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
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
John B. Moore, MSc, MS3
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
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:
– 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
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
CBD
Pancreatic duct
Pancreas
Splenic artery
Celiac artery
SMV
IVC
Aorta
C+ axial CT abdomen & pelvis BIDMC, PACS
Patient 1: Initial CT+ contrast
4
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
5
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
Patient 1: Initial CT+ contrast
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
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
Patient 1: Initial CT+ contrast
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
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
Patient 1: Initial CT+ contrast
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
Anatomy of the periampullary region
8
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
March 2013
10
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
Let’s continue with several CT images of companion patients with
other periampullary cancers.
11
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
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.
C+ axial CT abdomen & pelvis BIDMC, PACS
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
Companion Patient 3: Pancreatic adenocarcinoma on CT
Hypoenhancing mass in pancreatic head consistent with
pancreatic adenocarcinoma.
C+ axial CT abdomen & pelvis BIDMC, PACS
13
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
Menu of tests
• Transabdominal US
• Abdominal CT
• MR and MRCP
• ERCP
• EUS
• IDUS
• Percutaneous transhepatic cholangiography (PTC)
March 2013
14
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
March 2013
15
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)
March 2013
16
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
CT – abdominal (cont’d.)
March 2013
17
• 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
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
18
Patient 1: CTA abdomen
Ampullary
mass
BIDMC, PACS C+/- coronal CTA abdomen
CBD Stent
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
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
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
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
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
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
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
• 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)
22
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
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
23
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
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
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
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
25
BIDMC, ERCP
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
March 2013
• Cons:
– Technically challenging
– Operator dependent
– No stent ability
– Less adept at nodal-staging in
comparison to tumor-staging
26
Especially useful when ERCP has
found low-grade dysplasia
→ Could allow for local resection
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
27
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
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
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
28
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
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
29
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
March 2013
30
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
Ampullary carcinoma: location correlates with prognosis
31
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
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
32
Ampullary carcinoma: location correlates with prognosis
→ which correlates with histology
From: Adsay V, et al., Ampullary Region Carcinomas, 2012
Largest, highest
incidence of LN
mets. Minimal
intra-amp lumen.
Mostly intestinal
histology (75%).
3-y survival, 69%
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
33
Ampullary carcinoma: location correlates with prognosis
→ which correlates with histology
From: Adsay V, et al., Ampullary Region Carcinomas, 2012
Ulcero-nodular
tumors, does not
show features of
other subtypes.
Intermediate
tumor size.
3-y survival, 54%
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
34
Ampullary carcinoma: location correlates with prognosis
→ which correlates with histology
From: Adsay V, et al., Ampullary Region Carcinomas, 2012
Smallest but worst
prognosis,
presumably due to
the pancreatic
histology or origin
(in 86%).
3-y survival, 41%
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
35
Ampullary carcinoma: location correlates with prognosis
→ which correlates with histology
From: Adsay V, et al., Ampullary Region Carcinomas, 2012
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
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
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
Diagnostic-Therapeutic Algorithm
37 From: Roberts KJ, et al., Endoscopic ultrasound assessment of lesions of the ampulla
of Vater, 2013.
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 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
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
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
39
John B. Moore, MSc, MS3
Gillian Lieberman, MD March 2013
• Dr. Gunjan Senapati
• Dr. Arthur J. Moser
• Dr. Gillian Lieberman
• Claire Odom
• Victoria Van Voorhees
40
Acknowledgments