Endoscopic Diagnosis of Ampullary Tumors Using Conventional Endoscopic Ultrasonography and Intraductal Ultrasonography in the Era of Endoscopic Papillectomy: Advantages and Limitations

Jong Ho Moon

doi:10.5946/ce.2014.47.2.127

Articles

Page Path: HOME > Clin Endosc > Volume 47(2); 2014 > Article

Commentary Endoscopic Diagnosis of Ampullary Tumors Using Conventional Endoscopic Ultrasonography and Intraductal Ultrasonography in the Era of Endoscopic Papillectomy: Advantages and Limitations: Jong Ho Moon; Clinical Endoscopy 2014;47(2):127-128.
DOI: https://doi.org/10.5946/ce.2014.47.2.127
Published online: March 31, 2014

Department of Internal Medicine, Digestive Disease Center and Research Institute, Soonchunhyang University College of Medicine, Bucheon, Korea.

Correspondence: Jong Ho Moon. Department of Internal Medicine, Digestive Disease Center and Research Institute, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, 170 Jomaru-ro, Wonmi-gu, Bucheon 420-767, Korea. Tel: +82-32-621-5094, Fax: +82-32-621-5080, jhmoon@schmc.ac.kr

• Received: January 31, 2014 • Revised: March 3, 2014 • Accepted: March 3, 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

5,751 Views
78 Download
5 Web of Science
4 Crossref
4 Scopus

prev next

Full Article

Download PDF

NOTES
REFERENCES

See "Endosonographic Preoperative Evaluation for Tumors of the Ampulla of Vater Using Endoscopic Ultrasonography and Intraductal Ultrasonography" by Naoki Okano, Yoshinori Igarashi, Seiichi Hara, et al., on page [Related article:] 174-177

The diagnosis of ampullary tumors during screening endoscopy or radiological imaging studies is increasing. Traditional management for ampullary tumors is surgical resection. However, surgical intervention needs radical excision, including excision of the surrounding organs around the ampulla of Vater. With the development of endoscopic techniques, endoscopic resection for ampullary tumors has largely replaced classical surgical resection for the treatment of ampullary tumors, as it is a less invasive intervention.1 However, owing to the inherited limitation of resection depth by using the endoscopic procedure, only ampullary adenoma or very early stage cancer of the ampulla of Vater are indicated for endoscopic resection.2 Radiologic imaging studies, including cross sectional imaging such as computed tomography or magnetic resonance imaging, have poor accuracy for the T-staging of ampullary cancer.3,4 Therefore, further investigation with another endoscopic modality in conjunction with duodenoscopic evaluation is needed to identify ampullary lesions suitable for endoscopic resection. In this issue of Clinical Endoscopy, Okano et al.5 reports the analyzed accuracy of conventional endoscopic ultrasonography (EUS) and transpapillary intraductal ultrasonography (IDUS) for diagnosing ampullary tumors by focusing on finding early-stage tumors as an indication for endoscopic papillectomy (EP) with a snare. EP was used to treat 35 of 48 patients (72.9%) with ampullary tumors. The authors examined the ampullary tumors with EUS and IDUS before endoscopic resection or surgical excision. The overall diagnostic accuracy was the same (85%) for both EUS and IDUS. Diagnostic accuracies for ampullary adenoma or pTis cancer and T1 early-stage cancer were similar with 97% and 73% for EUS, and 94% and 73% for IDUS, respectively. Extension of the tumor into the bile duct and pancreatic duct was diagnosed with accuracies of 90% and 92% by using EUS, respectively, and 88% and 88% by using IDUS, respectively.

Ito et al.6 reported the results of a similar study of 40 patients. IDUS was more accurate than EUS for ampullary adenoma and T1 (86% vs. 62%), and the overall accuracy in T-staging (78% vs. 63%). The overall accuracy in the assessment of ductal invasion for IDUS (90% in both the bile duct and the pancreatic duct) was very similar to that of EUS (88% in the bile duct and 90% in the pancreatic duct).

