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Periampullary Tumors: High-Spatial-Resolution MR Imaging and Histopathologic Findings in Ampullary Region Specimens¹

¹ From the Department of Radiology, NTT East Tohoku Hospital, 2–29-1, Yamatomachi Wakabayashi-ku, Sendai, Japan (R.S., A.F.); Department of Gastroenterology, Sendai City Medical Center, Japan (K.I., N.F.); Department of Pathology, Tohoku University School of Dentistry, Sendai, Japan (R.I.); and Department of Radiology, Tohoku University School of Medicine, Sendai, Japan (S.T.). Received May 12, 2003; revision requested July 22; revision received October 20; accepted December 9. Address correspondence to R.S. (e-mail: reiji.s@thk.mhc.east.ntt.co.jp).

View larger version (89K): [in a new window]   Figure 1a. Schemata of (a) normal duodenal ampullary region and (b-e) International Union Against Cancer classification of periampullary cancers with tumor classification. (a) Common bile duct and pancreatic duct terminals penetrate the duodenal wall and form a common channel surrounded by Oddi muscle. (1) m = mucosa, (2) sm submucosa, (3) pm = muscularis propria, (4) ss = serosa or subserosa, (5) Panc = pancreatic head, (6) PD = pancreatic duct, (7) BD = bile duct, and D = duodenal cavity. Structures are those depicted at MR imaging and are listed in the Table. (b) Ampullary cancer. T1 indicates tumor limited to Oddi muscle; T2, tumor with invasion of duodenal wall; and T3, tumor with invasion of pancreas. (c) Extrahepatic bile duct cancer. T1 indicates tumor confined to bile duct; T2, tumor with invasion beyond wall of bile duct; T3, tumor with invasion of pancreas; and T4, tumor with invasion of duodenum or adjacent organs. (d) Pancreatic cancer. T1 indicates tumor (2 cm in greatest dimension) limited to pancreas; T2, tumor (>2 cm in greatest dimension) limited to pancreas; and T3, tumor with extension beyond pancreas. (e) Duodenal cancer. T1 indicates tumor with invasion of lamina propria or submucosa; T2, tumor with invasion of muscularis propria; T3, tumor with invasion through muscularis propria into subserosa; and T4, tumor with direct invasion of other organs or structures.

View larger version (73K): [in a new window]   Figure 1b. Schemata of (a) normal duodenal ampullary region and (b-e) International Union Against Cancer classification of periampullary cancers with tumor classification. (a) Common bile duct and pancreatic duct terminals penetrate the duodenal wall and form a common channel surrounded by Oddi muscle. (1) m = mucosa, (2) sm submucosa, (3) pm = muscularis propria, (4) ss = serosa or subserosa, (5) Panc = pancreatic head, (6) PD = pancreatic duct, (7) BD = bile duct, and D = duodenal cavity. Structures are those depicted at MR imaging and are listed in the Table. (b) Ampullary cancer. T1 indicates tumor limited to Oddi muscle; T2, tumor with invasion of duodenal wall; and T3, tumor with invasion of pancreas. (c) Extrahepatic bile duct cancer. T1 indicates tumor confined to bile duct; T2, tumor with invasion beyond wall of bile duct; T3, tumor with invasion of pancreas; and T4, tumor with invasion of duodenum or adjacent organs. (d) Pancreatic cancer. T1 indicates tumor (2 cm in greatest dimension) limited to pancreas; T2, tumor (>2 cm in greatest dimension) limited to pancreas; and T3, tumor with extension beyond pancreas. (e) Duodenal cancer. T1 indicates tumor with invasion of lamina propria or submucosa; T2, tumor with invasion of muscularis propria; T3, tumor with invasion through muscularis propria into subserosa; and T4, tumor with direct invasion of other organs or structures.

View larger version (48K): [in a new window]   Figure 1c. Schemata of (a) normal duodenal ampullary region and (b-e) International Union Against Cancer classification of periampullary cancers with tumor classification. (a) Common bile duct and pancreatic duct terminals penetrate the duodenal wall and form a common channel surrounded by Oddi muscle. (1) m = mucosa, (2) sm submucosa, (3) pm = muscularis propria, (4) ss = serosa or subserosa, (5) Panc = pancreatic head, (6) PD = pancreatic duct, (7) BD = bile duct, and D = duodenal cavity. Structures are those depicted at MR imaging and are listed in the Table. (b) Ampullary cancer. T1 indicates tumor limited to Oddi muscle; T2, tumor with invasion of duodenal wall; and T3, tumor with invasion of pancreas. (c) Extrahepatic bile duct cancer. T1 indicates tumor confined to bile duct; T2, tumor with invasion beyond wall of bile duct; T3, tumor with invasion of pancreas; and T4, tumor with invasion of duodenum or adjacent organs. (d) Pancreatic cancer. T1 indicates tumor (2 cm in greatest dimension) limited to pancreas; T2, tumor (>2 cm in greatest dimension) limited to pancreas; and T3, tumor with extension beyond pancreas. (e) Duodenal cancer. T1 indicates tumor with invasion of lamina propria or submucosa; T2, tumor with invasion of muscularis propria; T3, tumor with invasion through muscularis propria into subserosa; and T4, tumor with direct invasion of other organs or structures.

