Os adenomas túbulo-vilosos da ampola duodenal são neoplasias raras. Neste trabalho apresentamos um caso com correlação radiológico-endoscópica e patológica, tendo a paciente sido submetida à duodenopancreatectomia com boa evolução pós-operatória. Com os avanços dos métodos de imagem, em especial da ressonância magnética e ultrassonografia endoscópica, aspectos locorregionais, além da invasão extraluminal, linfovascular e metastática, têm sido discutidos de maneira crescente como contribuintes na decisão terapêutica. Essa evolução contribui para o melhor estadiamento destas lesões e é especialmente útil para selecionar candidatos elegíveis ao tratamento endoscópico.

PALAVRAS-CHAVE:
Neoplasias Intestinais; Adenoma; Adenoma Viloso; Diagnóstico por Imagem; Imagem por Ressonância Magnética

Autoria

Daniel Alvarenga Fernandes CORRESPONDING AUTHOR: Daniel Alvarenga Fernandes, Rua Tessália Vieira de Camargo, 126, Cidade Universitária Zeferino Vaz, Campinas, SP, Brasil – 13083-887 Tel: +55 19 3521-7029 E-mail: daniel_alvafer@yahoo.com.br

Departamento de Radiologia, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM- Unicamp), Campinas, SP, Brasil.Universidade Estadual de CampinasBrasilCampinas, SP, BrasilDepartamento de Radiologia, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM- Unicamp), Campinas, SP, Brasil.

http://orcid.org/0000-0001-8138-1316

Yuri Longatto Boteon

University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom.University Hospitals Birmingham NHS Foundation TrustUnited KingdomBirmingham, United KingdomUniversity Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom.

Centre for Liver and Gastrointestinal Research, Institute for Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.University of BirminghamUnited KingdomBirmingham, United KingdomCentre for Liver and Gastrointestinal Research, Institute for Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom.

http://orcid.org/0000-0002-1709-9284

Amanda Pinter Carvalheiro da Silva Boteon

http://orcid.org/0000-0003-0354-2991

Rachid Marwan Pinheiro Sousa

http://orcid.org/0000-0003-2413-8306

Daniel Lahan Martins

http://orcid.org/0000-0003-4691-7634

Thiago José Penachim

http://orcid.org/0000-0002-0782-362X

Ricardo Hoelz de Oliveira Barros

http://orcid.org/0000-0001-7542-9184

Rita de Cássia Perina Martins

Departamento de Anatomia Patológica, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM- Unicamp), Campinas, SP, Brasil.Universidade Estadual de CampinasBrasilCampinas, SP, BrasilDepartamento de Anatomia Patológica, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM- Unicamp), Campinas, SP, Brasil.

http://orcid.org/0000-0002-6145-874X

Larissa Bastos Eloy da Costa

http://orcid.org/0000-0001-6932-8600

Everton Cazzo

Departamento de Cirurgia, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM- Unicamp), Campinas, SP, Brasil.Universidade Estadual de CampinasBrasilCampinas, SP, BrasilDepartamento de Cirurgia, Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM- Unicamp), Campinas, SP, Brasil.

http://orcid.org/0000-0002-5804-1580

Martinho Antônio Gestic

http://orcid.org/0000-0002-4527-676X

Elinton Adami Chaim

http://orcid.org/0000-0001-9370-9518

Nelson Marcio Gomes Caserta

http://orcid.org/0000-0001-8404-8092

CORRESPONDING AUTHOR: Daniel Alvarenga Fernandes, Rua Tessália Vieira de Camargo, 126, Cidade Universitária Zeferino Vaz, Campinas, SP, Brasil – 13083-887 Tel: +55 19 3521-7029 E-mail: daniel_alvafer@yahoo.com.br

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Figuras (3)

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FIGURE 1
ABDOMINAL ULTRASOUND SHOWED A SOLID MASS CLOSE TO THE DISTAL BILE DUCT. IT EXHIBITED INSIDE FLOW ON DOPPLER STUDY (A, UPPER LEFT) AND INTRAHEPATIC AND EXTRAHEPATIC BILE DUCT DILATION (B, UPPER RIGHT). AXIAL (C, LOWER LEFT) AND CORONAL (D, LOWER RIGHT) COMPUTED TOMOGRAPHY SECTIONS SHOW CHOLECYSTOLITHIASIS (BLACK ARROW) AND A SOLID MASS IN THE DUODENAL PAPILLARY TOPOGRAPHY (WHITE ARROWS). THE MASS WAS 5.5 CM × 4.0 CM × 2.5 CM IN SIZE, WITH MODERATE AND HOMOGENEOUS IMPREGNATION AFTER CONTRAST AND A SWIRL SURFACE PATTERN (CALLED “INTRADUODENAL CEREBELLUM” SIGN BY THE AUTHORS DUE TO THE SWIRL PATTERN OF THE TUMOR SURFACE).

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FIGURE 2
CORONAL SECTION OF T1-WEIGHTED MAGNETIC RESONANCE IMAGE AFTER CONTRAST SHOWS HOMOGENEOUS MASS IMPREGNATION IN THE DUODENAL PAPILLARY TOPOGRAPHY IN ADDITION TO CHOLECYSTOLITHIASIS (A, UPPER LEFT). DIFFUSION-WEIGHTED IMAGES WITH A B-VALUE OF 1,000 SHOW RESTRICTION OF WATER MOLECULE DIFFUSION BY THE MASS (B, UPPER RIGHT). MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (C, LOWER LEFT) SHOWS INTRAHEPATIC AND EXTRAHEPATIC BILE DUCT DILATION UP TO THE MASS PLANE IN THE DUODENAL PAPILLARY TOPOGRAPHY. UPPER DIGESTIVE ENDOSCOPY (D, LOWER RIGHT) SHOWS A LESION IN THE POST-BULBAR REGION IN THE DUODENAL PAPILLARY TOPOGRAPHY, WITH A LOBULATED AND WHITISH SURFACE, DEFINED LIMITS, AND A VESSEL IN ITS CENTER ASSOCIATED WITH ADJACENT WHITISH MUCOUS LINING.

