The survivor. Ampullary Adenoma changing to Adenocarcinoma – Long term observation of a patient refusing surgery and having two more primary malignancy (case report)

Introduction: Ampullary adenomas are dysplastic lesions of the Vater papilla. They can be sporadic or can occur as the part of FAP. It is important to distinguish this two types with respect to management and surveillance. Papillary adenomas have pre-malignant potential. They can undergo through an adenoma-carcinoma sequence. In our case an ampullary adenoma was diagnosed in 2004 but the patient refused treatment. In nine years he developed an adenocarcinoma. The curiosity of the case is that during this nine years he underwent a nephrectomy due to adenocarcinoma and was diagnosed with a pulmonary adenocarcinoma, which was not removed as well as the ampullary tumor. Case report: 69 year old man was referred to our department in 2004 with abdominal pain and elevated liver enzymes. Ultrasound: dilated bile ducts, gallstones in the cholecyst and suspected malignancy in the left kidney. ERCP: ampullary lesion and choledocholithiasis. Stone removal and biopsy of the papilla was done. Histology proved tubular adenoma, low grade dysplasia. The left kidney was removed and its tumor proved to be a clear cell adenocarcinoma, not breaking through the renal capsule. In 2006 pulmonary screening detected a novel mass in the lung. Histology verified an adenocarcinoma (T2NXM1), which was independent from the former kidney adenocarcinoma. The patient was referred again in 2013 with fever and elevated liver enzymes. His common bile duct had been double stented in 2006, and the obturated stents caused cholangitis. We removed stents, repeated biopsy from the papilla. The former adenoma has been transformed into in situ adenocarcinoma. Surgical treatment was disapproved by the surgeon due to coexistant diseases. In july, 2014, he lost weight, his pulmonary tumor showed progression. Conclusions: in line with our case we reviewed the clinical appearance, the diagnostic and therapeutic modalities of the ampullary lesions. Endoscopic papillectomy is a good therapeutic modality in most of the ampullary adenomas. It is less invasive than surgery but only in experienced hands. The complications are high compared to other endoscopic therapies. Surgery remains the standard curative procedure for the suspected or confirmed adenocarcinomas, but endoscopy can provide proper palliation in cases where patients have high risk for surgery.