Endoscopic Approach to the Patient with Benign or Malignant Ampullary Lesions

Adenoma and adenocarcinoma are the most common ampullary lesions. Advances in diagnostic modalities including endoscopic ultrasonography and intraductal ultrasonography have provided useful information that aids in diagnosing and managing ampullary lesions. Endoscopic papillectomy can be a curative therapy for localized ampullary adenoma and have a role in the diagnosis of indeterminate ampullary lesions that may contain a hidden malignancy. However, the consensus on how and when to use endoscopic papillectomy has not been fully established. This article reviews the approach to the patient with benign or malignant ampullary lesion.

Key points

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Adenoma is the most common benign ampullary lesion and clinically most important because of its potential to undergo malignant transformation to ampullary cancer. Adenocarcinoma is the most common malignant ampullary lesion.
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Endoscopic examination using side-viewing duodenoscopy with tissue sampling is typically needed to establish the diagnosis. However, endoscopic biopsy may not detect intramural tumor and early focal adenocarcinoma.
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Endoscopic ultrasonography or transpapillary intraductal ultrasonography can provide more detailed and accurate information on the extent of ampullary tumors, including the dimensions, echogenicity, involvement of duodenal layers, and possibly regional lymph node status.
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Endoscopic papillectomy is regarded as a curative treatment of ampullary adenoma and may be a curative treatment of ampullary adenoma with high-grade intraepithelial neoplasia/in situ tumor. The current data also suggest that when an endoscopically resected specimen has a well-differentiated intramucosal cancer with clear margins and no angiolymphatic invasion, subsequent radical surgery may not be necessary.
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There is no standardized technique for endoscopic removal of ampullary tumors (eg, submucosal injection, endoscopic resection, electrocautery setting, pancreatic stenting, biliary stenting, pancreatic or biliary sphincterotomy), because of complexity of the procedure.
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Future randomized, long-term, follow-up studies are required to address many unresolved issues and to provide evidence for future consensus in this field.