View larger version (67K): [in a new window]   Figure 1d. Schemata of (a) normal duodenal ampullary region and (b-e) International Union Against Cancer classification of periampullary cancers with tumor classification. (a) Common bile duct and pancreatic duct terminals penetrate the duodenal wall and form a common channel surrounded by Oddi muscle. (1) m = mucosa, (2) sm submucosa, (3) pm = muscularis propria, (4) ss = serosa or subserosa, (5) Panc = pancreatic head, (6) PD = pancreatic duct, (7) BD = bile duct, and D = duodenal cavity. Structures are those depicted at MR imaging and are listed in the Table. (b) Ampullary cancer. T1 indicates tumor limited to Oddi muscle; T2, tumor with invasion of duodenal wall; and T3, tumor with invasion of pancreas. (c) Extrahepatic bile duct cancer. T1 indicates tumor confined to bile duct; T2, tumor with invasion beyond wall of bile duct; T3, tumor with invasion of pancreas; and T4, tumor with invasion of duodenum or adjacent organs. (d) Pancreatic cancer. T1 indicates tumor (2 cm in greatest dimension) limited to pancreas; T2, tumor (>2 cm in greatest dimension) limited to pancreas; and T3, tumor with extension beyond pancreas. (e) Duodenal cancer. T1 indicates tumor with invasion of lamina propria or submucosa; T2, tumor with invasion of muscularis propria; T3, tumor with invasion through muscularis propria into subserosa; and T4, tumor with direct invasion of other organs or structures.

View larger version (63K): [in a new window]   Figure 1e. Schemata of (a) normal duodenal ampullary region and (b-e) International Union Against Cancer classification of periampullary cancers with tumor classification. (a) Common bile duct and pancreatic duct terminals penetrate the duodenal wall and form a common channel surrounded by Oddi muscle. (1) m = mucosa, (2) sm submucosa, (3) pm = muscularis propria, (4) ss = serosa or subserosa, (5) Panc = pancreatic head, (6) PD = pancreatic duct, (7) BD = bile duct, and D = duodenal cavity. Structures are those depicted at MR imaging and are listed in the Table. (b) Ampullary cancer. T1 indicates tumor limited to Oddi muscle; T2, tumor with invasion of duodenal wall; and T3, tumor with invasion of pancreas. (c) Extrahepatic bile duct cancer. T1 indicates tumor confined to bile duct; T2, tumor with invasion beyond wall of bile duct; T3, tumor with invasion of pancreas; and T4, tumor with invasion of duodenum or adjacent organs. (d) Pancreatic cancer. T1 indicates tumor (2 cm in greatest dimension) limited to pancreas; T2, tumor (>2 cm in greatest dimension) limited to pancreas; and T3, tumor with extension beyond pancreas. (e) Duodenal cancer. T1 indicates tumor with invasion of lamina propria or submucosa; T2, tumor with invasion of muscularis propria; T3, tumor with invasion through muscularis propria into subserosa; and T4, tumor with direct invasion of other organs or structures.

View larger version (90K): [in a new window]   Figure 2a. Images of normal ampullary region show pancreatic lobulus (P) and duodenal wall with four layers: mucosa (m), submucosa (sm), muscularis propria (pm), and subserosa or serosa (ss). (a) Oblique high-spatial-resolution T1-weighted spin-echo MR image (500/20). Intermediate- to low-signal-intensity band (arrowheads) indicates complex of Oddi muscle and connective tissue. (b) Oblique high-spatial-resolution T2-weighted fast spin-echo MR image (4,000/85; echo train length, 12). Low-signal-intensity band (arrowheads) indicates complex of Oddi muscle and connective tissue. (c) Photomicrograph shows that ampullary region is composed of complex (arrowheads) of Oddi muscle and connective tissue. Cystic lesion in ampullary wall shows glandular proliferation. (Hematoxylin-eosin stain; original magnification, x1.3.)

View larger version (98K): [in a new window]   Figure 2b. Images of normal ampullary region show pancreatic lobulus (P) and duodenal wall with four layers: mucosa (m), submucosa (sm), muscularis propria (pm), and subserosa or serosa (ss). (a) Oblique high-spatial-resolution T1-weighted spin-echo MR image (500/20). Intermediate- to low-signal-intensity band (arrowheads) indicates complex of Oddi muscle and connective tissue. (b) Oblique high-spatial-resolution T2-weighted fast spin-echo MR image (4,000/85; echo train length, 12). Low-signal-intensity band (arrowheads) indicates complex of Oddi muscle and connective tissue. (c) Photomicrograph shows that ampullary region is composed of complex (arrowheads) of Oddi muscle and connective tissue. Cystic lesion in ampullary wall shows glandular proliferation. (Hematoxylin-eosin stain; original magnification, x1.3.)

