Atlas of Radiological Modalities in the Evaluation of Ampullary Masses

John B. Moore, MSc, MS3

Gillian Lieberman, MD March 2013 March 2013

Atlas of Radiological Modalities in the

Evaluation of Ampullary Masses

John B. Moore, MSc, HMSIII

Gillian Lieberman, MD


Gillian Lieberman, MD March 2013



Agenda • Patient Presentation

• Normal anatomy of the hepato-pancreatico-biliary system

• Differential diagnosis for a periampullary mass

• Menu of tests

• Radiological evaluation of the ampulla of Vater

• Categorizing the lesion with imaging

• Discussion of ampullary carcinoma

• Correlating findings with prognosis

March 2013

2



Patient 1: HPI • 58 yo M who presented with symptomatic obstructive

jaundice. Developed pruritus and dark urine of 3 weeks duration before presentation. Mild weight loss over past 3 months. No abdominal pain, nausea, vomiting, alcohol use. – PMH significant only for glaucoma – takes timolol

– Father passed away from unknown GI malignancy

• Labs were significant for following: – ALT: 192 IU/L

– AST: 133 IU/L

– Total bilirubin: 1.9 mg/dl

– Lipase: 1498 IU/L

– CA 19-9: 36 (normal < 34 U/ml)

3



CBD

Pancreatic duct

Pancreas

Splenic artery

Celiac artery

SMV

IVC

Aorta

C+ axial CT abdomen & pelvis BIDMC, PACS

Patient 1: Initial CT+ contrast

4



5

The common bile

duct and the

pancreatic duct

are dilated.

This finding is

known as the

“double duct sign”





6

C+ coronal CT abdomen & pelvis C+ coronal CT abdomen & pelvis BIDMC, PACS BIDMC, PACS

Dilated common bile duct and

pancreatic duct on coronal imaging

Distended gallbladder in absence

of clear obstructing lesions or stones




7 Duodenum with pancreatic duct and CBD

converging in periampullary region.

No overt mass seen

C+ coronal CT abdomen &

pelvis

BIDMC, PACS C+ coronal CT abdomen &

pelvis

BIDMC, PACS




Anatomy of the periampullary region

8



Anatomy of the ampulla

From Martin & Moser, Ampullary carcinoma, UpToDate 9



Differential Diagnosis • Benign periampullary masses

– Duodenal adenoma

– Ampullary adenoma

– Gallstones (choledocholithiasis or gallstone pancreatitis)

• Periampullary cancers – Pancreatic ductal adenocarcinoma

– Carcinoma of the bile duct

• Cholangiocarcinoma (extra-hepatic)

– Carcinoma of the ampulla itself

– Carcinoma of the periampullary duodenum

March 2013

10



Let’s continue with several CT images of companion patients with

other periampullary cancers.

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12

Companion Patient 2: Cholangiocarcinoma on CT

Ill-defined hypodense mass seen near common bile duct stent

with a dilated gastroduodenal artery. The pancreas is atrophic.




Companion Patient 3: Pancreatic adenocarcinoma on CT

Hypoenhancing mass in pancreatic head consistent with

pancreatic adenocarcinoma.


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Menu of tests

• Transabdominal US

• Abdominal CT

• MR and MRCP

• ERCP

• EUS

• IDUS

• Percutaneous transhepatic cholangiography (PTC)

March 2013

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Transabdominal US

• First imaging technique in pts with jaundice

• Can potentially assess vascular involvement, biliary

dilation, liver lesions

• Overall accuracy in finding ampullary masses only 15% – If no gallstones or obvious pancreatic head mass → proceed to other

modality

• For patient 1, US was not initially done – No abdominal pain, low suspicion for stones

March 2013

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CT – abdominal

• Once ampullary mass suspected → order “pancreatic mass

protocol”

• Water as “oral contrast” and IV contrast – water distends duodenum but w/o high attenuation of usual contrast

• allows vessels to be clearly visualized

– contrast allows for arterial- and venous-phase imaging

• Acquire images 1.0 to 2.5 mm intervals (helps see pancreas)

March 2013

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CT – abdominal (cont’d.)

March 2013

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• Pros: – More sensitive than US in

assessing periampullary region

– Can pick up distant mets

– Visualize regional lymph nodes,

liver, peritoneum, lungs, and

bone

• Cons: – Inadequate for staging because

lacks spatial resolution for

invasion of nearby structures

– Can not see small ampullary

neoplasms

• Detection as low as 20%

• For patient 1, he subsequently had CTA abdomen & pelvis

several days after initial CT abdomen



18

Patient 1: CTA abdomen

Ampullary

mass

BIDMC, PACS C+/- coronal CTA abdomen

CBD Stent



19

Patient 1: CTA abdomen

BIDMC, PACS C+/- coronal CTA abdomen PANC DUCT MINIP

Pneumobilia

Air in central

intrahepatic ducts Air in central

intrahepatic ducts and

pneumobilia

secondary to CBD

stent placement



20

MR and MR cholangiopancreatography (MRCP)