Endosonographic evaluation, especially EUS, is now widely available; however, there is still no consensus regarding the indication of EUS and/or IDUS to make a therapeutic decision in patients with ampullary tumors. Accurate T-staging of ampullary cancer and involvement of the biliopancreatic ductal system are the most important factors that guide appropriate therapy. There is still no consensus on the indication for EP of ampullary tumors. However, ampullary adenoma, highgrade dysplasia, and Tis without ductal involvement are absolute indications for EP. In a retrospective study by Yoon et al.,7 10 clearly resected patients with high-grade dysplasia/Tis and six patients with focal T1 cancer had no sign of recurrence of cancer during a mean follow-up of 27 to 32 months. Therefore, T1 cancer and cancer focally limited to the major papilla can be relative indications for EP in cases without lymph node metastasis. In the case of T2 ampullary cancer, radical surgery is needed for cancer invasion to the duodenal muscularis propria. EUS can provide accurate assessment for involvement of the duodenal wall layers. Therefore, theoretically, EUS can be an excellent tool to detect a lesion limited to the major papilla. The reported accuracy of EUS for diagnosing a T1 ampullary cancer is around 90%.4 This is particularly relevant as IDUS is the only imaging modality to reveal a layer of the sphincter of Oddi, but it is not visible in every case. It can help discriminate adenomas or Tis lesions from TI lesions. Of the three published trials that compared EUS with IDUS, two showed that IDUS had higher overall accuracy compared to that with EUS.6,8,9 In some cases, the complete assessment of duodenal involvement is difficult with EUS because of unclear visualization of the proper muscle layer of the duodenum. Indeed, Ito et al.6 reported that duodenal involvement could not be estimated by using EUS in 15% of patients, compared with the 100% visualization of the duodenal proper muscle layer by using IDUS. Therefore, EUS is preferable for large tumors that invade the pancreatic parenchyma or the duodenum.

Extension of ampullary tumors into the bile duct or pancreatic duct can reduce the complete resection rate achieved with EP. Therefore, preoperative evaluation of tumor involvement of the bile duct or pancreatic duct, or both, is important when assessing candidates for EP. Additionally, EUS and IDUS can show high accuracy for the assessment of intraductal involvement. IDUS is the more accurate tool because the probe can travel through the lumen of the bile duct in a direction perpendicular to the duct. Therefore, IDUS seems to be more accurate than EUS for tumor assessment, including T-staging and intraductal extension. However, the potential over-staging of the lesion, especially as T2, or just over T2, is a limitation of IDUS.6,10 The new electronic radial echoendoscope can be used to overcome the limitation of the conventional radial echoendoscope. However, there is still no comparative data about the impact of EUS and IDUS in predicting complete and clear resection after EP.11 The evaluation of tumor infiltration of the sphincter of Oddi is still challenging, even with IDUS.6 With EUS/IDUS, diagnosis of foci of an adenocarcinoma or focal invasion of the duodenal wall layer is difficult.

In conclusion, endosonographic modalities, including EUS and IDUS, can provide highly accurate diagnostic information for the staging of ampullary tumors, and are helpful to identify lesions indicated for endoscopic resection. However, even these tools have limitations and are not perfect diagnostic tools, because of the potential for over- and under-staging and the difficulty in evaluating focal infiltration. Further refinement of endoscopic procedures is needed for the precise assessment of ampullary tumors.

The author has no financial conflicts of interest.

