 patient), diathermic fulguration (2 patients), or combined treatment (2 patients). Three of these 5 patients were free of disease at 13, 52, and 53 months. One patient was lost to follow-up, and 1 patient underwent a pancreaticoduodenectomy after repeated fulgurations failed to completely ablate adenomatous tissue.
Silvis correctly urged caution and careful consideration of several points before embarking on endoscopic papillectomy of benign ampullary tumors. First, the patients in the study of Binmoeller et al are unusual in that no patient had cancer within the adenoma, whereas the incidence in other reports ranges from 26-63%. Second, papillectomy is associated with a significant recurrence rate and, therefore, only should be considered for patients who are likely to be compliant with an extended schedule of follow-up endoscopic surveillance procedures. Third, a papillectomy only should be performed by an endoscopist who is an expert in ERCP. Lastly, this procedure should be restricted to either patients who refuse surgery or patients who are at high risk for extensive surgical procedures.
Prognosis
Based on a review of available follow-up data, Schulten et al calculated a 5-year survival rate of 21% for patients with villous adenoma of the duodenum harboring malignant change. Celik et al also concluded that radical excision of malignant, ampullary, villous adenomas in patients at good risk provides long-term survival in one third of these patients.
Neuroendocrine Tumors
Background
In a number of cases, neuroendocrine tumors have both neurogenic and endocrine elements. Lesions of endocrine origin have been termed carcinoid tumors. Duodenal carcinoids have both morphologic and functional similarities to pancreatic islet-cell tumors.
Neuroendocrine tumors are rare. Duodenal carcinoids only account for 1-5% of the total. Fewer than 40 cases of ampullary carcinoids exist in the world literature.
No sexual or age-related predilection exists.
Clinical
Although most carcinoid tumors are asymptomatic and are found incidentally, those arising at the ampulla tend to cause symptoms related to intermittent biliary obstruction.
- Abdominal pain
- Melena
- Jaundice
- Recurrent pancreatitis
- Carcinoid syndrome has not been reported in association with an ampullary carcinoid tumor. This observation probably reflects the smaller size of these tumors when detected at the ampulla, a key factor in predicting the incidence of metastases.
Differential diagnosis
The association between ampullary carcinoid islet-cell tumors and Von Recklinghausen disease was first recognized by Lee and Garber in 1970; a number of subsequent reports exist. Both cutaneous and viscerocutaneous neurofibromatoses have been associated with ampullary carcinoid islet-cell tumors.
Diagnosis
Endoscopy: No distinctive endoscopic features exist.
CT scan, MRI, and EUS: The tumor may spread locally to the duodenal wall, pancreas, or bile duct, or it may spread by metastases to local and regional lymph nodes. Lymph node metastases are observed in 25-50% of cases.
Management
In surgical management, local excision and pancreaticoduodenectomy are the 2 operations most commonly employed. Although available data are limited, pancreaticoduodenectomies may be assumed to be associated with a higher perioperative morbidity and mortality.
Prognosis
The 5-year survival rate for patients with carcinoid tumors without apparent metastasis who undergo resection was 68% and 95% in 2 different studies. Of note, the 5-year survival rates in patients with regional lymph node or distant metastasis are 83% and 38%, respectively.
Secondary Tumors
Secondary tumors are rare.
Causes of secondary tumors include the following:
- Renal cell carcinoma
- Melanoma
- Lymphoma
- Lymphangioma
- Endometrial adenocarcinoma
Patients present with GI bleeding, obstruction, and perforation. The treatment of secondary tumors is palliative.
Sphincterotomy-associated Biliary Strictures
Narrowing of the biliary orifice after previous endoscopic biliary sphincterotomy (EBS) has been referred to as sphincterotomy stenosis. Sphincterotomy stenosis is recognized late and is an uncommon complication of this procedure.
Background
Since its introduction in 1974, EBS has become widely accepted as the preferred treatment of choledocholithiasis, particularly in patients who have had cholecystectomies, elderly patients, or patients who are infirm. The advent of laparoscopic cholecystectomy and the resultant emphasis on minimally invasive therapy for gallstone disease has further broadened the application of this technique.
The pathogenesis of sphincterotomy-associated biliary strictures remains unclear.
