The Assessment of Specimens Procured by Endoscopic Ampullectomy
Dept of Pathology, University of Virginia Health System, Charlottesville, VA 22908, USA. American Journal of Clinical Pathology
(Impact Factor: 2.51).
10/2009; 132(4):506-13. DOI: 10.1309/AJCPUZWJ8WA2IHBG
Endoscopic ampullectomy (EA) is increasingly used in the management of ampullary neoplasia. Although studies on the safety and efficacy of this procedure exist, no study has specifically addressed the histopathologic features of the specimens. We review our experience with 45 EA specimens assessed for the following: diagnosis, high-grade dysplasia (HGD), submucosal ampullary gland/ductule involvement, specimen integrity, and margin status. Familial adenomatous polyposis (FAP) status and the endoscopist's impression of completeness of removal were also ascertained. Previous biopsy diagnoses were compared with ampullectomy diagnoses, and histologic and clinical features were correlated with disease persistence. The histologic features of the ampullectomy specimens were as follows: diagnosis (no diagnostic abnormality, 3; reactive, 8; adenoma, 26; adenocarcinoma, 7; other, 1); HGD, 1; submucosal ampullary gland/ductule involvement, 20; specimen integrity (intact, 22; fragmented, 23); and margin status (positive, 20; negative, 2; could not be assessed, 12). Five patients had FAP, and EA was deemed complete in 21 (47%). The diagnostic agreement between preampullectomy biopsy and ampullectomy was 64%. Of the patients, 33 (73%) had documented persistent disease. None of the histologic or clinical features had a statistically significant relationship with disease persistence.
Available from: Andreas Polydorou
- "Keypoints for successful outcome are negative resection margins and endoscopic surveillance , but primarily clinical suspicion that the presence of painless jaundice in a patient with history of renal cancer and negative CT scanning for pancreatic or other causes of obstruction should alert for prompt investigation for an ampullary metastasis. "
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ABSTRACT: Renal cell carcinoma is often characterized by the presence of metachronous metastases in unusual sites. The presence of isolated metastases is treated with surgical excision with good anticipated results. On the other hand, systemic chemotherapy is administered in the context of metastatic spread, usually sunitib or sorafenib. In such cases, however, the presence of symptomatic foci calls for minimal intervention.
We present a case of a 77-year-old patient who presented with obstructive jaundice due to an ampullary mass. Endoscopic excision and biopsy set the diagnosis of metastatic renal cell carcinoma. Consequently, imaging studies revealed the presence of multiple foci in the lungs and bone. Therefore, pancreatoduodenectomy was excluded and the patient underwent endoscopic ampullectomy and was set to oral sunitinib. Interestingly, despite generalized spread, local control was achieved until the patient succumbed to carcinomatosis.
Painless obstructive jaundice in a patient with history of renal cancer and negative computed tomography scanning for pancreatic or other causes of obstruction should alert for prompt investigation for an ampullary metastasis.
Available from: ncbi.nlm.nih.gov
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ABSTRACT: Ampullary adenoma is a pre-cancerous lesion arising from the duodenal papilla that is often asymptomatic. It is important to distinguish whether the adenoma is sporadic or arises in the setting of familial adenomatous polyposis as this has important implications with respect to management and surveillance. Multiple modalities are available for staging of these lesions to help guide the most appropriate therapy. Those that are used most commonly include computed tomography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography. In recent years, endoscopy has become the primary modality for therapeutic management of the majority of ampullary adenomas. Surgery remains the standard curative procedure for confirmed or suspected adenocarcinoma. This review will provide the framework for the diagnosis and management of ampullary adenomas from the perspective of the practicing gastroenterologist.
Available from: Eugene P Ceppa
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ABSTRACT: OBJECTIVE:: The objective of this study was to compare the effectiveness, morbidity, and mortality associated with endoscopic ampullectomy (EA) and surgical ampullectomy (SA). BACKGROUND:: The proposed management of benign ampullary lesions includes local resection (EA or SA) and en bloc resection (pancreaticoduodenectomy). Most agree that en bloc resection entails a significant morbidity and mortality. No study has previously compared EA and SA for the treatment of benign ampullary lesions. METHODS:: Medical records of patients selected for ampullectomy at Duke University Medical Center from 1991 to 2010 were reviewed. RESULTS:: After review, 109 patients were confirmed to have undergone ampullectomy for a suspected benign ampullary lesion. Sixty-eight patients underwent EA, whereas 41 patients underwent SA. Patients in each group were identical in terms of age, sex, race, and comorbid conditions, except that EA had a higher rate of severe obesity (body mass index >35). Endoscopic ampullectomy was found to have a significantly reduced length of stay, lower morbidity, and readmission rates, but it had similar rates of mortality, margin-positive excisions, and reinterventions. CONCLUSIONS:: In patients selected for ampullectomy for benign ampullary lesions, EA was found to have equivalent efficacy when compared with SA. Moreover, EA had lower morbidity and identical mortality. These findings suggest that patients would likely benefit from an aggressive endoscopic approach before consideration for surgery.
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