Clinical, Pathological, and Immunohistochemical Features of Adenomyoma in the Ampulla of Vater

Yong Hyeok Choi; Mi Jin Kim; Joung-Ho Han; Soon Man Yoon; Hee Bok Chae; Sei Jin Youn; Min Ho Kang; Rohyun Sung; Jae Woon Choi; Seon Mee Park

doi:10.4166/kjg.2013.62.6.352

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Choi, Kim, Han, Yoon, Chae, Youn, Kang, Sung, Choi, and Park: Clinical, Pathological, and Immunohistochemical Features of Adenomyoma in the Ampulla of Vater

Original Article

Korean J Gastroenterol 2013;62(6):352-358.

Published online: 4 October 2013

DOI: https://doi.org/10.4166/kjg.2013.62.6.352

Clinical, Pathological, and Immunohistochemical Features of Adenomyoma in the Ampulla of Vater

Yong Hyeok Choi, Mi Jin Kim, Joung-Ho Han, Soon Man Yoon, Hee Bok Chae, Sei Jin Youn, Min Ho Kang¹, Rohyun Sung², Jae Woon Choi³, Seon Mee Park

Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea

¹Department of Radiology, Chungbuk National University College of Medicine, Cheongju, Korea

²Department of Pathology, Chungbuk National University College of Medicine, Cheongju, Korea

³Department of Surgery, Chungbuk National University College of Medicine, Cheongju, Korea

Correspondence to: Seon Mee Park, Department of Internal Medicine, Chungbuk National University College of Medicine, 52 Naesudong-ro, Heungdeok-gu, Cheongju 361-711, Korea. Tel: +82-43-269-6019, Fax: +82-43-27-3252, E-mail: smpark@chungbuk.ac.kr

Received 1 August 2013 Revised 1 September 2013 Accepted 12 September 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

Ampullary adenomyoma is a benign lesion whose malignant potential has yet to be confirmed. Despite its benign nature, adenomyoma is frequently misdiagnosed as a carcinoma or adenoma and is overtreated by extensive surgery. This study was performed to analyze the clinical, pathological, and immunohistochemical features of adenomyomas in the ampulla of Vater.

Methods

Nine cases of adenomyoma in the ampulla of Vater, diagnosed in Chungbuk National University Hospital between 2008 and 2011, were enrolled in this study. We reviewed the clinical data on the symptoms, laboratory data, and radiologic findings of the abdominal computed tomography and endoscopic retrograde cholangiopancreatography. For pathological analysis, all the slides were reviewed by one pathologist, and immunohistochemical stainings with antibodies against cytokeratin 7 (CK7), cytokeratin 20 (CK20), α-smooth muscle actin (α-SMA), and Ki-67 antigen were performed.

Results

All the cases were CK7 positive and CK20 negative. A strong cytoplasmic expression of α-SMA was confirmed in all cases. The Ki-67 index was less than 1% in eight cases and 5% in one case. Four cases underwent endoscopic papillectomy, and one case received surgical ampullectomy during colorectal cancer surgery. Five cases that underwent endoscopic or surgical treatment remained symptom-free for three years. Four cases that were closely observed with repeated endoscopic examinations exhibited no interval changes in the papillary lesions.

Conclusions

Endoscopic biopsy and immunohistochemistry can aid in the diagnosis of ampullary adenomyomas. Endoscopic papillectomy or surgical ampullectomy is adequate for the treatment of symptomatic ampullary adenomyomas.

Keywords: Adenomyoma, Ampulla of Vater, Immunohistochemistry

References

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Fig. 1.

Radiologic findings of adenomyomas in the ampulla of Vater. Abdominal CT (A, axial view; B, coronal view) showed a 1.4-cm mass protruding into the duodenal lumen with a dilated common bile duct (arrows). (C) Endoscopic retrograde cholangiopancreatography showed a dilated biliary tract (arrow).

Fig. 2.

Endoscopic view of ampullary adenomyomas. Enlarged major papilla and villous and granular mucosa around the papillary orifice could be identified in all cases; each case matched from A to I.

Fig. 3.