Incidence
The true incidence of procedure-related Oddi stenosis (OS) is not known, in part because of variations in definitions and the manner of assessing orifice width. The recurrence of the biliary pain is reported in approximately 15% of patients after having an EBS for choledocholithiasis. OS was noted in a mean of 50% (range 30-100%) of these patients who were symptomatic, with a mean age of 4.5 years. Papillary stenosis was found 363 times (2.7%) in 13,300 diagnostic ERCP examinations at 5 gastroenterology centers in Germany.
Clinical symptoms include cholangitis, recurrent biliary pain, and intermittent jaundice.
Differential diagnosis
Malignancy
Sphincter of Oddi (SO) dysfunction
Laboratory study results include increased AP, bilirubin, gamma-GT, and 5'-nucleotidase (5'-NT).
Diagnostic studies
Right upper quadrant ultrasound - Dilated CBD
ERCP - Retraction of papilla and dilated CBD
Endoscopic treatment
These recalcitrant lesions are not amenable to repeat sphincterotomy; however, studies suggest that they may be managed successfully by serial placement of stents of incrementally increasing diameter. Hydrostatic balloon dilatation could have been considered as an alternative therapy; however, these strictures, though short, were high grade and recalcitrant to treatment, necessitating prolonged periods of stent placement (median of 12.5 mo) to achieve resolution. Serial placement of stents of incrementally increasing diameter offers sustained radial expansion of the stricture over time, contrasting the short duration of the effect of the balloon.
Surgery
Consider surgery in cases resistant to endoscopic therapy.
Keywords
papilla, papillary adenomas, villous adenomas, pancreaticoduodenal tumors
More on Papillary Tumors |
| References |
References
Hustinx SR, Hruban RH, Leoni LM, Iacobuzio-Donahue C, Cameron JL, Yeo CJ. Homozygous deletion of the MTAP gene in invasive adenocarcinoma of the pancreas and in periampullary cancer: a potential new target for therapy. Cancer Biol Ther. Jan 2005;4(1):83-6. [Medline].
Hustinx SR, Fukushima N, Zahurak ML, Riall TS, Maitra A, Brosens L. Expression and prognostic significance of 14-3-3sigma and ERM family protein expression in periampullary neoplasms. Cancer Biol Ther. May 2005;4(5):596-601. [Medline].
Bettschart V, Rahman MQ, Engelken FJ, Madhavan KK, Parks RW, Garden OJ. Presentation, treatment and outcome in patients with ampullary tumours. Br J Surg. Dec 2004;91(12):1600-7. [Medline].
Kim RD, Kundhal PS, McGilvray ID, Cattral MS, Taylor B, Langer B. Predictors of failure after pancreaticoduodenectomy for ampullary carcinoma. J Am Coll Surg. Jan 2006;202(1):112-9. [Medline].
Beger HG, Thorab FC, Liu Z, Harada N, Rau BM. Pathogenesis and treatment of neoplastic diseases of the papilla of Vater: Kausch-Whipple procedure with lymph node dissection in cancer of the papilla of Vater. J Hepatobiliary Pancreat Surg. 2004;11(4):232-8. [Medline].
Jarufe NP, Coldham C, Mayer AD, Mirza DF, Buckels JA, Bramhall SR. Favourable prognostic factors in a large UK experience of adenocarcinoma of the head of the pancreas and periampullary region. Dig Surg. 2004;21(3):202-9. [Medline].
Yokoyama N, Shirai Y, Wakai T, Nagakura S, Akazawa K, Hatakeyama K. Jaundice at presentation heralds advanced disease and poor prognosis in patients with ampullary carcinoma. World J Surg. Apr 2005;29(4):519-23. [Medline].
Brown KM, Tompkins AJ, Yong S, Aranha GV, Shoup M. Pancreaticoduodenectomy is curative in the majority of patients with node-negative ampullary cancer. Arch Surg. Jun 2005;140(6):529-32; discussion 532-3. [Medline].
Adler DG, Qureshi W, Davila R, Gan SI, Lichtenstein D, Rajan E, et al. The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc. Dec 2006;64(6):849-54. [Medline].
Armstrong T, Strommer L, Ruiz-Jasbon F, Shek FW, Harris SF, Permert J, et al. Pancreaticoduodenectomy for peri-ampullary neoplasia leads to specific micronutrient deficiencies. Pancreatology. 2007;7(1):37-44. [Medline].
