Isolated Pancreatic/Periampullary

Mallika Tewari, Hari S Shukla
Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University.
Varanasi, UP, India
Dear Sir,
Although tuberculosis is endemic in this part of the
world, isolated pancreatic tuberculosis is extremely
rare. Thus, all lesions are first suspected as carcinoma
and not tuberculosis unless the clinical features are
suggestive of tuberculosis, for example, a history of
miliary tuberculosis with enlarged peripancreatic nodes
especially in an immunocompromised host. As our
patient had none of these findings, we investigated her
as one with possible periampullary carcinoma.
Currently, the cornerstone for diagnostic evaluation of
a pancreatic tumor is multiphase, multidetector helical
axial computed tomography (CT) performed according
to a defined pancreatic protocol (i.e. triphasic cross
sectional imaging and thin slices) [1, 2]. It has an
accuracy of approximately 80% for assessing
resectability preoperatively [1, 2]. Endoscopic
ultrasound (EUS) is usually indicated as an additional
imaging technique when no tumor is seen on CT and
there remains a high index of suspicion of an
underlying malignancy [2]. EUS is also helpful in
distinguishing benign and malignant strictures of the
bile duct when no mass lesion is apparent. However,
EUS is highly operator-dependent and is recommended
for use only in experienced hands. Magnetic resonance
cholangiopancreatography (MRCP) is another non-
invasive examination which helps in the diagnosis of
pancreatico-biliary tumors [1, 2, 3].
An endoscopic retrograde cholangiopancreatography
(ERCP) prior to resection is routinely avoided for fear
of its associated potential complications, such as
pancreatitis, cholangitis, bleeding and perforation
making eventual surgery difficult. However, this
investigation is of value especially when CT scan
findings are equivocal since fewer than 3% of patients
with pancreatic carcinoma have normal findings [1].
Though it is difficult to differentiate benign and
malignant strictures or stenosis, severe stenosis and
marked proximal dilatation more often indicate
malignancy [1].
Another important point is that tissue diagnosis is not a
prerequisite before routine resection. A suspicious
lesion on imaging (MRCP/CT), even without a mass
lesion should be treated with resection [1, 2]. Tissue
diagnosis is required when a patient is not a candidate
for resection or is enrolled in a neoadjuvant
chemo/radiation protocol.
Our patient had features suggestive of a periampullary
lesion, for example, a growth in the ampulla, irregular
lower bile duct stricture with proximal dilatation and a
history of jaundice. A periampullary tumor often
sloughs off relieving the jaundice temporarily. A
biopsy was attempted twice, once during endoscopy
and another time while doing an ERCP. Again, as
tuberculosis was not suspected either clinically or on
histopathology of the biopsy specimens, the biopsies
were thus not analyzed by polymerase chain reaction
(PCR) for Mycobacterium tuberculosis. It is well
known, as we have already stated in the discussion of
our paper, that preoperative endoscopic biopsy is rarely
diagnostic for tuberculosis [4]. It was only after a
granulomatous inflammation was revealed by
histopathology of the wide local excision specimen that
we decided to investigate it further by PCR.
But, indeed, if the suspicion of tuberculosis is strong,
repeated aspirations guided by a skilled endosonologist
may improve the diagnostic yield. But isolated lesions
of the ampulla, such as the one presented in the paper,
occur only rarely and tuberculosis remains a diagnosis
of exclusion.
Conflict of interest The authors have no potential
conflicts of interest
Received April 16th, 2009
Key words Carcinoma; Diagnosis; Endosonography; Pancreatic
Neoplasms; Tuberculosis
Correspondence Mallika Tewari

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JOP. J Pancreas (Online) 2009 May 18; 10(3):343-344.
JOP. Journal of the Pancreas - - Vol. 10, No. 3 - May 2009. [ISSN 1590-8577]
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Guidelines in Oncology. Pancreatic Adenocarcinoma. V.1.2009.
2. Royal RE, Wolff RA, Crane HC. Pancreatic Cancer. In: De Vita
TV, Lawrence TS, Rosenberg SA (eds). Cancer: Principles and
Practice of Oncolgy 8th Ed. pp. 1086-1129.
3. National Cancer Comprehensive Network Clinical Practice
Guidelines in Oncology. Hepatobiliary Cancers. V.2.2009.
4. Tewari M, Mishra RR, Kumar V, Kar AG, Shukla HS. Isolated
tuberculosis of the ampulla of vater masquerading as periampullary
carcinoma: a case report. JOP. J Pancreas (Online) 2009; 10(2):184-
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