Pathological and immunohistochemical features of adenomyomas in the ampulla of Vater. (A) Hyperplastic glandular lobules covered by a single layer of epithelium were surrounded by hyperplastic mesenchymal tissues composed of muscle fibers, fibroblasts, myofibroblasts, and capillaries (H&E, ×200). (B) Immunohistochemical staining with the Ki67 antibody level detected at less than 1% (×40). (C, D) α-SMA expression (arrows) in the myofibroblastic component (×40 and ×400, respectively). (E, F) Strong CK7 expression (arrows) in the epithelial lining of the glandular structures (×40 and ×400, respectively). (G, H) No CK20 expression (arrows) in the epithelial lining of the glandular structures (×40 and ×400, respectively).

Fig. 4.

Endoscopic papillectomy for an ampullary adenomyoma. (A) Endoscopic papillectomy was performed after pancreatic stent insertion. (B) Endoscopic view of the stent placed in the biliary duct after papillectomy. (C) Endoscopic papillectomy was performed without prior pancreatic stent insertion. (D) Endoscopic view of the major papilla after papillectomy.

Table 1.

Clinical Features of Nine Cases of Ampullary Adenomyoma

Case	Age (yr)/sex	Clinical symptom	CT finding	Endoscopic finding	Endoscopic biopsy	AST/ALT (IU/L)	ALP (IU/L)	T-bil (mg/dL)	Treatment
1	70/M	Abdominal pain	Focal enhancing lesion at AOV and CBD dilation (14 mm)	15 mm sized ampullary mass with granularity	Adenomyoma	78/30	268	0.57	Endoscopic papillectomy
2	71/M	Abdominal pain	Nonspecific finding	12 mm sized ampullary mass	Adenomyoma	55/92	432	1.83	Endoscopic papillectomy
3	72/M	Incidental	15×12 mm sized well defined nodule at AOV and CBD dilatation (13 mm)	12 mm sized ampullary mass with villous mucosa	Dysplasia →adenomyoma	25/11	180	0.36	Endoscopic papillectomy
4	53/M	Abdominal pain	Nonspecific finding	10 mm sized lobulated lesion	Chronic inflammation →adenomyoma	25/33	300	1.46	Endoscopic papillectomy
5	75/M	Incidental (colon cancer)	Focal enhancing lesion at AOV with diffuse IHD and CBD dilatation (11 mm)	Bulging and lobulated papilla	Adenomyoma	17/15	230	0.55	Surgical ampullectomy
6	75/F	Incidental	Mass (11 mm) at AOV, IHD and CBD dilatation (10 mm)	Bulging and lobulated papilla	Adenomyoma	23/16	251	0.36	Close observation
7	64/F	Incidental	CBD dilatation (10 mm)	Bulging papilla	Adenomyoma	44/33	178	0.60	Close observation
8	57/F	Incidental	Nonspecific finding	Enlarged and lobulated papilla	Atypical epithelial proliferation → adenomyoma	36/29	174	1.02	Close observation
9	65/F	Incidental	Not performed	Bulging and lobulated papilla	Adenomyoma	29/28	273	0.56	Close observation

M, male; F, female; AOV, ampulla of Vater; CBD, common bile duct; IHD, intrahepatic duct; T-bil, total bilirubin.

Table 2.

Clinical Features of Four Cases of Ampullary Adenomyoma Reported in the Literature

Year published	Age (yr)/ sex	Clinical symptom	CT finding	Endoscopic finding	Endoscopic biopsy	AST/ALT (IU/L)	ALP (IU/L)	T-bil (mg/dL)	Treatment
2004⁷	69/M	Hyperbilirubinemia	Mass at CBD with diffuse BD and PD dilatation	Normal AOV	Chronic inflammation	33/13	62	1.8	Pancreaticoduod enectomy
2005⁸	56/M	Mild jaundice	Mass at AOV with BD dilatation	Sessile mass	Focal nuclear atypia	Normal	350	2.1	Surgical ampullectomy
2007⁹	74/F	Abdominal pain (pancreatitis)	Diffuse dilated CBD without focal mass	Even and firm nodular mass with a granular and villous mucosa (after EST)	Muscle proliferation without atypia	31/11	85	1.3	Piecemeal resection with an electro-cautery snare
2010¹⁰	69/M	Abdominal pain/ anorexia	Diffuse BD and PD dilatation	Bulging and lobulated papilla	Focal adenoma	57/20	85	0.9	Endoscopic papillectomy

M, male; F, female; CBD, common bile duct; BD, bile duct; PD, pancreatic duct; AOV, ampulla of Vater; EST, endoscopic sphincterotomy; T-bil, total bilirubin.

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