PMC5583623_01
Endoscopic image showing an ampullary adenoma involving the ampullary orifice (vertical arrow), entire ampulla and spreading laterally (horizontal arrow)
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F1
ERCP performed at the Cleveland Clinic showed a large polyp at the ampulla along with bulging of the ampulla and extension into periampullary area as a flat, sessile component of about 2 cm in size [Figure 1].
Cytologic features of tubular adenoma on Papanicolaou-stained ThinPrep specimen. (a) Normal bile duct glandular epithelium (x400), (b) adenoma epithelium with nuclear palisading and hyperchromasia (x400), (c) adenoma epithelium with nuclear hyperchromasia, elongated thin nuclei and smooth nuclear contours (x400), (d) scattered single cells derived from the adenoma (x400)
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F2
ThinPrep Papanicolaou-stained slide showed a cellular preparation containing cohesive clusters, strips, and single columnar cells dispersed in a clean background. Two distinct cell populations were present; the first showing bland flat honeycomb sheets of typical benign ductal epithelium [Figure 2a] and the second showing mild architectural atypia/disorganization and discernible nuclear pseudostratification/palisading, the latter seen best at the periphery of the larger two-dimensional groups [Figure 2b]. In this second population, the columnar cells were slender and taller than usual biliary epithelial cells, had basal, elongated, and slender nuclei occupying at least a third to half of the cell length, with smooth nuclear contours, and hyperchromatic evenly dispersed chromatin [Figure 2c]. Single dispersed cells were observed but did not display overt nuclear atypia [Figure 2d].
Subsequent Whipple resection demonstrating the ampullary tubular adenoma involving the distal common bile duct (*) (x10). The insert shows the high power morphology including nuclear pseudostratification, hyperchromasia, and increased mitotic activity (x400)
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F3
Final histology confirmed an ampullary TA with low-grade dysplasia, 3 cm in largest dimension, extending into the distal CBD [Figure 3].