Artifon EL, Rodrigues AZ, Marques S, Halwan B, Sakai P, Bresciani C, et al. Laparoscopic deployment of biliary self-expandable metal stent (SEMS) for one-step palliation in 23 patients with advanced pancreatico-biliary tumors--a pilot trial. J Gastrointest Surg. Dec 2007;11(12):1686-91. [Medline].
Bal A, Joshi K, Vaiphei K, Wig JD. Primary duodenal neoplasms: a retrospective clinico-pathological analysis. World J Gastroenterol. Feb 21 2007;13(7):1108-11. [Medline].
Balachandran P, Sikora SS, Kapoor S, Krishnani N, Kumar A, Saxena R, et al. Long-term survival and recurrence patterns in ampullary cancer. Pancreas. May 2006;32(4):390-5. [Medline].
Bartsch DK, Fendrich V, Slater EP, Sina-Frey M, Rieder H, Greenhalf W, et al. RNASEL germline variants are associated with pancreatic cancer. Int J Cancer. Dec 10 2005;117(5):718-22. [Medline].
Belyaev O, Seelig MH, Muller CA, Tannapfel A, Schmidt WE, Uhl W. Intraductal papillary mucinous neoplasms of the pancreas. J Clin Gastroenterol. Mar 2008;42(3):284-94. [Medline].
Bhatia S, Miller RC, Haddock MG, Donohue JH, Krishnan S. Adjuvant therapy for ampullary carcinomas: the Mayo Clinic experience. Int J Radiat Oncol Biol Phys. Oct 1 2006;66(2):514-9. [Medline].
Bhutani M, Mishra G. EUS in pancreatobiliary disease. Pract Gastroenterol. 2001;25-43.
Blandamura S, D'Alessandro E, Guzzardo V, Giacomelli L, Moschino P, Parenti A, et al. Maspin expression in adenocarcinoma of the ampulla of Vater: relation with clinicopathological parameters and apoptosis. Anticancer Res. Mar-Apr 2007;27(2):1059-65. [Medline].
Bloomston M, Ellison EC, Muscarella P, Al-Saif O, Martin EW, Melvin WS, et al. Stromal osteonectin overexpression is associated with poor outcome in patients with ampullary cancer. Ann Surg Oncol. Jan 2007;14(1):211-7. [Medline].
Bourke MJ, Elfant AB, Alhalel R, Scheider D, Kortan P, Haber GB. Sphincterotomy-associated biliary strictures: features and endoscopic management. Gastrointest Endosc. Oct 2000;52(4):494-9. [Medline].
Bucher P, Chassot G, Durmishi Y, Ris F, Morel P. Long-term results of surgical treatment of Vater's ampulla neoplasms. Hepatogastroenterology. Jun 2007;54(76):1239-42. [Medline].
Buscail L, Pages P, Berthelemy P, Fourtanier G, Frexinos J, Escourrou J. Role of EUS in the management of pancreatic and ampullary carcinoma: a prospective study assessing resectability and prognosis. Gastrointest Endosc. Jul 1999;50(1):34-40. [Medline].
Chahal P, Prasad GA, Sanderson SO, Gostout CJ, Levy MJ, Baron TH. Endoscopic resection of nonadenomatous ampullary neoplasms. J Clin Gastroenterol. Aug 2007;41(7):661-6. [Medline].
Coughlin SS, Calle EE, Patel AV, Thun MJ. Predictors of pancreatic cancer mortality among a large cohort of United States adults. Cancer Causes Control. Dec 2000;11(10):915-23. [Medline].
Defrain C, Chang CY, Srikureja W, Nguyen PT, Gu M. Cytologic features and diagnostic pitfalls of primary ampullary tumors by endoscopic ultrasound-guided fine-needle aspiration biopsy. Cancer. Oct 25 2005;105(5):289-97. [Medline].
Dittrick GW, Mallat DB, Lamont JP. Management of ampullary lesions. Curr Treat Options Gastroenterol. Sep 2006;9(5):371-6. [Medline].
Elkharwily A, Gottlieb K. The pancreas in familial adenomatous polyposis. JOP. Jan 8 2008;9(1):9-18. [Medline].
