Synchronous Intra-ampullary Papillary-Tubular Neoplasm and Gallbladder Cancer

Intra-ampullary papillary-tubular neoplasms (IAPNs) are rare precursor lesions of the ampulla of Vater, with a high propensity for progression to invasive carcinoma. Synchronous primary malignancies of the biliary tract are uncommon, and their occurrence in the absence of congenital anomalies such as pancreaticobiliary maljunction (PBM) has not been well documented. We report a case of an IAPN coexisting with a synchronous gallbladder carcinoma in a patient without identifiable predisposing anomalies. A 70-year-old woman with a history of interstitial pneumonia, acute pancreatitis, and mixed connective tissue disease on chronic steroids was under surveillance for branch-duct intraductal papillary mucinous neoplasm of the pancreatic body. Follow-up contrast-enhanced computed tomography revealed a 14-mm enhancing mass at the ampulla of Vater, with upstream dilation of both the pancreatic and bile ducts. Endoscopic evaluation and biopsy confirmed adenocarcinoma, and she underwent pancreaticoduodenectomy. A Grade B bile leak complicated postoperative recovery, which was managed conservatively; she was discharged on postoperative day 28. Histology demonstrated a 20 × 17 mm IAPN confined to the ampullary bile duct without invasion of adjacent ducts, and immunophenotyping confirmed a gastric/pancreatobiliary phenotype. Incidentally, a separate 32 × 30 mm gallbladder fundus tumor was identified and diagnosed as primary gallbladder carcinoma invading only the muscular layer (pT1b, pN0). Resection margins were negative, and no adjuvant therapy was administered due to comorbid pulmonary disease. This case underscores the importance of thorough preoperative evaluation of the gallbladder in patients with ampullary neoplasms, even in the absence of known biliary tract anomalies. Recognition of synchronous malignancies may alter surgical planning and improve outcomes. Vigilant imaging, including targeted ultrasonography, should be incorporated into the preoperative workup for ampullary lesions to detect occult gallbladder carcinoma.