Thumbnail

FIGURE 3
MACROSCOPICALLY, SURGICAL SPECIMEN (A) SHOWS A POLYPOID LESION MEASURING 5.5 CM × 4.0 CM × 2.5 CM, WITH IRREGULAR SURFACE, VILLOUS APPEARANCE, AND FRIABLE CONSISTENCY. MACROSCOPIC ANATOMOPATHOLOGICAL EVALUATION (B) SHOWS THE TRANSVERSE SECTION OF THE LESION AT THE LEVEL OF THE BILE DUCT (ARROW), SHOWING A CEREBELLAR PRESENTATION WITH A SWIRL PATTERN SIMILAR TO THAT OBSERVED IN THE RADIOLOGICAL IMAGES. MICROSCOPIC EXAMINATION (C) SHOWS VILLOUS STRUCTURES LINED BY COLUMNAR EPITHELIUM WITH PALISADED ARRANGEMENT OF NUCLEI (HEMATOXYLIN AND EOSIN, 100×). SUPERFICIAL ADENOCARCINOMATOUS FOCI WITH ATYPICAL NUCLEI FORMING GLANDULAR STRUCTURES (D) ARE OBSERVED (HEMATOXYLIN AND EOSIN, 400×).

FIGURE 1 ABDOMINAL ULTRASOUND SHOWED A SOLID MASS CLOSE TO THE DISTAL BILE DUCT. IT EXHIBITED INSIDE FLOW ON DOPPLER STUDY (A, UPPER LEFT) AND INTRAHEPATIC AND EXTRAHEPATIC BILE DUCT DILATION (B, UPPER RIGHT). AXIAL (C, LOWER LEFT) AND CORONAL (D, LOWER RIGHT) COMPUTED TOMOGRAPHY SECTIONS SHOW CHOLECYSTOLITHIASIS (BLACK ARROW) AND A SOLID MASS IN THE DUODENAL PAPILLARY TOPOGRAPHY (WHITE ARROWS). THE MASS WAS 5.5 CM × 4.0 CM × 2.5 CM IN SIZE, WITH MODERATE AND HOMOGENEOUS IMPREGNATION AFTER CONTRAST AND A SWIRL SURFACE PATTERN (CALLED “INTRADUODENAL CEREBELLUM” SIGN BY THE AUTHORS DUE TO THE SWIRL PATTERN OF THE TUMOR SURFACE).

FIGURE 2 CORONAL SECTION OF T1-WEIGHTED MAGNETIC RESONANCE IMAGE AFTER CONTRAST SHOWS HOMOGENEOUS MASS IMPREGNATION IN THE DUODENAL PAPILLARY TOPOGRAPHY IN ADDITION TO CHOLECYSTOLITHIASIS (A, UPPER LEFT). DIFFUSION-WEIGHTED IMAGES WITH A B-VALUE OF 1,000 SHOW RESTRICTION OF WATER MOLECULE DIFFUSION BY THE MASS (B, UPPER RIGHT). MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (C, LOWER LEFT) SHOWS INTRAHEPATIC AND EXTRAHEPATIC BILE DUCT DILATION UP TO THE MASS PLANE IN THE DUODENAL PAPILLARY TOPOGRAPHY. UPPER DIGESTIVE ENDOSCOPY (D, LOWER RIGHT) SHOWS A LESION IN THE POST-BULBAR REGION IN THE DUODENAL PAPILLARY TOPOGRAPHY, WITH A LOBULATED AND WHITISH SURFACE, DEFINED LIMITS, AND A VESSEL IN ITS CENTER ASSOCIATED WITH ADJACENT WHITISH MUCOUS LINING.

FIGURE 3 MACROSCOPICALLY, SURGICAL SPECIMEN (A) SHOWS A POLYPOID LESION MEASURING 5.5 CM × 4.0 CM × 2.5 CM, WITH IRREGULAR SURFACE, VILLOUS APPEARANCE, AND FRIABLE CONSISTENCY. MACROSCOPIC ANATOMOPATHOLOGICAL EVALUATION (B) SHOWS THE TRANSVERSE SECTION OF THE LESION AT THE LEVEL OF THE BILE DUCT (ARROW), SHOWING A CEREBELLAR PRESENTATION WITH A SWIRL PATTERN SIMILAR TO THAT OBSERVED IN THE RADIOLOGICAL IMAGES. MICROSCOPIC EXAMINATION (C) SHOWS VILLOUS STRUCTURES LINED BY COLUMNAR EPITHELIUM WITH PALISADED ARRANGEMENT OF NUCLEI (HEMATOXYLIN AND EOSIN, 100×). SUPERFICIAL ADENOCARCINOMATOUS FOCI WITH ATYPICAL NUCLEI FORMING GLANDULAR STRUCTURES (D) ARE OBSERVED (HEMATOXYLIN AND EOSIN, 400×).

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[1] CORRESPONDING AUTHOR: Daniel Alvarenga Fernandes, Rua Tessália Vieira de Camargo, 126, Cidade Universitária Zeferino Vaz, Campinas, SP, Brasil – 13083-887 Tel: +55 19 3521-7029 E-mail: daniel_alvafer@yahoo.com.br