55-year-old female with jaundice. Diagnostic radiology reveals double duct sign, irregular pancreatic head, ampullary mass, distal bile duct obstruction. Biopsy proven ampullary adenocarcinoma (see Case #19161 )

Procedure: Whipple resection (Pancreaticoduodenectomy).

Gross: The specimen consists of a Whipple resection specimen, containing a portion of the pancreatic head, connected duodenum, and distal segment of the stomach. The entire specimen weighs 224 gms. The resected distal portion of the stomach measures 8.5 cm. in length, with diameters ranging from 4 to 6.5 cm. The mucosal rugae are grossly unremarkable with slightly flattened at the pyloric region. The resected duodenal measures 15 cm. in length with circumferences of 5.5 to 6.6 cm. The ampullar is bulging and prominent measuring 1.4 x 1.1 x 0.6 cm. The rest of the duodenal mucosa is grossly unremarkable with the usual folds. The pancreatic head measures 1.8 cm. in length with a diameter of 4.5 cm. The bile duct is grossly dilated and measuring 4.5 cm. in length, with a maximal diameter of 1.2 cm. The inner surface of the dilated bile duct is grossly smooth with no definite papillary lesions. The dilated pancreatic duct measures 4.5 cm. in length with a maximal diameter of 0.8 cm. The opening of the ampulla of Vater is largely stenotic. Representative sections are submitted.

Micro: Sections through the ampullary mass lesion show a moderately differentiated invasive adenocarcinoma. The tumor is mainly located at, and limited to the ampulla of vater. The tumor is composed of proliferation of complex neoplastic glands with glandular crowding and anastomosis. Irregular cribriform differentiation and intraluminal micropapillary formations are noted. Foci of invasive tumor glands and individual tumor cells are also present. The tumor cells show relatively high N/C ratio with opened chromatin and prominent nucleoli. Frequent mitotic figures are noted with a few atypical forms. Intracellular mucin and accumulation of extracellular, intraluminal mucin are also noted and demonstrated by mucicarmine stain. Scattered foamy macrophages are present in the lumens of neoplastic glands. The duodenal mucosa, dilated bile ducts, and pancreatic duct mucosa are free of tumor involvement. The pancreatic margin, duodenal margin, stomach margin, and bile duct margin are negative for malignancy. The uninvolved duodenal mucosa shows normal villous architecture with mild nonspecific chronic inflammation and mucosal lymphoid aggregates. Six benign lymph nodes are negative for metastatic adenocarcinoma. H & E stain

IHC stains:
CK 7 Positive, diffuse
CK 20 Negative
CDX-2 Negative
CK 17 Positive, patchy
Ki-67 Positive (about 80% of tumor cells)
MUC-1 Positive
MUC-2 Negative