Feasibility of Endoscopic Papillectomy in Early Stage Ampulla of Vater Cancer

Abstract

Objectives: Traditional treatment for ampullary tumors was surgical procedures including pancreaticoduodenectomy (PD), pylorus-preserving PD (PPPD), and local resection of the ampulla. Endoscopic papillectomy appears to be an effective method for treating ampullary adenomas. The delicate question is about early stage ampullary adenocarcinoma (pTis, pT1). The aim of this study was to indirectly assess the factors to predict malignancy, lymph node metastasis and suggest potential indication of endoscopic papillectomy in ampulla of Vater tumor by analyzing clinicopathologic datas in patents with this disease. Method: We retrospectively evaluated clinocopathologic factors and long term outcome of 235 patients with ampullary cancer and 24 patients with ampullary adenoma diagnosed between 1991 and 2006. Results: In symptoms leading to the diagnosis for ampullary tumor, 14 (58%) of 24 patients with adenoma had no symptoms and were diagnosed incidentally during routine examinations for health checkups. Twelve of 14 patients with no symptom were diagnosed by endoscopy and the statistical difference was significant (p < 0.001). In patients with ampullary adenocarcinoma, 118 patients (50%) were presented with jaundice (p < 0.001) and 104 patients (44%) showed high bilirubin level (>3 mg/dL) (p < 0.001). Endoscopic biopsies missed malignancy in 33 cases (16%). Seventeen cases (71%) of 24 adenomas with high grade and 9 cases (75%) of 12 adenoma with atypism in endoscopic biopsy specimen were adenocarcinomas, whereas two cases (15%) of 13 adenomas with low grade was adenocarcinomas. Tumor size, histologic grade, depth of invasion, common bile duct invasion, angiolymphatic invasion and venous invasion were significantly related with lymph-node metastasis. Early stage ampullary adenocarcinoma less than 2 cm in size and a well-differentiated histology (n = 17) showed no lymph node metastasis and no recurrence during the median follow up period of 35.9 months. Patients with early stage ampullary adenocarcinoma had a significant higher survival rate, compared to pT2 or pT3 stage adenocarcinoma (P = 0.002 and p < 0.001, respectively). The overall 5 year survival rates of early stage, pT2 and pT3 stages adenocarcinomas was 88%, 65% and 56% resepectively. Conclusion: Endoscopic papillectomy can be applied as a viable alternative to surgery in patients with early stage ampullary adenocarcinoma less than 2 cm in size and a well-differentiated histology. When the resected specimen showed a well-differentiated histology, no resection margin involvement, and no angiolymphatic invasion, the subsequent radical surgery is not needed.