Erkan M, Kleeff J, Reiser C, Hinz U, Esposito I, Friess H. Preoperative acute pancreatitis in periampullary tumors: implications for surgical management. Digestion. 2007;75(2-3):165-71. [Medline].
Eswaran SL, Sanders M, Bernadino KP, Ansari A, Lawrence C, Stefan A, et al. Success and complications of endoscopic removal of giant duodenal and ampullary polyps: a comparative series. Gastrointest Endosc. Dec 2006;64(6):925-32. [Medline].
Fong D, Steurer M, Obrist P, Barbieri V, Margreiter R, Amberger A, et al. Ep-CAM expression in pancreatic and ampullary carcinomas: frequency and prognostic relevance. J Clin Pathol. Jan 2008;61(1):31-5. [Medline].
Giannopoulos G, Kavantzas N, Parasi A, Tiniakos D, Peros G, Tzanakis N, et al. Morphometric microvascular characteristics in the prognosis of pancreatic and ampullary carcinoma. Pancreas. Jul 2007;35(1):47-52. [Medline].
Gleisner AL, Assumpcao L, Cameron JL, Wolfgang CL, Choti MA, Herman JM, et al. Is resection of periampullary or pancreatic adenocarcinoma with synchronous hepatic metastasis justified?. Cancer. Dec 1 2007;110(11):2484-92. [Medline].
Guidelines for the management of patients with pancreatic cancer periampullary and ampullary carcinomas. Gut. Jun 2005;54 Suppl 5:v1-16. [Medline].
Gupta C, Mazzara PF. High-grade pancreatic intraepithelial neoplasia in a patient with familial adenomatous polyposis. Arch Pathol Lab Med. Nov 2005;129(11):1398-400. [Medline].
Hsu HP, Shan YS, Hsieh YH, Yang TM, Lin PW. Predictors of recurrence after pancreaticoduodenectomy in ampullary cancer: comparison between non-, early and late recurrence. J Formos Med Assoc. Jun 2007;106(6):432-43. [Medline].
Hsu HP, Yang TM, Hsieh YH, Shan YS, Lin PW. Predictors for patterns of failure after pancreaticoduodenectomy in ampullary cancer. Ann Surg Oncol. Jan 2007;14(1):50-60. [Medline].
Hwang S, Lee SG, Lee YJ, Han DJ, Kim SC, Kwon SH, et al. Radical surgical resection for carcinoid tumors of the ampulla. J Gastrointest Surg. Apr 2008;12(4):713-7. [Medline].
Hwang S, Moon KM, Park JI, Kim MH, Lee SG. Retroduodenal resection of ampullary carcinoid tumor in a patient with cavernous transformation of the portal vein. J Gastrointest Surg. Oct 2007;11(10):1322-7. [Medline].
Iacono C, Verlato G, Zamboni G, Scarpa A, Montresor E, Capelli P, et al. Adenocarcinoma of the ampulla of Vater: T-stage, chromosome 17p allelic loss, and extended pancreaticoduodenectomy are relevant prognostic factors. J Gastrointest Surg. May 2007;11(5):578-88. [Medline].
Ito K, Fujita N, Noda Y, Kobayashi G, Horaguchi J, Takasawa O, et al. Preoperative evaluation of ampullary neoplasm with EUS and transpapillary intraductal US: a prospective and histopathologically controlled study. Gastrointest Endosc. Oct 2007;66(4):740-7. [Medline].
Kamisawa T, Tu Y, Egawa N, Nakajima H, Horiguchi S, Tsuruta K. Clinicopathologic features of ampullary carcinoma without jaundice. J Clin Gastroenterol. Feb 2006;40(2):162-6. [Medline].
Kashima K, Ohike N, Mukai S, Sato M, Takahashi M, Morohoshi T. Expression of the tumor suppressor gene maspin and its significance in intraductal papillary mucinous neoplasms of the pancreas. Hepatobiliary Pancreat Dis Int. Feb 2008;7(1):86-90. [Medline].
Kawakami H, Kuwatani M, Onodera M, Hirano S, Kondo S, Nakanishi Y, et al. Primary acinar cell carcinoma of the ampulla of Vater. J Gastroenterol. Aug 2007;42(8):694-7. [Medline].
