To evaluate the diagnostic accuracy of four imaging criteria obtained with a tailored duodenal MDCT to differentiate non-ampullary duodenal carcinoma (NADC) and intestinal-type ampullary carcinoma (ITAC).

In this retrospective single-center study, patients with resected ITAC and NADC who underwent preoperative contrast-enhanced MDCT using a tailored duodenal protocol were included. Three radiologists independently reviewed each MDCT, using four imaging criteria to differentiate the two cancer types: lesion shape, ductal cutoff, duodenopancreatic groove fixation and pancreatico-duodenal artery infiltration. Sensitivity, specificity, positive and negative predictive values of the imaging criteria were calculated using histopathologic analysis as the reference standard. Interobserver agreements were assessed using kappa statistics.

57 patients (mean age 55 years ± 18.2 (standard deviation); 25 women) were included in the study. ITAC was significantly different in terms of lesion shape (p < 0.0001) and duodenopancreatic groove fixation (p < 0.0007). Sensitivity and specificity of the lesion shape for the three readers were 47-66%, 83-92% (κ = 0.72); of the ductal cutoff were 24-52%, 61-71% (κ = 0.52); of the duodenopancreatic groove fixation were 54-73%, 86-93% (κ = 0.81); of the pancreatico-duodenal artery infiltration were 19-28%, 48-52% (κ = 0.44). When all features were taken into account, sensitivity and specificity in differentiating between ITAC vs NADC were 85.7% and 83.3%.

The lesion shape and duodenopancreatic groove fixation have high specificity and moderate/strong interreader agreement for preoperative differentiation of ITAC and NADC on tailored duodenal MDCT.

Question Preoperative differentiation of non-ampullary duodenal carcinoma and intestinal-type ampullary carcinoma has potential implications on patients' management. Findings Two imaging criteria acquired on a tailored duodenal CT allowed to differentiate between intestinal-type ampullary carcinoma non-ampullary duodenal carcinoma with > 80% sensitivity and specificity. Clinical relevance A tailored duodenal CT is a reliable tool to differentiate between intestinal-type ampullary carcinoma and non-ampullary duodenal carcinoma, with potential treatment implications.

To investigate the added value of using contrast-enhanced magnetic resonance imaging (MRI) in conjunction with contrast-enhanced computed tomography (CT) for differentiating malignant and benign ampullary strictures.

The present retrospective study included 90 patients with ampullary strictures who underwent preoperative contrast-enhanced CT and contrast-enhanced MRI at two tertiary institutions. The image sets (i.e., CT alone vs. combined CT and MRI) were evaluated by three abdominal radiologists, who used a five-point Likert scale to score their confidence for diagnosing malignancy in patients with ampullary strictures. Diagnostic accuracy was calculated using receiver-operating characteristic (ROC) curve analysis, sensitivity, specificity, and accuracy. Additionally, interobserver agreement regarding the scoring of potential malignancies of the ampullary strictures was assessed.

The addition of contrast-enhanced MRI to contrast-enhanced CT showed a significant improvement in predicting malignant ampullary strictures in all three observers (p = 0.007, 0.001, and 0.002) using ROC curve analysis, and a significant improvement was observed in diagnostic sensitivity and accuracy for predicting malignancy (p = 0.016 and 0.029 for observer 1; p = 0.023 and 0.010 for observer 2; and p = 0.010 and 0.011 for observer 3). The interobserver agreement for the five-point scale in determining malignancies of the ampullary strictures was 0.86 for CT alone and 0.93 for the combined set of CT and MRI.

The addition of contrast-enhanced MRI to CT provided added value for differentiating malignant from benign ampullary strictures.

To construct a predictive nomogram based on contrast-enhanced magnetic resonance imaging (MRI) and clinical findings for differentiating malignant from benign ampullary strictures.

