MANAGEMENT OF AMPULLARY ADENOMA - … of...EPIDEMIOLOGY AMPULLARY ADENOMAS • Incidence 5...

Marc LaFonte PGY5 SUNY Downstate

July 2nd, 2015

MANAGEMENT OF AMPULLARY ADENOMA

www.downstatesurgery.org

CASE PRESENTATION

• 68F s/p endoscopic papillectomy for low grade adenoma 2012 – < 2cm

• Re-excision of adenoma 2014 twice – Low grade dysplasia – Offered surgery, refused

• Obstructive jaundice


Presenter

Presentation Notes

Original symptoms: Epigastric/RUQ abdominal discomfort, anorexia Underwent original EUS and biopsy 2012, low grade adenoma (< 2cm). Screening EUS x 2 in 2014 showed dysplasia low grade Offered surgery, refused Presented to King’s County: Anorexia, RUQ pain, fevers, weight loss, pruritis, clay stool

CASE PRESENTATION • PSH: Cholecystectomy, appendectomy

• Social: ½ ppd x 40 years

• Family: Non-contributory

• Colonoscopy March 2015: 4 benign polyps


Presenter

Presentation Notes

Polyps completely excised

PHYSICAL EXAM • T 98.4F BP 121/71 HR 61 RR 12 100% RA • Anicteric

• Abd: soft, epigastric tenderness, ND

• No rectal masses, Guaiac negative


LABS • WBC: 7 • AST/ALT: 95/142, Alk phos: 597, T bili: 1.9

• Amylase: 125, Lipase: 101


IMAGING • EUS/ERCP:

– polypoid mass at ampullectomy site – CBD and pancreatic duct dilatation – Biopsy: carcinoma in situ

• Abdominal MRI/MRCP: 1.4x1.7cm periampullary lesion – No hepatic lesions or lymphadenopathy


Presenter

Presentation Notes

Side viewing EUS Most recent ERCP: “normal duodenal mucosa”, “grandular and polypoid” ampullectomy site

OR • Whipple (pancreaticoduodenectomy)

– No evidence of metastatic disease – Pylorus sparing

– No Involvement of SMA

– JPx3: HJ, APD, PPD


POST-OPERATIVE COURSE • TPN and Octreotide taper

• Clears POD#7, advanced

• Discharged home uneventfully


PATHOLOGY • Ampullary adenocarcinoma (pancreaticobiliary type, well

differentiated) – CBD and pancreatic margins negative – 1/13 lymph nodes positive (peri-pancreatic) – T2N1Mx (stage IIb)

• Adjuvant chemotherapy and radiation


QUESTIONS?


OVERVIEW AMPULLARY ADENOMAS • Anatomy and epidemiology • Clinical features • Diagnosis • Management and controversy • Summary


DEFINITION AMPULLA

• Junction of biliary and pancreatic ducts within duodenum

• Tumors usually detected earlier, more favorable prognosis – Intestinal better than pancreaticobiliary


Presenter

Presentation Notes

Ampulla is lined by epithelium that transitions from pancreatic/biliary origin to duodenal mucosal – can have different histologic morphology Intestinal have lower incidence of EGFr and p53 overexpression, fewer K-ras mutations

EPIDEMIOLOGY AMPULLARY ADENOMAS • Incidence 5 cases/million

• 20% tumor-related obstructions of the CBD

• Age 65, men • Malignant transformation (>5cm) • Sporadic or genetic (FAP)


Presenter

Presentation Notes

Malignant transformation: 90% resection specimens for adenocarcinoma Sporadic Mutations: APC (2/3), KRAS (1/2) FAP: 90% patients with FAP develop adenomas in small intestines, most of which are duodenum, ampulla, and periampullary region. 124 fold greater risk for carcinoma vs. general population.

