S3464 Rare GI Malignancy: Case of Ampullary Carcinoma

Abstract

Introduction: Ampullary Pancreatic Cancer is a rare malignant tumor that only counts for 0.2% of GI tract carcinomas. It often presents with non-specific symptoms requiring high clinical suspicion. Here we describe a case of ampullary carcinoma presenting as a 3 week history of abdominal pain. Case Description/Methods: This is a 64-year-old male with a medical history of HTN and Dyslipidemia, who presented with 3-week history of dull aching intermittent epigastric abdominal pain. Exam was significant for scleral icterus and positive Murphy’s sign. Labs were significant for elevated liver enzymes, alkaline phosphatase and total bilirubin. Abdominal US showed dilated CBD measuring 11 mm and biliary sludge in the gall bladder. MRCP confirmed CBD dilatation; however, it was negative for choledocholithiasis. Subsequently, the patient underwent EUS and ERCP that showed an ampullary mass (Figure 1). Pathology findings were consistent with tubulovillous adenoma with focal adenocarcinoma. The patient underwent an exploratory laporatomy and pancreaticoduodenectomy. Biopsy revealed final pathology consistent with invasive adenocarcinoma involving the ampulla and periampullary duodenum extending to the pancreas of > 0.5 cm (mixed intestinal and pancreatobiliary type) with uninvolved margins. The postoperative course was uneventful, and he was discharged with the intention to administer adjuvant chemotherapy in an outpatient setting. Discussion: Ampullary cancer accounts for about 6% of peri-ampullary malignancies. It usually presents earlier than other peri-ampullary malignancies due to its anatomic location that may cause early biliary obstruction with jaundice. Other clinical signs are abdominal pain, weight loss and lethargy, however not specific. Laboratory and radiological workup might reveal elevation in liver enzymes and biliary dilatation, which often prompt the need for endoscopic ultrasound evaluation. In our case, the pathology report revealed stage 2 ampullary adenocarcinoma with mixed intestinal and pancreatobiliary features without metastasis or lymph node involvement. Pancreaticoduodenectomy is the first-line therapy for such patients. Prognosis and utility of adjuvant chemotherapy depend on tumor subtype with intestinal variant appear to have better outcomes. Additional research is needed to evaluate the best regimen of adjuvant chemotherapy and its significance in affecting survival for such patients following surgery.Figure 1.: A and B: two views of a mass surrounding major papilla (arrow).