Advertisement

Prospective evaluation of EUS versus CT scan for staging of ampullary cancer

  • Everson L.A. Artifon
    Affiliations
    Current affiliations: Department of Gastroenterology (E.L.A., D.S.C., P.S.), University of São Paulo School of Medicine, São Paulo, Brasil, Division of Gastroenterology (E.B.d.S.), Portland VA Medical Center, Oregon Health and Science University, Portland, Oregon, USA
    Search for articles by this author
  • Decio Couto Jr.
    Affiliations
    Current affiliations: Department of Gastroenterology (E.L.A., D.S.C., P.S.), University of São Paulo School of Medicine, São Paulo, Brasil, Division of Gastroenterology (E.B.d.S.), Portland VA Medical Center, Oregon Health and Science University, Portland, Oregon, USA
    Search for articles by this author
  • Paulo Sakai
    Affiliations
    Current affiliations: Department of Gastroenterology (E.L.A., D.S.C., P.S.), University of São Paulo School of Medicine, São Paulo, Brasil, Division of Gastroenterology (E.B.d.S.), Portland VA Medical Center, Oregon Health and Science University, Portland, Oregon, USA
    Search for articles by this author
  • Eduardo B. da Silveira
    Correspondence
    Reprint requests: Eduardo B. da Silveira, MD, MSc (Epidemiology), 3710 SW US Veterans Hospital Road, MC: P3GI, Portland, OR 97239.
    Affiliations
    Current affiliations: Department of Gastroenterology (E.L.A., D.S.C., P.S.), University of São Paulo School of Medicine, São Paulo, Brasil, Division of Gastroenterology (E.B.d.S.), Portland VA Medical Center, Oregon Health and Science University, Portland, Oregon, USA
    Search for articles by this author

      Background

      Malignancies of the biliary and pancreatic systems are associated with a poor prognosis. However, ampullary cancer carries a better prognosis and is often diagnosed when curative treatment is still possible. Accurate staging is important for the determination of the most appropriate treatment option.

      Objectives

      (1) To determine the test performance characteristics of EUS and CT in loco-regional staging of ampullary neoplasms, and (2) to determine the impact of CT scan results on the test performance characteristics of EUS.

      Design and Setting

      Prospective single-arm intervention study performed in 2 academic hospitals.

      Results and Main Outcome Measurements

      Thirty-seven patients were screened and 33 staged with EUS and CT. A total of 27 patients (13 men; mean age, 69.5 years; mean serum bilirubin level, 12.6 mg/dL) with locally advanced disease completed the protocol with EUS and CT and underwent surgical resection. Tumor classifications were as follows: 2 patients (7.4%), T1 tumors; 13 patients (48.1%), T2 tumors; and 12 patients (44.4%), T3 tumors, as per surgical pathology. Seventeen tumors (62.9%) were classified as N0 and 10 (37.1%) as N1. The difference in proportion of correct tumor (74.1% vs 51.8%; P = .15, 95% CI, -0.06-0.50) and lymph node (81.4% vs 55.5%; P = .07, 95% CI, -0.01-0.53) staging by EUS and CT, respectively, was not statistically significantly different. However, the strength of tumor (kappa 0.51 vs 0.11) and nodal (kappa 0.59 vs 0.05) agreement with pathology was statistically significantly higher for EUS than for CT (P < .05). EUS was more sensitive and specific than CT for tumor and nodal staging, and the association of CT to EUS data did not improve the final test accuracy.

      Limitation

      Low number of T1 tumors.

      Conclusions

      EUS is an accurate diagnostic test and exhibits a high level of agreement with surgical pathology. CT findings do not improve the test performance characteristics of EUS. Therefore, the evaluation for metastatic disease should not be compromised by CT protocols that aim to perform tumor and nodal staging. Further studies to determine the role of specialized CT protocols in patients with ampullary malignancies are needed.