REFERENCES

1. Han J, Kim MH. Endoscopic papillectomy for adenomas of the major duodenal papilla (with video). Gastrointest Endosc 2006;63:292–301.Article PubMed
2. Kim HK, Lo SK. Endoscopic approach to the patient with benign or malignant ampullary lesions. Gastrointest Endosc Clin N Am 2013;23:347–383.Article PubMed
3. Rosch T, Braig C, Gain T, et al. Staging of pancreatic and ampullary carcinoma by endoscopic ultrasonography: comparison with conventional sonography, computed tomography, and angiography. Gastroenterology 1992;102:188–199.Article PubMed
4. Cannon ME, Carpenter SL, Elta GH, et al. EUS compared with CT, magnetic resonance imaging, and angiography and the influence of biliary stenting on staging accuracy of ampullary neoplasms. Gastrointest Endosc 1999;50:27–33.Article PubMed
5. Okano N, Igarashi Y, Hara S, et al. Endosonographic preoperative evaluation for tumors of ampulla of Vater using endoscopic ultrasonography and intraductal ultrasongraphy. Clin Endosc 2014;47:174–177.Article PubMed PMC
6. Ito K, Fujita N, Noda Y, et al. Preoperative evaluation of ampullary neoplasm with EUS and transpapillary intraductal US: a prospective and histopathologically controlled study. Gastrointest Endosc 2007;66:740–747.Article PubMed
7. Yoon SM, Kim MH, Kim MJ, et al. Focal early stage cancer in ampullary adenoma: surgery or endoscopic papillectomy? Gastrointest Endosc 2007;66:701–707.Article PubMed
8. Itoh A, Goto H, Naitoh Y, Hirooka Y, Furukawa T, Hayakawa T. Intraductal ultrasonography in diagnosing tumor extension of cancer of the papilla of Vater. Gastrointest Endosc 1997;45:251–260.Article PubMed
9. Menzel J, Hoepffner N, Sulkowski U, et al. Polypoid tumors of the major duodenal papilla: preoperative staging with intraductal US, EUS, and CT--a prospective, histopathologically controlled study. Gastrointest Endosc 1999;49(3 Pt 1):349–357.Article PubMed
10. Tio TL, Sie LH, Kallimanis G, et al. Staging of ampullary and pancreatic carcinoma: comparison between endosonography and surgery. Gastrointest Endosc 1996;44:706–713.Article PubMed
11. El Hajj II, Cote GA. Endoscopic diagnosis and management of ampullary lesions. Gastrointest Endosc Clin N Am 2013;23:95–109.Article PubMed

Figure & Data

REFERENCES

Citations

Citations to this article as recorded by

The Long-Term Outcomes of Endoscopic Papillectomy and Management of Cases of Incomplete Resection: A Single-Center Study
Shinichiro Muro, Hironari Kato, Akihiro Matsumi, Yuki Ishihara, Yosuke Saragai, Shuntaro Yabe, Saimon Takata, Daisuke Uchida, Takeshi Tomoda, Kazuyuki Matsumoto, Shigeru Horiguchi, Hiroyuki Okada
Journal of Gastrointestinal Surgery.2021; 25(5): 1247. CrossRef
Effect of submucosal injection in endoscopic papillectomy of ampullary tumor: Propensity‐score matching analysis
Kwang Hyun Chung, Sang Hyub Lee, Jin Ho Choi, Jinwoo Kang, Woo Hyun Paik, Dong-Won Ahn, Ji Kon Ryu, Yong-Tae Kim
United European Gastroenterology Journal.2018; 6(4): 576. CrossRef
Comparison of postoperative early and late complications between pancreas-sparing duodenectomy and pancreatoduodenectomy
Yusuke Nakayama, Masaru Konishi, Naoto Gotohda, Yuichiro Kato, Hidetoshi Aizawa, Masashi Kudo, Satoshi Okubo, Daigoro Takahashi, Yasunori Nishida, Kazuhiko Kitaguchi, Shinichiro Takahashi
Surgery Today.2017; 47(6): 705. CrossRef
Recent Advances in Endoscopic Papillectomy for Ampulla of Vater Tumors: Endoscopic Ultrasonography, Intraductal Ultrasonography, and Pancreatic Stent Placement
Jimin Han, Dong Wook Lee, Ho Gak Kim
Clinical Endoscopy.2015; 48(1): 24. CrossRef

PubReader
ePub Link

Cite

CITE: export Copy Download Format; Close

Download Citation

Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

Format:

RIS — For EndNote, ProCite, RefWorks, and most other reference management software
BibTeX — For JabRef, BibDesk, and other BibTeX-specific software

Include:

Citation for the content below
Citation and abstract for the content below

Endoscopic Diagnosis of Ampullary Tumors Using Conventional Endoscopic Ultrasonography and Intraductal Ultrasonography in the Era of Endoscopic Papillectomy: Advantages and Limitations

Clin Endosc. 2014;47(2):127-128. Published online March 31, 2014

DOI: https://doi.org/10.5946/ce.2014.47.2.127

XML Download

Endoscopic Diagnosis of Ampullary Tumors Using Conventional Endoscopic Ultrasonography and Intraductal Ultrasonography in the Era of Endoscopic Papillectomy: Advantages and Limitations