In this retrospective study, 76 patients with ampullary strictures (51 benign and 25 malignant) who underwent contrast-enhanced MRI were enrolled. Imaging findings were evaluated independently by two abdominal radiologists who reached consensus. Clinical findings were also collected. Significant findings for malignant ampullary strictures were assessed by univariable and multivariable logistic regression analyses. Based on the results of multivariable analysis, a nomogram to differentiate malignant from benign ampullary strictures was developed and internally validated.

In multivariable analysis, presence of an ampullary mass (odds ratio [OR]: 8.42, p = 0.047), bulging ampulla (OR: 8.32, p = 0.033), diffusion restriction of the ampulla (OR: 42.76, p = 0.004) on MRI, and jaundice (OR: 12.41, p = 0.019) were significant predictors of malignant ampullary strictures. A predictive nomogram was constructed using these findings. Among them, diffusion restriction of the ampulla showed the highest OR and predictor score on the nomogram. The calibration plots for internal validation achieved strong agreement between the predicted probabilities and the actual rates of malignant ampullary strictures.

A combination of significant contrast-enhanced MRI and clinical findings of ampullary mass, bulging ampulla, diffusion restriction of the ampulla, and jaundice may be useful in the prediction of malignant ampullary stricture.

To construct a predictive nomogram for differentiating malignant from benign ampullary strictures using contrast-enhanced computed tomography (CT) findings combined with clinical findings.

In this retrospective study, 152 patients with ampullary stricture (98 benign and 54 malignant) who underwent contrast-enhanced CT were included. Various imaging findings of the ampulla, bile duct, main pancreatic duct, and periampullary area were evaluated and clinical findings including the presence of jaundice, carbohydrate antigen 19-9 level, and history of cholecystectomy were collected. Among them, statistically significant findings were identified using univariable and multivariable logistic regression analyses. A nomogram was constructed to differentiate benign and malignant ampullary strictures and was internally validated.

Multivariable analysis revealed that jaundice (odds ratio [OR]: 17.33, p < 0.001), presence of an ampullary mass (OR: 24.40, p < 0.001), non-similar enhancement of the ampulla to the duodenum (OR: 31.96, p = 0.003), and proportional dilatation of the bile duct (OR: 7.98, p = 0.001) were independent significant factors for predicting the malignant ampullary stricture, and were used to construct a nomogram. Among them, non-similar enhancement of the ampulla to the duodenum showed the highest OR and predictor point on the nomogram. The calibration plots showed excellent agreement between the predicted probabilities and the actual rates of malignant ampullary strictures, on internal validation.

Combination of clinical and imaging findings could aid in predicting malignant ampullary strictures using significant findings of jaundice, presence of ampullary mass, non-similar enhancement of the ampulla to the duodenum, and proportional dilatation of the bile duct.

• The presence of jaundice, ampullary mass, non-similar enhancement of the ampulla, and proportional bile duct dilatation were significant findings for predicting malignant ampullary strictures. • Non-similar enhancement of the ampulla to the duodenum was a significant feature with the highest odds ratio for differentiating benign and malignant ampullary strictures. • The nomogram constructed using contrast-enhanced computed tomography imaging and clinical findings could aid in predicting malignant ampullary strictures.

To stratify and weigh the computed tomography (CT) imaging and clinical features differentiating a neoplastic ampullary obstruction from a non-neoplastic ampullary obstruction and to develop a nomogram for estimating individualized risk of neoplastic potential in patients with a suspected ampulla of Vater (AOV) lesion on CT.

135 patients (92 non-neoplastic and 43 neoplastic) with a suspected ampullary obstruction on a CT scan between February 2015 and May 2019 were included after the exclusion criteria were applied. Significant imaging and clinical findings of the neoplastic lesions were assessed using univariate and multivariate logistic regression analyses. Based on the significant variables in the multivariate analysis, a nomogram was developed to predict neoplastic potential in patients suspected of ampullary obstruction. The area under the receiver operating characteristic curve (AUC) was used to assess the diagnostic value in the external validation cohort (36 non-neoplastic and 13 neoplastic).