      Abbreviations:

      CI (confidence interval), NPV (negative predictive value), PPV (positive predictive value), SD (standard deviation)
      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Jemal A.
        • Tiwari R.C.
        • Murray T.
        • et al.
        Cancer statistics, 2004.
        CA Cancer J Clin. 2004; 54: 8-29
        • Rosewicz S.
        • Wiedenmann B.
        Pancreatic carcinoma.
        Lancet. 1997; 349: 485-489
        • Fernandez-del Castillo C.
        • Rattner D.W.
        • Warshaw A.L.
        Standards for pancreatic resection in the 1990s.
        Arch Surg. 1995; 130: 295-299
        • Cameron J.L.
        • Pitt H.A.
        • Yeo C.J.
        • et al.
        One hundred and forty-five consecutive pancreaticoduodenectomies without mortality.
        Ann Surg. 1993; 217: 430-435
        • Pyun D.K.
        • Moon G.
        • Han J.
        • et al.
        A carcinoid tumor of the ampulla of Vater treated by endoscopic snare papillectomy.
        Korean J Intern Med. 2004; 19: 257-260
        • Wong R.F.
        • DiSario J.A.
        Approaches to endoscopic ampullectomy.
        Curr Opin Gastroenterol. 2004; 20: 460-467
        • Baillie J.
        Endoscopic ampullectomy.
        Am J Gastroenterol. 2005; 100: 379-381
        • Rosch T.
        • Braig C.
        • Gain T.
        • et al.
        Staging of pancreatic and ampullary carcinoma by endoscopic ultrasonography: comparison with conventional sonography, computed tomography, and angiography.
        Gastroenterology. 1992; 102: 188-199
        • Mukai H.
        • Yasuda K.
        • Nakajima M.
        Tumors of the papilla and distal common bile duct: diagnosis and staging by endoscopic ultrasonography.
        Gastrointest Endosc Clin N Am. 1995; 5: 763-772
        • Schueller G.
        • Schima W.
        • Schueller-Weidekamm C.
        • et al.
        Multidetector CT of pancreas: effects of contrast material flow rate and individualized scan delay on enhancement of pancreas and tumor contrast.
        Radiology. 2006; 241: 441-448
        • Freeny P.C.
        • Traverso L.W.
        • Ryan J.A.
        Diagnosis and staging of pancreatic adenocarcinoma with dynamic computed tomography.
        Am J Surg. 1993; 165: 600-606
      1. International Union Against Cancer (UICC).
        in: Hermanek P. Sobin L.H. TNM classification of malignant tumours. 4th ed. Springer-Verlag, Berlin, Germany1987: 62-67
        • Horwhat J.D.
        • Gress F.G.
        Defining the diagnostic algorithm in pancreatic cancer.
        JOP. 2004; 5: 289-303
        • Shoup M.
        • Hodul P.
        • Aranha G.V.
        • et al.
        Defining a role for endoscopic ultrasound in staging periampullary tumors.
        Am J Surg. 2000; 179: 453-456
        • Muller M.F.
        • Meyenberger C.
        • Bertschinger P.
        • et al.
        Pancreatic tumors: evaluation with endoscopic US, CT, and MR imaging.
        Radiology. 1994; 190: 745-751
        • Cannon M.E.
        • Carpenter S.L.
        • Elta G.H.
        • et al.
        EUS compared with CT, magnetic resonance imaging, and angiography and the influence of biliary stenting on staging accuracy of ampullary neoplasms.
        Gastrointest Endosc. 1999; 50: 27-33
        • Legmann P.
        • Vignaux O.
        • Dousset B.
        • et al.
        Pancreatic tumors: comparison of dual-phase helical CT and endoscopic sonography.
        AJR Am J Roentgenol. 1998; 170: 1315-1322
        • Kubo H.
        • Chijiiwa Y.
        • Akahoshi K.
        • et al.
        Pre-operative staging of ampullary tumours by endoscopic ultrasound.
        Br J Radiol. 1999; 72: 443-447