Performance characteristics of EUS for locoregional evaluation of ampullary lesions

Abstract

Background The accuracy of EUS in the locoregional assessment of ampullary lesions is unclear. Objectives To compare EUS with ERCP and surgical pathology for the evaluation of intraductal extension and local staging of ampullary lesions. Design Retrospective cohort study. Setting Tertiary-care referral center. Patients All patients who underwent EUS primarily for the evaluation of an ampullary lesion between 1998 and 2012. Intervention EUS. Main Outcome Measurements Comparison of EUS sensitivity/specificity for intraductal and local extension with ERCP and surgical pathology by using the area under the receiver-operating characteristic (AUROC) curves and outcomes of the subgroup referred for endoscopic papillectomy. Results We identified 119 patients who underwent EUS for an ampullary lesion, of whom 99 (83%) had an adenoma or adenocarcinoma. Compared with ERCP (n = 90), the sensitivity/specificity of EUS for any intraductal extension was 56%/97% (AUROC = 0.77; 95% confidence interval [CI], 0.64-0.89). However, when using surgical pathology as the reference (n = 102), the sensitivity/specificity of EUS (80%/93%; AUROC = 0.87; 95% CI, 0.76-0.97) and ERCP (83%/93%; AUROC = 0.88; 95% CI, 0.77-0.99) were comparable. The overall accuracy of EUS for local staging was 90%. Of 58 patients referred for endoscopic papillectomy, complete resection was achieved in 53 (91%); in those having intraductal extension by EUS or ERCP, complete resection was achieved in 4 of 5 (80%) and 4 of 7 (57%), respectively. Limitation Retrospective design. Conclusions EUS and ERCP perform similarly in evaluating intraductal extension of ampullary adenomas. Additionally, EUS is accurate in T-staging ampullary adenocarcinomas. Future prospective studies should evaluate whether EUS can identify characteristics of ampullary lesions that appropriately direct patients to endoscopic or surgical resection. (Gastrointest Endosc 2015;81:380-8.)

The role of endoscopy in ampullary and duodenal adenomas

“…EUS has been shown to be superior to CT, magnetic resonance imaging, or transabdominal US for tumor staging. [55][56][57][58][59][60][61][62]66 Magnetic resonance imaging has been found to be superior to EUS for nodal staging for these patients, whereas CT scans and positron emission tomography scans can detect small metastases not seen on EUS or intraductal US. 59,60 One prospective study comparing EUS, intraductal US, and CT scans found that tumor visualization was superior with intraductal US (100%) compared with EUS (59%) and CT (30%).…”

“…Both modalities perform similarly in evaluating intraductal extension of ampullary adenomas. 66 Several authors have used evidence of intraductal extension as a criterion for surgical referral. [67][68][69] Other investigators have shown that <1 cm of extension into the common bile duct or pancreatic duct does not preclude endoscopic therapy because tissue invading to this level may be endoscopically exposed and ablated.…”

Assessment of Duodenal Adenomas and Strategies for Curative Therapy

“…In addition, magnetic resonance cholangiopancreatography is also used to exclude IDE and pancreas divisum [29,30]. EUS is needed for local tumor staging, mostly reserved for lesion larger than 2 cm and those endoscopically suspicious for cancer with overall accuracy up to 90% [30][31][32][33]. ERCP should be performed to evaluate IDE to locate the pancreatic/biliary orifice during the placement of stents following papillectomy [34].…”

“…Yet, magnetic resonance imaging is more precise for nodal staging and CT is more sensitive for detecting metastases. Additionally, compared with surgical pathology, the sensitivity and specificity of EUS and ERCP are the complementary for IDE [51].…”

Endoscopic papillectomy andKRASexpression in the treatment of adenoma in the major duodenal papilla

“…Since the start of our study in 2005, EUS has increasingly been established as a preinterventional standard, at least for lesions larger than 1 cm [28]. However, the value of EUS in preinterventional staging is still under investigation [29], perhaps future research in biomarkers, narrow band imaging, magnifying endoscopy and/or confocal endomicroscopy can shed more light on the issue. In the present series, histopathology from endoscopic biopsies of the papilla was in exact agreement with post-papillectomy histopathology in only 48% of the cases, a finding consistent with previous observations [10,11].…”