eMedicine Specialties > Oncology > Carcinomas of the Gastrointestinal Tract
Ampullary Carcinoma: Differential Diagnoses & Workup
Updated: Jul 18, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Differential Diagnoses
| Bile Duct Strictures | Lymphoma, Non-Hodgkin |
| Bile Duct Tumors | Pancreatic Cancer |
| Carcinoma of the Ampulla of Vater | |
| Cholangiocarcinoma | |
| Gallbladder Cancer |
Other Problems to Be Considered
Biliary cirrhosis
Workup
Laboratory Studies
- Routine laboratory studies include a complete blood cell count, electrolyte panel, liver function studies (prothrombin time, bilirubin [direct and indirect], transaminases, alkaline phosphatase), CEA, and CA 19-9.
- CA 19-9 is a recently discovered tumor marker that is detectable in serum. It often is elevated in pancreatic malignancies and might have a role in assessing response to therapy, predicting tumor recurrence, or both.
- CEA is another nonspecific tumor marker that sometimes is elevated in pancreatic malignancies. It might have a role in assessing response to treatment or predicting tumor recurrence. Because CEA also is elevated in patients with other gastrointestinal malignancies (eg, colon and rectal in particular), exclude the possibility of a second primary tumor in these patients.
Imaging Studies
- Ultrasound of the abdomen
- Obtain an ultrasound image of the abdomen to evaluate the common bile duct and the pancreatic ducts.
- Dilatation of these ducts essentially is diagnostic for extrahepatic obstruction.
- CT scan of the abdomen and/or pelvis: Obtain a CT scan image to evaluate the local region of interest and evaluate for possible metastases.
- Endoscopic retrograde cholangiopancreatography
- Obtain ERCP findings to evaluate the ductal architecture further.
- Narrowing or irregularities might suggest malignancy.
- Chest radiograph: Obtain a chest x-ray film to complete the workup (ie, for staging purposes).
- Positron emission tomography (PET) or PET-CT scans: These scans have been widely adopted in the author's clinic as a means of imaging the metabolic activity of a particular tumor. When metastases are smaller than they can be reliably detected on a CT scan, PET or PET-CT scans can detect them.
Staging
Over the years, multiple systems for staging this tumor have been proposed.
- Martin proposed a 4-stage system, as follows:
- Stage I - Vegetating tumor limited to the epithelium with no involvement of the sphincter of Oddi
- Stage II - Tumor localized in the duodenal submucosa without involvement of the duodenal muscularis propria but possible involvement of the sphincter of Oddi
- Stage III - Tumor of the duodenal muscularis propria
- Stage IV - Tumor of the periduodenal area or pancreas, with proximal or distal lymph node involvement
- The classification system of Yamaguchi and Enjoji is similar to the Martin classification.
- Talbot et al devised a system that scored tumors according to the degree of infiltration (from 1-4 according to increasing infiltration) and according to tumor differentiation (from 1-3 for well, moderately, and poorly differentiated tumors), the sum of which separated the patients into 2 groups (scores 2-4 and scores 5-7).
- The currently accepted American Joint Committee on Cancer staging system for ampullary carcinoma emphasizes the importance of pancreatic invasion and lymph node metastases (see below and see Table 1, below). Size has little impact on tumor stage. The definition of primary tumor (T), regional lymph node (N), and remote metastases (M) for classification and staging of thyroid node metastasis and staging for cancer of the ampulla of Vater is as follows:
- Primary tumor
- TX – Primary tumor cannot be assessed
- T0 – No evidence of primary tumor
- Tis – Carcinoma in situ
- T1 – Tumor limited to ampulla of Vater
- T2 – Tumor invades duodenal wall
- T3 – Tumor invades less than 2 cm into pancreas
- T4 – Tumor invades more than 2 cm into pancreas or other organs
- Regional lymph nodes
- NX – Regional lymph nodes cannot be assessed
- N0 – No regional lymph node metastases
- N1 – Lymph node metastases
- Distant metastases
- MX – Presence of distant metastases cannot be assessed
- M0 – No distant metastases
- M1 – Distant metastases
- Primary tumor
- Table 1. Staging of Ampullary Cancers by the TNM System
Open table in new window
[ CLOSE WINDOW ]Table
Stage T N M Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2-3 N0 M0 Stage III T1-3 N1 M0 Stage IV T4 N0-1 M0 … T1-4 N0-1 M1 Stage T N M Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2-3 N0 M0 Stage III T1-3 N1 M0 Stage IV T4 N0-1 M0 … T1-4 N0-1 M1
More on Ampullary Carcinoma |
| Overview: Ampullary Carcinoma |
 Differential Diagnoses & Workup: Ampullary Carcinoma |
| Treatment & Medication: Ampullary Carcinoma |
| Follow-up: Ampullary Carcinoma |
| References |
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Further Reading
Keywords
cancer, carcinoma, bile duct cancer, common bile duct, duodenal mucosa, pancreatic duct, adenocarcinoma, gastrointestinal malignancy, gastrointestinal cancer, GI cancer, GI malignancy, ampulla of Vater, ampullary carcinoma, periampullary carcinoma, cancer of the ampulla of Vater, pancreaticoduodenal resection, Whipple procedure
