Co-Existence of Peri-Ampullary Carcinoma

Chirag S Desai
1
, Murad Lala
1
, Anand Joshi
2
, Philip Abraham
2
, Devendra Desai
2
,
Ramesh B Deshpande
3
, Sudeep R Shah
1
1
Departments of Surgery,
2
Gastroenterology and
3
Surgical Pathology, PD Hinduja Hospital and
Medical Research Center. Mumbai, India
ABSTRACT
Context
Pancreatic tuberculosis and
peripancreatic tuberculous lymphadenitis are
rare, mimicking various pathologies of the
pancreas. The coexistence of peri-ampullary
malignancy with peripancreatic tuberculous
lymphadenitis has not been reported.
Case report We present the case of a young
woman who had been operated on with a
preoperative diagnosis of peri-ampullary
adenocarcinoma in whom a frozen section of
regional lymph nodes revealed tuberculosis.
The final pathology confirmed the co-
existence of tuberculosis with malignancy.
The patient made an uneventful recovery.
Conclusion In countries with high endemicity
for tuberculosis, the co-existence of
malignancy and tuberculosis should be
considered and resection, which is the only
chance for cure, should not be abandoned due
to observations based solely on frozen
sections.
INTRODUCTION
Pancreatic tuberculosis and peripancreatic
tuberculous lymphadenitis are rare clinical
entities. Pancreatic tuberculosis often mimics
pancreatic cancer, pancreatic abscess, cystic
tumors of the pancreas, pseudocysts of the
pancreas or chronic pancreatitis with head
mass on preoperative non-invasive diagnostic
tests [1]. Peripancreatic tuberculous
lymphadenitis
mimicking
pancreatic
pseudotumor is also reported in the literature
[2]. However, the coexistence of peri-
ampullary malignancy with peripancreatic
tuberculous lymphadenitis has not been
reported. We report the case of a young
woman presenting with peri-ampullary
carcinoma associated with tuberculous
peripancreatic lymphadenitis.
CASE REPORT
A 28 year old woman presented with
jaundice, pruritus and alcoholic stools
alternating with melena of one month
duration. She had had abdominal pain with
radiation to the back and vomiting for one
year. She had lost significant weight in the
month before. On examination, she had
icterus, scratch marks and palpable
gallbladder.
On admission, serum total bilirubin was 11.3
mg/dL (reference range: 0.2-1.0 mg/dL),
direct bilirubin was 6.9 mg/dL (reference
value: less than 0.3 mg/dL) and alkaline
phosphatase was 469 IU/L (reference range:
40-120 IU/L). Ultrasonography and a CT scan
showed dilatation of the intra and extrahepatic
biliary tree and the pancreatic duct but only

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146
small lymph nodes (Figure 1). There was no
mass in the head of the pancreas. Side-
viewing endoscopy revealed an infiltrating
growth in the peri-ampullary region extending
to the first part of the duodenum. Cannulation
of either duct was not possible. Brush
cytology and mucosal biopsy revealed
adenocarcinoma.
Intraoperatively, there was no evidence of
liver or peritoneal metastasis. A mass was
palpable in the peri-ampullary region. There
was extensive peripancreatic lympha-
denopathy (Figure 2). A frozen section of
these nodes suggested tuberculosis. Whipple’s
procedure was performed in view of the
earlier biopsy report of adenocarcinoma. Her
postoperative recovery was uneventful. She
was discharged on four-drug antituberculous
therapy and was doing well on follow-up two
months later.
Histopathology
confirmed
high-grade
adenocarcinoma in the peri-ampullary region
(Figure 3) infiltrating transmurally, reaching
up to the serosa and infiltrating pancreatic
lobules peripherally. A peripancreatic lymph
node showed multiple caseating epitheloid
granulomas with Langhans’ type giant cells
(Figure 4).
DISCUSSION
The incidence of pancreatic tuberculosis is
very low. Even in the presence of miliary
tuberculosis, pancreatic tuberculosis accounts
for 0-4.7% of cases of abdominal tuberculosis
[3, 4]. Pancreatic tuberculosis often mimics
Figure 1. CT scan of the abdomen showing a dilated
bile duct and small nodes adjacent to the superior
mesenteric artery (SMA).
Figure 3. Histopathology of the ampullary mass;
poorly differentiated adenocarcinoma
Figure 4. Histopathology of the lymph node showing
caseating necrosis and Langhans’ type giant cells
(arrow).
Figure 2. Intraoperative photograph following roux
loop pancreaticojejunostomy showing an enlarged node
in the bowel mesentery (arrow).

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JOP. J Pancreas (Online) 2004; 5(3):145-147.
JOP. Journal of the Pancreas – http://www.joplink.net – Vol. 5, No. 3 – May 2004. [ISSN 1590-8577]
147
various pathologies. In the majority of
patients, the diagnosis is obtained at
laparotomy [5, 6]. There are few reports in
literature mentioning isolated peripancreatic
and
retroduodenal
tuberculous
lymphadenopathy simulating a pancreatic
tumor [2, 7], but no evidence of the
coexistence of both [1].
Turan et al. [2] reported a case in which a
frozen section of a lymph node was
inconclusive and, hence, Whipple's procedure
was performed; histopathology suggested
tuberculosis. On the other hand, laparotomies
have been abandoned on the basis of
histology suggestive of tuberculosis [8]. In
our case, since we had pre-operative brush
cytology and biopsy, even though frozen
sections of peripancreatic nodes were
suggestive of tuberculosis, surgery could be
proceeded with.
In countries with high endemicity for
tuberculosis, the co-existence of malignancy
and tuberculosis should be considered and
resection, which is the only chance for cure,
should not be abandoned due to observations
based solely on frozen sections. If
preoperative or intraoperative biopsies are
suggestive of this benign pathology, careful
follow-up imaging is essential to show
regression of the mass on anti-tuberculosis
therapy; failing this, the surgical option
should be revisited.
Received October 27
th
, 2003 - Accepted
January 26
th
, 2004
Key words Adenocarcinoma; Mycobacterium
tuberculosis; Pancreas; Pancreatic Neoplasms;
Tuberculosis; Tuberculosis, Gastrointestinal;
Tuberculosis, Lymph Node
Correspondence
Sudeep R Shah
PD Hinduja National Hospital
Veer Savarkar Marg
Mahim
Mumbai, 400 016
India
Phone: +91-22 2444.7126
Fax: +91-22.2444.0425
E-mail address: shahsudeep@hotmail.com
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