John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Atlas of Radiological Modalities in the
Evaluation of Ampullary Masses
John B. Moore, MSc, HMSIII
Gillian Lieberman, MD
John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Agenda
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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
2
John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
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:
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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)
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Patient 1: Initial CT+ contrast
CBD
Pancreatic duct
Pancreas
Splenic artery
Celiac artery
SMV
IVC
Aorta
C+ axial CT abdomen & pelvis
BIDMC, PACS
4
John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Patient 1: Initial CT+ contrast
The common bile
duct and the
pancreatic duct
are dilated.
This finding is
known as the
“double duct sign”
C+ axial CT abdomen & pelvis
BIDMC, PACS
5
John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Patient 1: Initial CT+ contrast
C+ coronal CT abdomen & pelvis
BIDMC, PACS
Dilated common bile duct and
pancreatic duct on coronal imaging
C+ coronal CT abdomen & pelvis
BIDMC, PACS
Distended gallbladder in absence
of clear obstructing lesions or stones
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Patient 1: Initial CT+ contrast
C+ coronal CT abdomen &
pelvis
BIDMC, PACS
C+ coronal CT abdomen &
pelvis
Duodenum with pancreatic duct and CBD
converging in periampullary region.
BIDMC, PACS
No overt mass seen
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Anatomy of the periampullary region
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Anatomy of the ampulla
From Martin & Moser, Ampullary carcinoma, UpToDate
9
John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
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
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Let’s continue with several CT images of companion patients with
other periampullary cancers.
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Companion Patient 2: Cholangiocarcinoma on CT
C+ axial CT abdomen & pelvis
BIDMC, PACS
Ill-defined hypodense mass seen near common bile duct stent
with a dilated gastroduodenal artery. The pancreas is atrophic.
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Companion Patient 3: Pancreatic adenocarcinoma on CT
C+ axial CT abdomen & pelvis
BIDMC, PACS
Hypoenhancing mass in pancreatic head consistent with
pancreatic adenocarcinoma.
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Menu of tests
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Transabdominal US
Abdominal CT
MR and MRCP
ERCP
EUS
IDUS
Percutaneous transhepatic cholangiography (PTC)
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
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
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
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)
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
CT – abdominal (cont’d.)
• 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
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Patient 1: CTA abdomen
Ampullary
mass
CBD Stent
C+/- coronal CTA abdomen
BIDMC, PACS
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Patient 1: CTA abdomen
Air in central
intrahepatic ducts
Pneumobilia
C+/- coronal CTA abdomen PANC DUCT MINIP
BIDMC, PACS
Air in central
intrahepatic ducts and
pneumobilia
secondary to CBD
stent placement
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
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
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
MR and MR cholangiopancreatography (MRCP)
Companion Patient 4
MRCP
Coronal T2
From Kim JH et al.,
Differential Diagnosis of
Periampullary Carcinomas
at MR, 2002
Axial T2
Hypointense
mass
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Endoscopic retrograde cholangiopancreatography
(ERCP)
• 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
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Removal of some stones
Insertion of stent (retrograde)
Dilation of strictures
Biopsy
• Does have some contraindications, complications
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
Normal ERCP
March 2013
Common
Hepatic Duct
Endoscope
Cystic Duct
Gallbladder
Common Bile
Duct
Pancreatic Duct
Ampulla
Duodenum
From Greenberger NJ, Blumberg RS, Burakoff R, CURRENT
Diagnosis & Treatment, 2nd Edition
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Patient 1: Ampullary lesion on ERCP
• Mass was visualized and biopsied.
– Stent placed → obstruction relieved
BIDMC, ERCP
Sphincterotomy
with stent
placement
Ampullary mass
From Martin & Moser, Ampullary
carcinoma, UpToDate
Companion Patient 5
Nodular
ampullary
carcinoma
(reference case)
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Patient 1: ERCP Results (cont’d.)
• Fluoroscopy image sequence:
– Stent placed → obstruction relieved
BIDMC, ERCP
Dilated common
bile duct on
cholangiogram
Stricture of distal
CBD due to
ampullary mass
Stricture,
obstruction,
and dilation
relieved
Stent being
placed
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
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
• Cons:
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Technically challenging
Operator dependent
No stent ability
Less adept at nodal-staging in
comparison to tumor-staging
Especially useful when ERCP has
found low-grade dysplasia
→ Could allow for local resection
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
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
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Companion Patient 7
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
Malignant
stricture
Companion Patient 8
Benign
stricture
From: Stavropoulos S et al., Intraductal
ultrasound for the evaluation of patients
with biliary strictures , 2005
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
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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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
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
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Ampullary carcinoma: location correlates with prognosis
→ which correlates with histology
Large overall size,
small invasive
component, best
overall prognosis.
3-y survival, 73%
From: Adsay V, et al., Ampullary Region Carcinomas, 2012
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Ampullary carcinoma: location correlates with prognosis
→ which correlates with histology
Largest, highest
incidence of LN
mets. Minimal
intra-amp lumen.
Mostly intestinal
histology (75%).
3-y survival, 69%
From: Adsay V, et al., Ampullary Region Carcinomas, 2012
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Ampullary carcinoma: location correlates with prognosis
→ which correlates with histology
Ulcero-nodular
tumors, does not
show features of
other subtypes.
Intermediate
tumor size.
3-y survival, 54%
From: Adsay V, et al., Ampullary Region Carcinomas, 2012
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Ampullary carcinoma: location correlates with prognosis
→ which correlates with histology
Smallest but worst
prognosis,
presumably due to
the pancreatic
histology or origin
(in 86%).
3-y survival, 41%
From: Adsay V, et al., Ampullary Region Carcinomas, 2012
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Ampullary carcinoma: location correlates with prognosis
→ which correlates with histology
From: Adsay V, et al., Ampullary Region Carcinomas, 2012
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
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
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Diagnostic-Therapeutic Algorithm
From: Roberts KJ, et al., Endoscopic ultrasound assessment of lesions of the ampulla
of Vater, 2013.
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Summary
• Ampullary masses can be difficult to assess on crosssectional 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
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
References
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-andstaging?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.
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John B. Moore, MSc, MS3
Gillian Lieberman, MD
March 2013
Acknowledgments
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Dr. Gunjan Senapati
Dr. Arthur J. Moser
Dr. Gillian Lieberman
Claire Odom
Victoria Van Voorhees
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