• Usually, in patients where ERCP contraindicated

• Masses usually appear isointense or hypointense on T1- and

T2-weighted images

• When mass not seen on MR, bulging duodenal papilla may

be only indication of ampullary cancer – Bulging caused by dilated pancreatic and bile ducts

• MRCP – noninvasive way to visualize pancreaticobiliary tree

• Some signs that differentiate one periampullary cancer from

another – So-called “four segment sign” on MR in pancreatic adenocarcinoma



21

MR and MR cholangiopancreatography (MRCP)

From Kim JH et al., Differential Diagnosis of Periampullary Carcinomas at MR, 2002

MRCP

Hypointense

mass

Axial T2 Coronal T2

Companion Patient 4



• Combines endoscopy and fluoroscopy

• Visualizes stomach, duodenum, ampulla – Cannot evaluate extent of local tumor invasion

• Fluoroscopy with contrast allows for radiographic visualization of bile ducts and pancreatic duct

• Diagnostic and therapeutic – Removal of some stones

– Insertion of stent (retrograde)

– Dilation of strictures

– Biopsy

• Does have some contraindications, complications

Endoscopic retrograde cholangiopancreatography

(ERCP)

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Normal ERCP

From Greenberger NJ, Blumberg RS, Burakoff R, CURRENT Diagnosis & Treatment, 2nd Edition

Endoscope

Gallbladder

Cystic Duct

Common

Hepatic Duct

Common Bile

Duct Pancreatic Duct

Ampulla

Duodenum

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Patient 1: Ampullary lesion on ERCP

Ampullary mass

Sphincterotomy

with stent

placement

• Mass was visualized and biopsied. – Stent placed → obstruction relieved

Nodular

ampullary

carcinoma

(reference case)

From Martin & Moser, Ampullary carcinoma, UpToDate

24

BIDMC, ERCP

Companion Patient 5



Patient 1: ERCP Results (cont’d.)

• Fluoroscopy image sequence: – Stent placed → obstruction relieved

Dilated common

bile duct on

cholangiogram

Stricture of distal

CBD due to

ampullary mass

Stent being

placed

Stricture,

obstruction,

and dilation

relieved

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BIDMC, ERCP



Endoscopic Ultrasound (EUS)

• Pros: – Higher spatial resolution than

CT/MRI

– Can show surrounding anatomy including lymph nodes

– Discerns duodenal wall and pancreas interface

– More accurate in detecting ampullary tumors than US and CT

• As in 100% accurate

– FNA ability

– Great for preop planning and T-stage

• 70-90% accurate in T-stage

March 2013

• Cons: – Technically challenging

– Operator dependent

– No stent ability

– Less adept at nodal-staging in

comparison to tumor-staging

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Especially useful when ERCP has

found low-grade dysplasia

→ Could allow for local resection



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Companion Patient 6: Tumor on EUS

DL: duodenal lumen

T: tumor mass

CBD: common bile duct

m: muscularis propria

nLN: non-metastatic lymph node

P: pancreas

From Skordilis P et al., Is endosonography an effective method for detection and local staging of the ampullary carcinoma?, 2002



Intraductal ultrasound

(IDUS) • Small miniprobes ~2mm

• From endoscope into biliary or pancreatic duct

• Only modality that can differentiate sphincter of Oddi muscle from papilla

• Useful in identifying tumor strictures when no mass seen on imaging or indeterminate strictures – Increases accuracy of ERCP

March 2013

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Malignant

stricture

Benign

stricture

From: Stavropoulos S et al., Intraductal ultrasound for the evaluation of patients with biliary strictures , 2005

Companion Patient 7

Companion Patient 8



Patient 1: Diagnosis & Surgery • Cytology sent from ERCP

brushings – “Adenomatous mucosa with

villous and papillary features, and

at least high grade dysplasia” –

Path Report BIDMC

• Given HGD → surgery – Whipple:

pancreaticoduodenectomy

– In this case, Robot-assisted,

pylorus-preserving

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Carcinoma of ampulla of Vater: Some facts

• 6-35% of pancreaticoduodenal malignancies – But, rare: 4-6 cases per million people

– Average age of diagnosis for sporadic cases → 60-70

• Can be earlier in genetic syndromes, e.g. FAP w/increased risk

– Male-to-female ratio 2:1

• Papillary orifice of ampulla commonly involved by tumor – Means symptoms appear early

– Abdominal pain, pruritus, obstructive jaundice, steatorrhea, weight loss

• Survival is ~25% at 5 years for pts with +LNs and 50% in those without involved nodes – 80% thought to be resectable at Dx

March 2013

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Ampullary carcinoma: location correlates with prognosis

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Large overall size,

small invasive

component, best

overall prognosis.

