What is the management approach for a patient with an ampullary mass?

Management of Ampullary Mass

The management of an ampullary mass should include comprehensive imaging with endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) for proper staging, followed by tissue diagnosis through biopsy and appropriate intervention based on histology findings. 1

Diagnostic Approach

Initial Evaluation

• Imaging studies:
  • Contrast-enhanced pancreatic protocol CT (first choice) or MRI/MRCP 2
  • EUS for detailed assessment of the ampullary region and to determine depth of invasion 1
  • Combined EUS and MRCP provide optimal staging information 1

Tissue Diagnosis

• Side-viewing duodenoscope is preferred over forward-viewing endoscope for better visualization and sampling 3
• Direct endoscopic biopsy of the ampullary mass is essential before any therapeutic intervention 1
• Multiple biopsies should be taken to improve diagnostic accuracy 3

Management Algorithm Based on Histology

For Benign Ampullary Adenomas

1. Endoscopic papillectomy is recommended when:

   • Confirmed adenoma without intraductal extension 1
   • Size ≤ 2-3 cm 1
   • No evidence of malignancy on imaging or biopsy

2. Technical considerations for endoscopic papillectomy:

   • En bloc resection is preferred for optimal histopathology and lower recurrence 1
   • Direct snare resection without submucosal injection 1
   • Prophylactic pancreatic duct stenting to reduce pancreatitis risk 1

3. Surgical management is indicated when:

   • Adenoma > 4 cm 1
   • Intraductal extension > 20 mm 1
   • Technical limitations (e.g., location within duodenal diverticulum) 1

For Malignant Ampullary Masses (Adenocarcinoma)

1. Surgical resection (pancreaticoduodenectomy/Whipple procedure) for:

   • Localized, resectable disease 4, 5
   • No evidence of metastasis

2. Neoadjuvant therapy may be considered for:

   • Borderline resectable disease 5
   • Locally advanced disease

3. Adjuvant therapy after resection:

   • Chemotherapy regimens similar to those used for pancreatic cancer 5

4. Palliative management for unresectable/metastatic disease:

   • Biliary stenting for obstructive jaundice 2
   • Systemic chemotherapy 5

Post-Treatment Surveillance

• For patients who undergo endoscopic papillectomy:

  • Duodenoscopy with biopsies of the scar within 3 months 1
  • Follow-up at 6 and 12 months 1
  • Annual surveillance for at least 5 years 1

• For patients who undergo surgical resection:

  • Regular imaging surveillance with CT or MRI 2
  • Monitoring for recurrence and metastasis

Pitfalls to Avoid

1. Diagnostic errors:

   • Discordance between endoscopic appearance and biopsy results is common 3
   • When imaging and biopsy disagree, re-evaluation is necessary 3

2. Technical considerations:

   • Avoid diagnostic/therapeutic papillectomy when adenoma is not proven 1
   • Risk of complications with endoscopic papillectomy including pancreatitis, bleeding, and perforation 1
   • Endoscopic management of ampullary disease appears less safe than other locations with higher complication rates (up to 45%) and recurrence rates (up to 58%) 6

3. Management decisions:

   • Referral to a specialized hepato-pancreatico-biliary (HPB) center is recommended for complex cases 6
   • Multidisciplinary team approach involving gastroenterologists, surgeons, and oncologists is essential

By following this structured approach to ampullary masses, clinicians can ensure appropriate diagnosis and treatment while minimizing complications and optimizing outcomes for patients.