The multivariate analysis revealed that the presence of an AOV mass (odds ratio (OR), 77.21; 95% confidence intervals (CI) 1.51-3950.38), AOV size > 12 mm (OR, 23.93; 95% CI 2.96-193.60), total bilirubin > 1.2 mg/dl (OR, 9.99; 95% CI 1.37-73.06) and age ≤ 63 years (OR, 7.52; 95% CI 1.33-42.48) were independent significant parameters that predicted a neoplastic lesion in the AOV. The AUC for the nomogram was 0.93 on the internal validation and 0.91 (95% CI 0.79-0.97) on the external validation.

A nomogram using imaging and clinical findings was useful to estimate a neoplastic ampullary obstruction in patients with a suspected AOV lesion on CT and suggests a further evaluation.

To determine the multidetector CT (MDCT) findings that differentiate adenomyoma of the ampulla of Vater (AOV) from localized adenocarcinoma of the AOV.

Sixteen and 30 patients with adenomyoma and localized adenocarcinoma of the AOV, respectively, were evaluated using MDCT. We analyzed the size and attenuation value and presence of uniform enhancement of the lesions, diameters of the extrahepatic bile duct (EHD) and main pancreatic duct, presence of regional lymph node enlargement, and laboratory findings. We determined the independent findings for differentiating adenomyoma from localized adenocarcinoma of the AOV using multivariate analysis.

The size of the lesion and diameter of the EHD were significantly smaller for adenomyoma than those for localized adenocarcinoma of the AOV (all p < 0.001). In multivariate analyses, a lesion size of ≤ 1.3 cm, an EHD diameter of ≤ 1.3 cm, and an alanine transaminase level of ≤ 31 IU/L significantly differentiated adenomyoma from localized adenocarcinoma of the AOV. When all of these three findings were met, the specificity for adenomyoma of the AOV was 93.3%.

MDCT imaging may facilitate the differential diagnosis of adenomyoma and localized adenocarcinoma of the AOV based on the size of the lesion and diameter of the EHD.

Identifying the accurate origin of periampullary cancers is important because different origins may trigger different clinicopathological behaviors. The presence of intraepithelial precursor lesions, including high-grade pancreatic intraepithelial neoplasias (PanINs) and/or high-grade biliary intraepithelial neoplasias (BilINs), may be suggestive of the origin of the periampullary carcinoma in challenging cases. To prove the usefulness of high-grade intraepithelial precursor lesions in identifying the origin of ambiguous periampullary cancers, the status and grades of PanINs and BilINs were evaluated in 256 periampullary carcinomas with a well-defined cancer origin as a test set, including 114 pancreatic cancers, 82 distal bile duct cancers, 54 ampullary cancers, and 6 duodenal cancers. One hundred twelve periampullary carcinomas with clinically equivocal epicenter either by radiologic imaging or by endoscopic finding used as a validation set. High-grade PanINs were found more commonly in pancreatic cancers than in distal bile duct, ampullary, and duodenal cancers both in test (P = .002) and validation sets (P < .001). Similarly, high-grade BilINs were identified more frequently in distal bile duct cancers than in ampullary, pancreatic, and duodenal cancers both in test (P < .001) and validation sets (P = .039). High-grade PanINs were found most commonly in pancreatic cancers, whereas high-grade BilINs were seen most frequently in distal bile duct cancers. In addition, both high-grade PanINs and high-grade BilINs are uncommonly noted in ampullary or duodenal cancers. The recognition of high-grade intraepithelial lesions can help identify the primary origin of periampullary cancers, especially when the epicenter of the periampullary cancer is ambiguous.

The purpose of this study was to evaluate the utility of ampullary MDCT in the noninvasive, preoperative differentiation of pancreatobiliary and intestinal subtypes of ampullary adenocarcinoma.