3-y survival, 73%

→ which correlates with histology

From: Adsay V, et al., Ampullary Region Carcinomas, 2012



32




Largest, highest

incidence of LN

mets. Minimal

intra-amp lumen.

Mostly intestinal

histology (75%).

3-y survival, 69%



33




Ulcero-nodular

tumors, does not

show features of

other subtypes.

Intermediate

tumor size.

3-y survival, 54%



34




Smallest but worst

prognosis,

presumably due to

the pancreatic

histology or origin

(in 86%).

3-y survival, 41%



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36

Patient 1: Subsequent course • Final path of mass:

– Ampullary adenocarcinoma, moderately differentiated, 1+ node of 29

– T1N1 → tumor limited to Ampulla of Vater w/regional LN met. Negative

margins

• Unfortunately, pancreaticobiliary histology – Cytokeratin 7 (CK7) and CK20 have recently (2013) been shown to

differentiate between pancreaticobiliary and intestinal ampullary histology

– CK20 → intestinal type; CK7 → pancreaticobiliary type

– Patient 1 was CK7+/CK20 – , which is pancreaticobiliary

• Now, receiving adjuvant chemo

– Still experimental: gemcitabine 1000 mg x2 weekly, 3 weeks on, 1 week off

for 4-6 months

• He will f/u with surgeon in 3 months for staging



Diagnostic-Therapeutic Algorithm

37 From: Roberts KJ, et al., Endoscopic ultrasound assessment of lesions of the ampulla of Vater, 2013.



Summary

38

• Ampullary masses can be difficult to assess on cross-sectional imaging

• CT and trans-abdominal US will usually be done to r/o other processes

• ERCP is first-line modality for suspected malignant strictures, supplemented by EUS

• MR with MRCP and IDUS in special circumstances

• Future refinement of radiological modalities to help correlate with new path subdivisions which predict prognosis



1) Adsay V, Ohike N, Tajiri T, et al. Ampullary Region Carcinomas: Definition and Site Specific Classification with Delineation of Four Clinicopathologically and Prognostically Distinct Subsets in an Analysis of 249 Cases. The American Journal of Surgical Pathology 2012; 36(11): 1592-1608.

2) Albores‐Saavedra, Jorge, et al. Cancers of the ampulla of Vater: demographics, morphology, and survival based on 5,625 cases from the SEER program. Journal of surgical oncology 2009; 100(7): 598-605.

3) Carr BI. Chapter 92. Tumors of the Liver and Biliary Tree. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012. http://www.accessmedicine.com.ezp-prod1.hul.harvard.edu/content.aspx?aID=9116154. Accessed March 24, 2013.

4) Greenberger NJ, Blumberg RS, Burakoff R. CURRENT Diagnosis & Treatment: Gastroenterology, Hepatology, & Endoscopy, 2nd Edition: www.accessmedicine.com. Accessed 24 March 2013.

5) Kim JH, Kim, MJ, Chung JJ, et al. Differential Diagnosis of Periampullary Carcinomas at MR Imaging. Radiographics 2002; 22(6): 1335-1352.

6) Martin JA, Moser AJ. Ampullary carcinoma: Epidemiology, clinical manifestations, diagnosis and staging. http://www.uptodate.com/contents/ampullary-carcinoma-epidemiology-clinical-manifestations-diagnosis-and-staging?source=search_result&search=ampullary+carcinoma&selectedTitle=2~21#. UpToDate. Accessed 22 March 2013.

7) Morini S, Perrone G, Borzomati D, et al. Carcinoma of the Ampulla of Vater: Morphological and Immunophenotypical Classification Predicts Overall Survival. Pancreas 2013; 42: 60-66.

8) Rivadeneira DE, Pochapin M, Grobmyer SR, et al. "Comparison of linear array endoscopic ultrasound and helical computed tomography for the staging of periampullary malignancies." Annals of surgical oncology (2003; 10(8): 890-897.

9) Roberts KJ, McCulloch N, Sutcliffe R, et al. Endoscopic ultrasound assessment of lesions of the ampulla of Vater is of particular value in low‐grade dysplasia. HPB 2013; 15; 18–23.

10) Skordilis P, Mouzas IA, Dimoulios PD, et al. Is endosonography an effective method for detection and local staging of the ampullary carcinoma? A prospective study. BMC surgery 2002; 2(1): 1-8.

11) Stavropoulos S, Larghi A, Verna E, et al. Intraductal ultrasound for the evaluation of patients with biliary strictures and no abdominal mass on computed tomography. Endoscopy 2005; 37(8): 715-721.

12) Talamini MA, Moesinger RC, Pitt HA, et al. Adenocarcinoma of the ampulla of Vater. A 28-year experience. Annals of surgery 1997; 225(5): 590.

References

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• Dr. Gunjan Senapati

• Dr. Arthur J. Moser

• Dr. Gillian Lieberman

• Claire Odom

• Victoria Van Voorhees

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Acknowledgments

Atlas of Radiological Modalities in the Evaluation of Ampullary Masses

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