Endoscopic Evaluation and Treatment of Ampullary Tumors

Abstract

OBJECTIVE: Endoscopic treatment of ampullary tumors has been well described but limited data is available regarding features predictive of malignancy and factors associated with successful resection of benign lesions. METHODS: 40 consecutive patients undergoing interventional endoscopy for ampullary tumors between March 2000 and November 2003 at the University of Virginia were included in the study. Clinical presentation, endoscopic treatment (biliary and/or pancreatic sphincterotomy, stenting, APC application, snare resection), EUS staging, pathology and final results were documented. Multivariate analysis was performed to determine whether the presence of Familial adenomatous polyposis (FAP), ability to lift the tumor after submucosal injection (cleavage plane), and EUS staging are predictive of malignancy. Additionally, age, gender, endoscopic treatment and ability to obtain a cleavage plane were statistically analyzed to determine which parameters serve as predictive factors of successful endoscopic resection of benign lesions. RESULTS: The mean age of the patients was 60.5 years. There were 21 males and 19 females. Clinical presentation at the time of diagnosis included: jaundice (21), incidental (9), pancreatitis (4) and other (6). Final diagnosis included: 23 adenomas with one HGD, 11 adenocarcinomas, 3 adenomyomas, 2 paragangliomas, and 1 neuroendocrine tumor. Of the 13 patients with malignancy 9 underwent curative surgery and 4 were found to have metastatic disease. 20/28 patients who underwent endoscopic resection were cured. A mean number of 2 endoscopic procedures were needed. 8/20 are still undergoing endoscopic therapy. Complications of endoscopic resection included bleeding requiring hemoclip placement(2) and pancreatitis (3) (two mild and one resulting in death). The factors significantly associated with predicting malignancy was EUS stage and inability to obtain a cleavage plane (see table). In benign lesions no predictive factor of successful endoscopic resection was identified. CONCLUSION: In ampullary lesions, the strongest predictor of malignancy is EUS stage followed by the inability to achieve a cleavage plane. Endoscopic treatment of benign ampullary tumors is effective, but no factors associated with successful resection were identified.