This retrospective study included 32 patients (20 men, 12 women; age range, 41-81 years) with resected ampullary adenocarcinoma who underwent preoperative contrast-enhanced ampullary MDCT. Two radiologists, blinded to pathologic diagnosis of adenocarcinoma subtype, evaluated the presence of seven MDCT features independently. MDCT findings and ampullary adenocarcinoma subtypes were correlated using chi-square and Fisher exact tests. Interobserver agreement was evaluated using the Cohen kappa statistic.

When evaluated with ampullary MDCT, the intestinal and pancreatobiliary subtypes were significantly different in terms of lesion morphology (p < 0.0001), papillary shape (p < 0.0001), common bile duct (CBD) infiltration and dilatation (p = 0.003 and p = 0.0004, respectively), duodenopancreatic groove infiltration (p = 0.0009), and pancreaticoduodenal artery involvement (p = 0.004). Pancreatobiliary subtype tumors were more often infiltrative in morphology (18/18) and showed retracted papilla (14/18), CBD (18/18) and main pancreatic duct (MPD) infiltration (12/18), dilated CBD (18/18) and MPD (13/18), fixed duodenopancreatic groove appearance (15/18), and pancreaticoduodenal artery involvement (12/18). Intestinal subtype carcinomas were more frequently nodular (14/14) and had a bulging papilla (13/14), a free duodenopancreatic groove appearance (11/14), and no pancreaticoduodenal artery involvement (2/14). When all features were taken into account, MDCT showed sensitivity of 85.7% and specificity of 83.3% in differentiating intestinal and pancreatobiliary subtype tumors. Accuracy, positive predictive value, and negative predictive value of MDCT were 84.4%, 80%, and 88.2%, respectively. Interobserver agreement was almost perfect for the presence of each imaging feature (κ > 0.8).

Ampullary MDCT can be useful to differentiate pancreatobiliary and intestinal subtypes of ampullary adenocarcinoma preoperatively, provided the duodenum is optimally distended at imaging.

The purpose of this two-part article is to review the cross-sectional anatomy of the ampulla and periampullary region, to propose novel and optimized MDCT and MRI techniques that allow accurate evaluation of the ampulla of Vater, and to summarize the cross-sectional imaging features of benign and malignant ampullary conditions. In this first part, we will review the normal anatomy of the ampullary region, provide suggestions on how to optimize evaluation of the ampullary region by MDCT and MRI, and review the imaging features of select epithelial neoplasms of the ampulla. Familiarity with the normal ampullary anatomy and the pathologic conditions involving the ampulla, as well as the use of optimized MDCT and MRI techniques, may improve the diagnostic accuracy of radiologists facing ampullary abnormalities.

To investigate the added value of diffusion-weighted imaging (DWI) when used with conventional T2-weighted magnetic resonance (MR) imaging (T2WI) and MR cholangiopancreatography (MRCP) for diagnosing bile duct dilatations.

Our institutional review board approved this retrospective study protocol and waived the informed consent requirement. The study included 151 consecutive patients (70 men, 81 women) with intra- and/or extra-hepatic bile duct dilatation examined using MR imaging. Two radiologists independently and randomly reviewed 3 image sets (A: MRCP and T2WI; B: DWI; and C: combined T2WI, MRCP, and DWI) at different occasions to differentiate between malignancy, biliary lithiasis, and benign dilatation. The sensitivity, specificity, and diagnostic accuracy of these imaging sets were calculated and compared.

For both readers, combined T2WI, MRCP, and DWI exhibited significantly higher sensitivity and diagnostic accuracy for malignant dilatation, compared with conventional T2WI and MRCP (P < 0.01 for both readers). However, DWI did not significantly affect the sensitivity and diagnostic accuracy for biliary lithiasis or benign dilatation.