View larger version (118K): [in a new window]   Figure 2c. Images of normal ampullary region show pancreatic lobulus (P) and duodenal wall with four layers: mucosa (m), submucosa (sm), muscularis propria (pm), and subserosa or serosa (ss). (a) Oblique high-spatial-resolution T1-weighted spin-echo MR image (500/20). Intermediate- to low-signal-intensity band (arrowheads) indicates complex of Oddi muscle and connective tissue. (b) Oblique high-spatial-resolution T2-weighted fast spin-echo MR image (4,000/85; echo train length, 12). Low-signal-intensity band (arrowheads) indicates complex of Oddi muscle and connective tissue. (c) Photomicrograph shows that ampullary region is composed of complex (arrowheads) of Oddi muscle and connective tissue. Cystic lesion in ampullary wall shows glandular proliferation. (Hematoxylin-eosin stain; original magnification, x1.3.)

View larger version (102K): [in a new window]   Figure 3a. Distal common bile duct cancer with invasion into ampullary region. (a) Oblique high-spatial-resolution T2-weighted MR image (4,000/85) shows tumor invasion (arrowheads) of pancreas (P). (b) Photomicrograph of same structure. (Hematoxylin-eosin stain; original magnification, x2.0.)

View larger version (158K): [in a new window]   Figure 3b. Distal common bile duct cancer with invasion into ampullary region. (a) Oblique high-spatial-resolution T2-weighted MR image (4,000/85) shows tumor invasion (arrowheads) of pancreas (P). (b) Photomicrograph of same structure. (Hematoxylin-eosin stain; original magnification, x2.0.)

View larger version (75K): [in a new window]   Figure 4a. Periampullary duodenal cancer without invasion into ampullary region. (a) Oblique high-spatial-resolution T2-weighted MR image (4,000/85) shows tumor (arrowheads). Arrow shows marker for location of tumor. (b). Photomicrograph of tumor (arrowheads). (Hematoxylin-eosin stain; original magnification, x1.3.)

View larger version (120K): [in a new window]   Figure 4b. Periampullary duodenal cancer without invasion into ampullary region. (a) Oblique high-spatial-resolution T2-weighted MR image (4,000/85) shows tumor (arrowheads). Arrow shows marker for location of tumor. (b). Photomicrograph of tumor (arrowheads). (Hematoxylin-eosin stain; original magnification, x1.3.)

View larger version (110K): [in a new window]   Figure 5a. Ampullary tumor with invasion of pancreas. (a) Single-section in vivo MR cholangiopancreatographic image (/880 [effective]) shows filling defect (arrow) at distal end of common bile duct and main pancreatic duct. (b) In vivo coronal single-shot T2-weighted fast spin-echo MR image (/94 [effective]) shows abrupt obstruction of the proximally dilated bile duct (arrow). Tumor cannot be discriminated from pancreas or duodenal wall, all of which appear as a hypointense area. (c, d) Oblique high-spatial-resolution T1- (500/20) and T2-weighted (4,000/85) MR images show tumor (white arrowheads) with invasion of duodenal muscularis propria and pancreas. Tumor interrupts duodenal muscularis propria (black arrowhead) and infiltrates pancreas (arrows). (e) Photomicrograph reveals tumor with extension. Arrowheads and arrows indicate same structures as in c and d. (Hematoxylin-eosin stain; original magnification, x1.3.)

View larger version (118K): [in a new window]   Figure 5b. Ampullary tumor with invasion of pancreas. (a) Single-section in vivo MR cholangiopancreatographic image (/880 [effective]) shows filling defect (arrow) at distal end of common bile duct and main pancreatic duct. (b) In vivo coronal single-shot T2-weighted fast spin-echo MR image (/94 [effective]) shows abrupt obstruction of the proximally dilated bile duct (arrow). Tumor cannot be discriminated from pancreas or duodenal wall, all of which appear as a hypointense area. (c, d) Oblique high-spatial-resolution T1- (500/20) and T2-weighted (4,000/85) MR images show tumor (white arrowheads) with invasion of duodenal muscularis propria and pancreas. Tumor interrupts duodenal muscularis propria (black arrowhead) and infiltrates pancreas (arrows). (e) Photomicrograph reveals tumor with extension. Arrowheads and arrows indicate same structures as in c and d. (Hematoxylin-eosin stain; original magnification, x1.3.)

