PMC5067299_01
CT scans show reduction of tumor (arrow heads) in the ampulla Vater (a,d), lymphnodes #8a (arrows) (b,e) and #12b (thick arrows) (c,f).
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A computed tomography (CT) scan revealed a dappled enhanced tumor 30 mm in size in the ampulla of Vater (Fig. 1a) with invasion to the duodenum and pancreas. Regional lymph nodes along the common hepatic artery (#8a) and in the hepatoduodenal ligament (#12b) had swollen to 21 mm and 33 mm in size, respectively (Fig. 1b, c); moreover, several distant lymph nodes around the abdominal aorta were also swollen, with one located between the upper border of the celiac artery and the lower border of the left renal vein (#16a2) swollen to 21 mm (Fig. 2a) and others located between the lower border of the left renal vein and the upper border of the origin of the inferior mesenteric artery (#16b1) swollen to 19 mm and 20 mm (Fig. 2b, c). A follow-up CT scan showed the shrinkage of the tumor in the ampulla of Vater (Fig. 1d), the disappearance of the lymph nodes at #8a (Fig. 1e), and the shrinkage of the lymph nodes at #12b (Fig. 1f) to 11 mm and 20 mm, respectively.
CT scans show reduction of lymph nodes #16a2 (arrow heads) (a,d) and #16b1 (arrows) (b,c,e,f).
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Regional lymph nodes along the common hepatic artery (#8a) and in the hepatoduodenal ligament (#12b) had swollen to 21 mm and 33 mm in size, respectively (Fig. 1b, c); moreover, several distant lymph nodes around the abdominal aorta were also swollen, with one located between the upper border of the celiac artery and the lower border of the left renal vein (#16a2) swollen to 21 mm (Fig. 2a) and others located between the lower border of the left renal vein and the upper border of the origin of the inferior mesenteric artery (#16b1) swollen to 19 mm and 20 mm (Fig. 2b, c). Moreover, the lymph node at #16a2 (Fig. 2d) had shrunk to 7 mm and the lymph nodes at #16b1 (Fig. 2e, f) had shrunk to 5 mm and 7 mm.
ERCP revealed exposed protruded mass in the ampulla of Vater (a), and obstruction in bile duct (b).
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An upper gastrointestinal endoscopy showed an exposed protruded tumor in the ampulla of Vater (Fig. 3a). Endoscopic retrograde cholangiopancreatography (ERCP) showed bile duct dilatation, and an endoscopic retrograde biliary drainage (ERBD) tube was placed to alleviate the obstructive jaundice (Fig. 3b).
Clinical course and changes in DUPAN-II and CEA.
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Four cycles later, the cancer markers CEA and DU-PAN-2 had decreased and were within the normal ranges (Fig. 4).
A macrophotograph of tumor (a) in the ampulla Vater, and microphotographs of HE staining of tumor (x20) (b) and lymph node around the aorta (x1.25) (c).
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The tumor in the ampulla of Vater was an exposed, protruded-type mass, and the tumor specimen had decreased to a diameter of 15 mm (Fig. 5a). A pathological examination of the specimen using hematoxylin and eosin (HE) staining showed necrotic tissue and epithelia with dysplasia that was thought to be a remnant of adenocarcinoma (Fig. 5b). The presence of histiocytes and fibrosis in the resected lymph nodes suggested inflammation (Fig. 5c).
pathological findings of lymph node in the hepatoduodenal ligament, showing the results of HE staining (x1.25) (a) and immunostaing with CK AE1/3(x1.25) (b).
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Especially, the immunostaining of lymph node #12b was positive for cytokeratin (CK) AE1/3 and was strongly suspected to have been a metastasis originating from the ampulla of Vater carcinoma (Fig. 6a, b).