The addition of DWI to T2WI and MRCP sequences yields significantly higher sensitivity and diagnostic accuracy when examining bile duct dilatations, particularly malignant dilatations.

Bile duct strictures in adults are secondary to a wide spectrum of benign and malignant pathologic conditions. Benign causes of bile duct strictures include iatrogenic causes, acute or chronic pancreatitis, choledocholithiasis, primary sclerosing cholangitis, IgG4-related sclerosing cholangitis, liver transplantation, recurrent pyogenic cholangitis, Mirizzi syndrome, acquired immunodeficiency syndrome cholangiopathy, and sphincter of Oddi dysfunction. Malignant causes include cholangiocarcinoma, pancreatic adenocarcinoma, and periampullary carcinomas. Rare causes include biliary inflammatory pseudotumor, gallbladder carcinoma, hepatocellular carcinoma, metastases to bile ducts, and extrinsic bile duct compression secondary to periportal or peripancreatic lymphadenopathy. Contrast material-enhanced magnetic resonance (MR) imaging with MR cholangiopancreatography is extremely helpful in the noninvasive evaluation of patients with obstructive jaundice, an obstructive pattern of liver function, or incidentally detected biliary duct dilatation. Some of these conditions may show characteristic findings at MR imaging-MR cholangiopancreatography that help in making a definitive diagnosis. Although endoscopic retrograde cholangiopancreatography with tissue biopsy or surgery is needed for the definitive diagnosis of many of these strictures, certain MR imaging characteristics of the narrowed segment (eg, thickened wall, long-segment involvement, asymmetry, indistinct outer margin, luminal irregularity, hyperenhancement relative to the liver parenchyma) may favor a malignant cause. Awareness of the various causes of bile duct strictures in adults and familiarity with their appearances at MR imaging-MR cholangiopancreatography are important for accurate diagnosis and optimal patient management.

Ampullary cancer is a relatively rare cancer of the digestive tract. In contrast to pancreatic cancer, ampullary cancer is often curable if detected at an early stage. The evaluation and management of ampullary cancer is similar to, but distinct from, that of other pancreaticobiliary tumors. This manuscript will review the current evaluation, diagnosis, and therapy of patients with ampullary cancer. The diagnosis of ampullary cancer is complicated by its similar clinical presentation to pancreatic cancer as well as its nonspecific laboratory findings. Diagnostic modalities such as ERCP, EUS, and biopsy are necessary for differentiating the 2 cancers, and noninvasive imaging techniques such as MRI and CT may be used for tumor staging. Although pancreaticoduodenectomy is considered the primary curative surgical option, consensus guidelines regarding adjuvant and neoadjuvant chemoradiation therapies are lacking.

Ampullary adenocarcinoma is considered to have a better prognosis than either pancreatic or bile duct adenocarcinoma. Pancreaticoduodenectomy is associated with significant mortality and morbidity. Some recent publications have advocated the use of endoscopic papillectomy for the treatment of early ampullary adenocarcinoma. This article reviews investigations and surgical treatment options of ampullary tumours.

A systematic review of English-language articles was carried out using an electronic search of the Ovid MEDLINE (from 1996 onwards), PubMed and Cochrane Database of Systematic Reviews databases to identify studies related to the investigation and management of ampullary tumours.

Distinguishing between ampullary adenoma and adenocarcinoma is challenging given the inaccuracy of endoscopic biopsy, for which high false negative rates of 25-50% have been reported. Endoscopic ultrasound is the most accurate method for local staging of ampullary lesions, but distinguishing between T1 and T2 adenocarcinomas is difficult. Lymph node metastasis occurs early in the disease process; it is lowest for T1 tumours, but the risk is still high at 8-45%. Case reports of successful endoscopic resection and transduodenal ampullectomy of T1 adenocarcinomas have been published, but their duration of follow-up is limited.

Optimal staging should be used to distinguish between ampullary adenoma and adenocarcinoma. Pancreaticoduodenectomy remains the treatment of choice for all ampullary adenocarcinomas.