CLINICAL FEATURES AMPULLARY ADENOMA • Often asymptomatic

• Jaundice

• *weight loss*

• Occult bleed

• rarely cholangitis, pancreatitis


Presenter

Presentation Notes

Discovered on endoscopy Other non-specific symptoms nausea, vomiting, abdominal pain

DIAGNOSIS AMPULLARY ADENOMA

• Elevated LFT, amylase/lipase

• EGD with side view and HD resolution – Single best test for diagnosis

• Endoscopic ultrasound (side view) – Depth, regional lymph nodes – Best staging test (Superior to CT and MRI)

• Transpapillary intraductal ultrasonography (IDUS) – Similar to EUS, not readily available

• ERCP – Visualize extent into biliary or pancreatic duct, decompress

• Biopsy


Presenter

Presentation Notes

EUS best staging AFTER diagnosis EUS and IDUS similar accuracy, IDUS higher resolution False negative biopsy 27%

MANAGEMENT AMPULLARY ADENOMA • Surveillance, endoscopic resection, or surgical intervention

– Sporadic vs. FAP

– Dysplasia

– Size

– Physical features


MANAGEMENT AMPULLARY ADENOMA • Sporadic

– Treat like flat adenoma colonic colon • US National Polyp Study

• FAP

– Score < 8: surveillance – Score >/=8: endoscopic resection – High grade dysplasia: endoscopic resection


Presenter

Presentation Notes

Study Upenn: Diminutive polyp have low prevalence of high grade dysplasia. A small adenoma does not identify patients with increased risk of metachronous cancer. Score 8 = stage 3 Spigelman system criticized: progression in stage of scoring more important weight on size and number of polyps versus histology Natural history studies in patients with FAP suggest slow histologic progression of proximal (upper GI) lesions and low risk of cancer development.

MANAGEMENT AMPULLARY ADENOMA • Size and physical features

– < 1cm diameter, without ulcer, induration, or bleeding – >1cm diameter with ulcer, induration, and/or bleeding

• Increased recurrence risk

• Dysplasia – Low grade

• 15% coexistent cancer – **High grade**

• 50% coexistent cancer


Presenter

Presentation Notes

<1cm or low grade = no imaging for staging, may resect or surveillance >1cm or high grade = stage, endoscopic resection, consider surgery Advocates for endoscopic resection for HGD if intraductal growth is less than 1 cm. Supported by literature along with a pT1 (limited to ampulla of vater or sphincter of Oddi) Proponents of radical surgery for HGD point to several studies that underlie the fact that diagnostic yield for picking up foci of adenocarcinoma and lymphovascular invasion pre-operatively is sub-optimal

ENDOSCOPIC MANAGEMENT OF AMPULLARY ADENOMA

• Papillectomy vs. “ampullectomy” • Braided vs. fine wire • En bloc vs. piecemeal

– Size (2cm cutoff) – abnormal tissue after en bloc

• Sphincterotomy – No consensus

• Complications – Pancreatitis

• Consider pancreatic stent placement


Presenter

Presentation Notes

Ampullectomy refers to removal of ampulla with surgical reconstruction of the CBD and pancreatic duct No difference in snare type No difference in position of snare (Cephalad to caudal or caudal to cephalad) En bloc resection shortens procedure time, less electrocautery, complete tissue sample Piecemeal can ruin specimen with more electrocautery, repeated submucosal injections

WHEN CONSIDERING A WHIPPLE FOR AMPULLARY ADENOMA

• High grade dysplasia • CiS or carcinoma • Features of malignancy on EUS/ERCP


FOLLOWING AMPULLARY ADENOMA • Surveillance

– Generally 1-6 months following resection – Then, 3-12 months for 2 years – High grade dysplasia = more frequent surveillance

• Screening colonoscopy if sporadic ampullary adenoma • FAP continue surveillance (even after proctocolectomy)


SUMMARY • Ampullary adenoma premalignant • Usually asymptomatic, jaundice when symptomatic

• Side view endoscope

– Beware the false negative and coexistent cancer with dysplasia

• Grey areas regarding endoscope vs. surgery

– Size, dysplasia, genetics, physical features aid in decision


REFERENCES

• The role of endoscopy in ampullary and duodenal adenomas. American Society For Gastrointestinal Endoscopy

• Chini P et al. Diagnosis and management of ampullary adenoma: The expanding role of endoscopy. World J Gastrointest Endosc. 2011 Dec 16; 3(12): 241–247

• Mastery of Surgery • Cameron 9th edition • Schwartz 9th edition


MANAGEMENT OF AMPULLARY ADENOMA - … of...EPIDEMIOLOGY AMPULLARY ADENOMAS • Incidence 5...

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