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Introduction
An 85 year old female presented with an abnormality at the level of the ampulla. Narrow band imaging and EUS suggested the lesion was too extensive to remove endoscopically. At the time of definitive surgery, a second T3N1 jejunal cancer was discovered and removed.
Case History
A previously healthy 85-year-old woman presented with weakness and flu like symptoms. She had been in her usual good health until she took a tropical vacation at which time she was on malaria prophylaxis. She began feeling poorly, discontinued the prophylaxis and eventually came to medical attention on return from her trip.
Her past history was significant for atrial fibrillation and chronic coumadin therapy. She has had two previous resections for colon cancer, the first was 15 years prior and was early stage, and the second was a stage III lesion, 5 years prior to this presentation. She received postoperative adjuvant chemotherapy for that her stage III colon cancer.
Additional surgery included a mastectomy for stage I breast cancer 10 years previously.
Despite the three previous cancers, she was doing well without any evidence of systemic illness.
Her family history was significant for her mother having pancreas cancer at an elderly age, but otherwise was unremarkable.
Her physical exam was normal for age except for a right upper quadrant fullness and a rash suggesting shingles.
Her liver chemistries were normal, but her INR was elevated at 11 (nl 2.5-3) and her sodium was low at 124 (nl>135). There was no evidence of malaria.
The patient's symptoms improved with hydration and correction of the INR.
Because her abdominal exam revealed right upper quadrant fullness, an abdominal ultrasound was obtained which suggested the findings were due to an enlarged gallbladder. A CT scan confirmed this feature but showed no other evidence of disease. An EGD was done which showed irregularity in the periampullary area. Biopsies showed inflammation but no dysplasia.
The patient was discharged and continued to feel well. Repeat endoscopy was done after 8 weeks of proton pump inhibitor therapy. A persistant periampullary abnormality but with less inflammation than on her original EGD. Biopsies now revealed high grade dysplasia. The patient underwent EUS staging for consideration of possible endoscopic removal of the lesion.
Narrow band imaging was done at the time of EUS staging.
Video 1 shows the EGD, initially with full wavelength light and then with narrow band imaging. The narrow band imaging significantly improves the visualization of the lesion and suggests the margins were rather large, and difficult to encompass.
EUS (Video 2) showed that the tumor had vague margins at the level of the ampulla, and there was possible involvement at the end of the pancreatic and common bile ducts.
Biopsies were taken using narrow band imaging guidance and carcinoma –in-situ was found.
Due to the endoscopic and EUS findings, and biopsy results, it was felt that this case would be best managed surgically rather than endoscopically. The patient underwent pancreaticoduodenectomy. At the time of surgery, an abnormal mesenteric lymph node was discovered. Further exploration revealed an unsuspected jejunal mass pathologically shown to be a T3N1 adenocarcinoma. The duodenectomy specimen revealed carcinoma in-situ with negative surgical margins. Evaluation for hereditary non-polyposis colon cancer syndromes (HNPCC) are ongoing.
Discussion
This patient presented for non-specific complaints and through a series of fortuitous events was discovered to have a neoplastic process in the periampullary region. Although the initial biopsies did not show evidence of dysplasia, this was probably due to sampling error associated with coexisting inflammation, since the dysplastic process became evident following acid suppressive therapy.
Endoscopic management was considered, but eventually was felt to have a low probability of success due to the extent of disease noted by narrow band imaging and EUS. Narrow band imaging reveals a clearer picture of the mucosa than white light 1-4 and is gaining acceptance throughout the GI tract. Recently, narrow band imaging has been suggested to be able to separate inflammatory from dysplastic processes in the vicinity of the ampulla 5. In this particular patient, narrow band imaging contributed to the impression that this duodenal lesion was more extensive than what could readily be managed endoscopically. Surgery resulted in the discovery of a synchronous but more advanced jejunal cancer.
This is an unusual case of a woman with multiple GI malignancies. Although a specific genetic component has not been identified, and features suggesting a possible HNPCC are raised in this particular case, despite her elderly age and lack of a concerning family history. If possible, the diagnosis of a specific mutation would be useful in assessing family members, since at this point, all first degree relatives have to assume to be at risk of a genetic propensity of cancer.
Conclusions:
In summary, this is a case of an elderly woman with multiple GI malignancies. Narrow band imaging was found to be useful in determining the management of this particular patient.
References
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