Kawakami H, Kuwatani M, Onodera M, Hirano S, Kondo S, Nakanishi Y, et al. Primary acinar cell carcinoma of the ampulla of Vater. J Gastroenterol. Aug 2007;42(8):694-7. [Medline].
Kawakami H, Kuwatani M, Onodera M, Hirano S, Kondo S, Nakanishi Y, et al. Primary acinar cell carcinoma of the ampulla of Vater. J Gastroenterol. Aug 2007;42(8):694-7. [Medline].
Khandekar S, Disario JA. Endoscopic therapy for stenosis of the biliary and pancreatic duct orifices. Gastrointest Endosc. Oct 2000;52(4):500-5. [Medline].
Kim YK, Han YM, Kim CS. Usefulness of fat-suppressed T1-weighted MRI using orally administered superparamagnetic iron oxide for revealing ampullary carcinomas. J Comput Assist Tomogr. Jul-Aug 2007;31(4):519-25. [Medline].
Lee SY, Jang KT, Lee KT, Lee JK, Choi SH, Heo JS, et al. Can endoscopic resection be applied for early stage ampulla of Vater cancer?. Gastrointest Endosc. May 2006;63(6):783-8. [Medline].
Lienert A, Bagshaw PF. Treatment of duodenal adenomas with endoscopic argon plasma coagulation. ANZ J Surg. May 2007;77(5):371-3. [Medline].
Long-term survival after radical resection for pancreatic head and ampullary cancer: a potential role for the EGF-R.
Malka D, Hammel P, Maire F, Rufat P, Madeira I, Pessione F, et al. Risk of pancreatic adenocarcinoma in chronic pancreatitis. Gut. Dec 2002;51(6):849-52. [Medline].
Michaud DS, Skinner HG, Wu K, Hu F, Giovannucci E, Willett WC. Dietary patterns and pancreatic cancer risk in men and women. J Natl Cancer Inst. Apr 6 2005;97(7):518-24. [Medline].
Ney JT, Zhou H, Sipos B, Buttner R, Chen X, Kloppel G, et al. Podocalyxin-like protein 1 expression is useful to differentiate pancreatic ductal adenocarcinomas from adenocarcinomas of the biliary and gastrointestinal tracts. Hum Pathol. Feb 2007;38(2):359-64. [Medline].
Noda T, Ohigashi H, Ishikawa O, Eguchi H, Yamada T, Sasaki Y, et al. Liver perfusion chemotherapy for selected patients at a high-risk of liver metastasis after resection of duodenal and ampullary cancers. Ann Surg. Nov 2007;246(5):799-805. [Medline].
Norton ID, Geller A, Petersen BT, Sorbi D, Gostout CJ. Endoscopic surveillance and ablative therapy for periampullary adenomas. Am J Gastroenterol. Jan 2001;96(1):101-6. [Medline].
Palanivelu C, Jani K, Senthilnathan P, Parthasarathi R, Rajapandian S, Madhankumar MV. Laparoscopic pancreaticoduodenectomy: technique and outcomes. J Am Coll Surg. Aug 2007;205(2):222-30. [Medline].
Palanivelu C, Jani K, Senthilnathan P, Parthasarathi R, Rajapandian S, Madhankumar MV. Laparoscopic pancreaticoduodenectomy: technique and outcomes. J Am Coll Surg. Aug 2007;205(2):222-30. [Medline].
Pandolfi M, Martino M, Gabbrielli A. Endoscopic treatment of ampullary adenomas. JOP. Jan 8 2008;9(1):1-8. [Medline].
Park JS, Yoon DS, Park YN, Lee WJ, Chi HS, Kim BR. Transduodenal local resection for low-risk group ampulla of vater carcinoma. J Laparoendosc Adv Surg Tech A. Dec 2007;17(6):737-42. [Medline].
Paulsen FP, Varoga D, Paulsen AR, Corfield A, Tsokos M. Prognostic value of mucins in the classification of ampullary carcinomas. Hum Pathol. Feb 2006;37(2):160-7. [Medline].
Qiao QL, Zhao YG, Ye ML, Yang YM, Zhao JX, Huang YT, et al. Carcinoma of the ampulla of Vater: factors influencing long-term survival of 127 patients with resection. World J Surg. Jan 2007;31(1):137-43; discussion 144-6. [Medline].
