PMC4066863_01
Magnetic resonance cholangiopancreatography showing dilated intrahepatic and extrahepatic bile ducts including the cystic duct and the gallbladder. The common bile duct measures 15 mm in diameter with abrupt concentric stenosis in its lower third and a cut-off point located 20 mm distally to the duodenal ampulla (arrow). The pancreatic duct is depicted as normal.
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The common bile duct (CBD) measured 15 mm in diameter with an abrupt concentric stenosis in its lower third and a cut-off point located 20 mm distally to the duodenal ampulla (Figure 1).
Endoscopic appearance showing the duodenal papilla covered with whitish tiny granules. The tumor of the ampulla of Vater is not exposed.
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The duodenal papilla was depicted as being covered with whitish tiny granules, whereas the tumor of the ampulla of Vater was not exposed (Figure 2).
Macroscopic findings of the tumor. The tumor of the ampulla of Vater forms a mass with ulceration and multiple small nodular lesions are found around it.
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Cross-sections of the resected specimen. The tumor is composed of follicular lymphoma (enclosed by curved yellow line) and adenocarcinoma (enclosed by curved red line) of the ampulla of Vater (arrow). Adenocarcinoma includes the lower part of the common bile duct (arrowheads).
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The duodenal FL formed a mass, measuring 40 mm in diameter, which involved the duodenal mucosa and submucosa (enclosed by curved yellow line in Figure 4). Adenocarcinoma of the ampulla of Vater formed a solid tumor (enclosed by curved red line in Figure 4), 25 x 20 mm, involving the lower CBD for 20 mm in length, pancreas (Figure 7(d)), and duodenum, with metastasis to regional lymph node (1/28 in total).
Representative histologic images of the follicular lymphoma. ((a)-(d)) The lesion reveals lymphoid follicular formations (a) with small-to-medium-sized centrocyte-like cells and a few centroblast-like cells (b). Small nodular lesions around the main tumor also consist of follicular lymphoma (c). Regional lymph nodes are partially involved by follicular lymphoma (d).
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The surface part of the tumor showed lymphoid follicular formations (Figure 5(a)) with small-to-medium-sized centrocyte-like cells and a few centroblast-like cells (Figure 5(b)). Atypical lymphocytes in small nodular lesions (Figure 5(c)) around this mass and regional lymph nodes (Figure 5(d)) in the duodenum were also immunohistochemically positive for CD10 (Figure 6(d)), CD20, CD79a, and BCL2 (Figures 6(e) and 6(f)).
Immunohistochemical findings of follicular lymphoma. ((a)-(f)) Atypical lymphoid cells are positive for CD10 (a) and CD20 (b). BCL2 protein is intensively expressed in the centers of the follicles (c). Atypical lymphocytes in small nodular lesions (Figure 5(c)) around the mass of the ampulla of Vater are immunohistochemically positive for CD10 (d) and BCL2 (e). In regional lymph nodes (Figure 5(d)) in the duodenum, BCL2 protein is intensively expressed in the centers of the follicles (f).
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Immunohistochemical study demonstrated that the atypical lymphoid cells were positive for CD10 (Figure 6(a)), CD20 (Figure 6(b)), and CD79a but negative for CD5 and cyclin D1. BCL2 protein was intensively expressed in the centers of the follicles (Figure 6(c)). Atypical lymphocytes in small nodular lesions (Figure 5(c)) around this mass and regional lymph nodes (Figure 5(d)) in the duodenum were also immunohistochemically positive for CD10 (Figure 6(d)), CD20, CD79a, and BCL2 (Figures 6(e) and 6(f)).
Representative histologic images of adenocarcinoma of the ampulla of Vater. ((a)-(d)) Follicles of follicular lymphoma are partially invaded by adenocarcinoma (a). Adenocarcinoma shows various patterns, including tubular (b), cribriform, and trabecular structure and nests (c), which invade the pancreas (d).
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The mass, consisting of FL, was partially invaded by adenocarcinoma (Figure 7(a)). Adenocarcinoma showed various patterns, including tubular (Figure 7(b)), cribriform, and trabecular structures and nests (Figure 7(c)), classified as the pancreatobiliary type. Adenocarcinoma of the ampulla of Vater formed a solid tumor (enclosed by curved red line in Figure 4), 25 x 20 mm, involving the lower CBD for 20 mm in length, pancreas (Figure 7(d)), and duodenum, with metastasis to regional lymph node (1/28 in total).