View larger version (109K): [in a new window]   Figure 5c. Ampullary tumor with invasion of pancreas. (a) Single-section in vivo MR cholangiopancreatographic image (/880 [effective]) shows filling defect (arrow) at distal end of common bile duct and main pancreatic duct. (b) In vivo coronal single-shot T2-weighted fast spin-echo MR image (/94 [effective]) shows abrupt obstruction of the proximally dilated bile duct (arrow). Tumor cannot be discriminated from pancreas or duodenal wall, all of which appear as a hypointense area. (c, d) Oblique high-spatial-resolution T1- (500/20) and T2-weighted (4,000/85) MR images show tumor (white arrowheads) with invasion of duodenal muscularis propria and pancreas. Tumor interrupts duodenal muscularis propria (black arrowhead) and infiltrates pancreas (arrows). (e) Photomicrograph reveals tumor with extension. Arrowheads and arrows indicate same structures as in c and d. (Hematoxylin-eosin stain; original magnification, x1.3.)

View larger version (122K): [in a new window]   Figure 5d. Ampullary tumor with invasion of pancreas. (a) Single-section in vivo MR cholangiopancreatographic image (/880 [effective]) shows filling defect (arrow) at distal end of common bile duct and main pancreatic duct. (b) In vivo coronal single-shot T2-weighted fast spin-echo MR image (/94 [effective]) shows abrupt obstruction of the proximally dilated bile duct (arrow). Tumor cannot be discriminated from pancreas or duodenal wall, all of which appear as a hypointense area. (c, d) Oblique high-spatial-resolution T1- (500/20) and T2-weighted (4,000/85) MR images show tumor (white arrowheads) with invasion of duodenal muscularis propria and pancreas. Tumor interrupts duodenal muscularis propria (black arrowhead) and infiltrates pancreas (arrows). (e) Photomicrograph reveals tumor with extension. Arrowheads and arrows indicate same structures as in c and d. (Hematoxylin-eosin stain; original magnification, x1.3.)

View larger version (143K): [in a new window]   Figure 5e. Ampullary tumor with invasion of pancreas. (a) Single-section in vivo MR cholangiopancreatographic image (/880 [effective]) shows filling defect (arrow) at distal end of common bile duct and main pancreatic duct. (b) In vivo coronal single-shot T2-weighted fast spin-echo MR image (/94 [effective]) shows abrupt obstruction of the proximally dilated bile duct (arrow). Tumor cannot be discriminated from pancreas or duodenal wall, all of which appear as a hypointense area. (c, d) Oblique high-spatial-resolution T1- (500/20) and T2-weighted (4,000/85) MR images show tumor (white arrowheads) with invasion of duodenal muscularis propria and pancreas. Tumor interrupts duodenal muscularis propria (black arrowhead) and infiltrates pancreas (arrows). (e) Photomicrograph reveals tumor with extension. Arrowheads and arrows indicate same structures as in c and d. (Hematoxylin-eosin stain; original magnification, x1.3.)

View larger version (116K): [in a new window]   Figure 6a. Pancreatic cancer with invasion into ampullary region. (a, b) Oblique high-spatial-resolution T2-weighted MR images (4,000/85). Pancreatic tumor (P) extends across muscularis propria (arrowheads and broken line) and infiltrates ampullary region (arrow) and surrounding duodenal wall. (b) Tumor (arrows) largely involves pancreas and compresses duodenal wall outward. (c) Photomicrograph shows a slight difference in position and angle between MR images and cross section of specimen. Arrow, arrowheads, and broken line indicate same structures as in a. (Hematoxylin-eosin stain; original magnification, x1.3.)

View larger version (78K): [in a new window]   Figure 6b. Pancreatic cancer with invasion into ampullary region. (a, b) Oblique high-spatial-resolution T2-weighted MR images (4,000/85). Pancreatic tumor (P) extends across muscularis propria (arrowheads and broken line) and infiltrates ampullary region (arrow) and surrounding duodenal wall. (b) Tumor (arrows) largely involves pancreas and compresses duodenal wall outward. (c) Photomicrograph shows a slight difference in position and angle between MR images and cross section of specimen. Arrow, arrowheads, and broken line indicate same structures as in a. (Hematoxylin-eosin stain; original magnification, x1.3.)

View larger version (138K): [in a new window]   Figure 6c. Pancreatic cancer with invasion into ampullary region. (a, b) Oblique high-spatial-resolution T2-weighted MR images (4,000/85). Pancreatic tumor (P) extends across muscularis propria (arrowheads and broken line) and infiltrates ampullary region (arrow) and surrounding duodenal wall. (b) Tumor (arrows) largely involves pancreas and compresses duodenal wall outward. (c) Photomicrograph shows a slight difference in position and angle between MR images and cross section of specimen. Arrow, arrowheads, and broken line indicate same structures as in a. (Hematoxylin-eosin stain; original magnification, x1.3.)