To evaluate the added value of diffusion-weighted magnetic resonance (MR) imaging in diagnostic performance of conventional MR imaging for diagnosis of ampullary carcinoma.

This retrospective study was institutional review board approved, and informed consent was waived. Twenty-three patients with malignant ampullary obstruction and 39 patients with benign ampullary obstruction were included. Qualitative (signal intensity and enhancement pattern) and quantitative (apparent diffusion coefficient [ADC]) analyses were conducted for visible or expected locations of duodenal papillae. Two observers independently reviewed conventional MR images and subsequently reviewed combined conventional and diffusion-weighted MR images. A five-point scale for likelihood of ampullary carcinoma was used. Fisher exact test and Mann-Whitney U test were used for comparing groups, and diagnostic performance (receiver operating characteristic [ROC] curve analysis), accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were evaluated.

Visible or expected duodenal papillae in benign group showed isointensity (27-38 of 39, 69%-97%) and similar enhancement pattern (27 of 39, 69%) to that of normal duodenal wall more frequently than in malignant group (seven to 18 of 23 [30%-78%] and three of 23 [13%], respectively) on conventional MR images (P < .05). On diffusion-weighted images, 21 of 23 (91%) ampullary carcinomas showed hyperintensity, whereas all benign cases showed isointensity compared with normal duodenal wall (P < .001). Mean ADC of ampullary carcinomas (1.23 × 10(-3) mm(2)/sec) was significantly lower than that of benign group (1.69 × 10(-3) mm(2)/sec) (P < .001). Diagnostic performance (area under ROC curve [Az]) of both observers improved significantly after additional review of diffusion-weighted images; Az improved from 0.923 to 0.992 (P = .029) for observer 1 and from 0.910 to 0.992 (P = .025) for observer 2. In addition, diagnostic accuracy, sensitivity, specificity, PPV, and NPV of combined conventional and diffusion-weighted MR images were higher than those of conventional MR images alone.

Addition of diffusion-weighted imaging to conventional MR imaging improves detection of ampullary carcinoma when compared with conventional MR imaging alone.

To investigate the value of DWI for differentiating malignant from benign strictures in the periampullary region.

We retrospectively analysed data from 78 patients who had undergone magnetic resonance cholangiopanreatography (MRCP) and diffusion-weighted imaging (DWI), in whom biliary strictures in the periampullary region were suspected. Twenty-two malignant and 56 benign lesions were included. One radiologist compared the signal intensity of malignant and benign periampullary lesions on DWI using b = 500 and 800 s/mm(2). The signal intensity of bile was also compared, and an optimal b value was determined for periampullary lesions. Two other radiologists reviewed MRCP alone and combined DWI and MRCP for the possibility of malignant periampullary lesions. Diagnostic accuracy was calculated for each reviewer by receiver operating characteristic (ROC) curve analysis.

Malignant periampullary lesions more frequently appeared hyperintense than benign lesions on DWI using the two b values (P < 0.001). Bile more frequently appeared hyperintense on DWI using b = 500 s/mm(2) (87.2 %) than b = 800 s/mm(2) (24.4 %). Therefore, b = 800 s/mm(2) was determined as the preferred sequence. Diagnostic accuracy for malignant periampullary lesions improved for both reviewers after adding DWI; from 0.714 to 0.924 (P = 0.006, for reviewer 1) and from 0.714 to 0.919 (P = 0.007, reviewer 2).

Combined DWI with MRCP can improve the diagnostic accuracy for differentiating malignant from benign strictures in the periampullary region.

• Diffusion-weighted magnetic resonance imaging provides yet more information about hepatobiliary structures. • Diffusion-weighted imaging (DWI) has now been applied to the biliary tree. • Most periampullary carcinomas appear hyperintense on high b value DWI. • DWI can help differentiate between malignant and benign periampullary lesions.