An Uncommon Tumor
Carcinoid tumors are uncommon and most frequently involve the gastrointestinal tract, with primary duodenal carcinoids accounting for only 2.6% of carcinoid tumors in the United States. Carcinoid tumors of the ampulla are even rarer. We report on a patient who presented with biliary colic and intermittent biliary obstruction. She was found to have a pedunculated periampullary carcinoid tumor that was successfully removed by endoscopic resection.
An otherwise healthy 45-year-old woman presented with recurrent attacks of biliary colic after cholecystectomy 5 months earlier. Although they were milder than before the surgery, symptoms did not improve even when she adhered to a low-fat diet. The patient also reported weight loss of more than 15 lb after surgery, but no fevers, chills, or jaundice. Recent blood tests showed aspartate aminotransferase and alanine aminotransferase values > 400 IU/L and normal total bilirubin.
Choledocholithiasis was suspected despite normal transabdominal ultrasonography. Endoscopic ultrasonography (EUS) showed mild dilatation (8.6 mm) of the common bile duct with a possible stricture at the level of the ampulla. Endoscopic view of the ampulla revealed a 4-cm pedunculated lesion growing from the inferior pole of the ampulla (Figure 1).
Endoscopic retrograde cholangiopancreatography (ERCP) was performed, but attempts to cannulate the common bile duct were unsuccessful owing to visual interference from the ampullary lesion (Figure 2). Findings and risks of endoscopic therapy were discussed with the patient, and repeat EUS was planned for endoscopic resection.
Figure 1. Endoscopic view of the ampulla.
Figure 2. Endoscopic retrograde cholangiopancreatography showing a 4-cm pedunculated lesion growing from the ampulla with a stalk (yellow arrow).
Repeat EUS revealed the periampullary lesion to be a 3.5-cm oval, well-circumscribed hypoechoic mass with internal calcifications (Figure 3). The mass was pedunculated and did not penetrate the muscularis propria of the duodenum. Two endoloops were deployed around the base of the lesion (Figure 4), which was then resected by snare polypectomy and removed by Roth Net retrieval basket (Figure 5). Minor bleeding was treated with 2 hemoclips (Figure 6).
Figure 3. Endoscopic ultrasonography showing a pedunculated periampullary polyp extending from the inferior margin of the ampulla.
Figure 4. Endoloops deployed around the base of the lesion.
Figure 5. Resection of the lesion by snare polypectomy.
Figure 6. Minor bleeding treated with 2 hemoclips.
Pathology examination revealed a 3.5-cm × 2.5-cm × 1-cm carcinoid tumor invading the lamina propria and submucosa (Figure 7). Immunohistochemical characteristics were consistent with a low-grade neuroendocrine carcinoid tumor (synaptophysin +++, chromogranin A -, CK AE1/3 Cocktail +, Ki-67:MIB-1 -, CK7 -). Margins were uninvolved by neuroendocrine tumor.
Figure 7. The carcinoid tumor that had invaded the lamina propria and submucosa.
The patient's postresection course was uneventful. The patient is currently in a surveillance program, and after more than 1 year, she is asymptomatic with no signs of local or distant recurrence.
Medscape Gastroenterology © 2013
Cite this: Simi Singh, Jason Bratcher, Franklin Kasmin, et. al. How Do You Treat a Carcinoid in the Duodenum? - Medscape - Jul 15, 2013.