Sakata E, Shirai Y, Yokoyama N, Wakai T, Sakata J, Hatakeyama K. Clinical significance of lymph node micrometastasis in ampullary carcinoma. World J Surg. Jun 2006;30(6):985-91. [Medline].
Santini D, Perrone G, Vincenzi B, Lai R, Cass C, Alloni R, et al. Human equilibrative nucleoside transporter 1 (hENT1) protein is associated with short survival in resected ampullary cancer. Ann Oncol. Apr 2008;19(4):724-8. [Medline].
Sessa F, Furlan D, Zampatti C, Carnevali I, Franzi F, Capella C. Prognostic factors for ampullary adenocarcinomas: tumor stage, tumor histology, tumor location, immunohistochemistry and microsatellite instability. Virchows Arch. Sep 2007;451(3):649-57. [Medline].
Sivak MV. Tumors of the main duodenal papilla. In: Gastroenterology Endoscopy. Vol 2. St. Louis, Mo: WB Saunders Co; 2000.
Sperti C, Pasquali C, Fiore V, Bissoli S, Chierichetti F, Liessi G, et al. Clinical usefulness of 18-fluorodeoxyglucose positron emission tomography in the management of patients with nonpancreatic periampullary neoplasms. Am J Surg. Jun 2006;191(6):743-8. [Medline].
Teras LR, Patel AV, Rodriguez C, Thun MJ, Calle EE. Parity, other reproductive factors, and risk of pancreatic cancer mortality in a large cohort of U.S. women (United States). Cancer Causes Control. Nov 2005;16(9):1035-40. [Medline].
Traverso LW. The State of the Highest Level of Evidence: An Overview of Systematic Reviews of Pancreaticobiliary Disease Customized for the Gastroenterologist and GI Surgeon. J Gastrointest Surg. Feb 2 2008;[Epub ahead of print].
Weigt J, Bellutti M, Malfertheiner P. Osteoclast-like giant-cell tumour of the pancreas causing painful ampullary obstruction. Dig Liver Dis. Oct 2007;39(10):952. [Medline].
Westgaard A, Tafjord S, Farstad IN, Cvancarova M, Eide TJ, Mathisen O, et al. Resectable adenocarcinomas in the pancreatic head: the retroperitoneal resection margin is an independent prognostic factor. BMC Cancer. Jan 14 2008;8:5. [Medline].
Westgaard A, Tafjord S, Farstad IN, Cvancarova M, Eide TJ, Mathisen O, et al. Resectable adenocarcinomas in the pancreatic head: the retroperitoneal resection margin is an independent prognostic factor. BMC Cancer. Jan 14 2008;8:5. [Medline].
Woo SM, Ryu JK, Lee SH, Yoo JW, Park JK, Kim YT, et al. Recurrence and prognostic factors of ampullary carcinoma after radical resection: comparison with distal extrahepatic cholangiocarcinoma. Ann Surg Oncol. Nov 2007;14(11):3195-201. [Medline].
Yang F, Long J, Fu DL, Jin C, Yu XJ, Xu J, et al. Aberrant hepatic artery in patients undergoing pancreaticoduodenectomy. Pancreatology. 2008;8(1):50-4. [Medline].
Yoon SM, Kim MH, Kim MJ, Jang SJ, Lee TY, Kwon S, et al. Focal early stage cancer in ampullary adenoma: surgery or endoscopic papillectomy?. Gastrointest Endosc. Oct 2007;66(4):701-7. [Medline].
Yoon YS, Kim SW, Park SJ, Lee HS, Jang JY, Choi MG, et al. Clinicopathologic analysis of early ampullary cancers with a focus on the feasibility of ampullectomy. Ann Surg. Jul 2005;242(1):92-100. [Medline].
Yuan LW, Tang W, Kokudo N, Seyama Y, Shi YZ, Karako H, et al. Disruption of pRb-p16INK4 pathway: a common event in ampullary carcinogenesis. Hepatogastroenterology. Jan-Feb 2005;52(61):55-9. [Medline].
Further Reading
Keywords
papilla, papillary adenomas, villous adenomas, pancreaticoduodenal tumors
