Carcinoma of the ampulla of Vater: the endoscopic approach

Carcinoma of the ampulla of Vater is a rare tumor. Early and accurate diagnosis of carcinoma of the ampulla of Vater will lead to early treatment and subsequent better prognosis. Endoscopy and endoscopic retrograde cholangiopancreaticography (ERCP) has been shown to be one of the best diagnostic modalities. Furthermore an endoscopic biliary drainage procedure can be performed immediately following the diagnostic procedure. The tumors may be seen as large, fleshy, friable exophytic growths, as ulcerated tumors into the duodenal wall or as a mass behind the orifice of the papilla, covered with normal duodenal mucosa. Forceps biopsies do not always suffice to show malignancy. Large snare biopsies often are necessary. Occasionally the final diagnosis of malignancy can only be made by examination of the surgical resection specimen. Tumors arising inside the ampulla form a bulge, covered by normal duodenal mucosa. An impacted stone may mimic this picture. Endoscopic papillotomy is then mandatory to make the final diagnosis. Histologic examination of forceps biopsies reveals malignancy in only 60% of cases. When snare biopsy is used, the diagnostic yield increases to 83%. The optimal treatment of carcinomas of the ampulla of Vater is surgical resection. Preoperative biliary drainage should theoretically be of benefit to the patient. The results of preoperative percutaneous drainage studies are, however, conflicting. Carcinoma of the ampulla of Vater is not resectable in 25-50% of the patients because of metastatic disease, deep extension of the tumor or general contraindications for major surgery. Endoscopic papillotomy or stent placement as a definitive treatment modality should be reserved for poor surgical candidates and for those patients with limited life expectancy due to metastatic disease.