Focal early stage cancer in ampullary adenoma: surgery or endoscopic papillectomy?

doi:10.1016/j.gie.2007.02.049

Gastrointestinal Endoscopy

Volume 66, Issue 4, October 2007, Pages 701-707

https://doi.org/10.1016/j.gie.2007.02.049 Get rights and content

Background

Recently, the evidence has been accumulating that endoscopic resection may be curative in treating ampullary adenoma that contains high-grade intraepithelial neoplasia/in situ tumor (HGIN/Tis). However, there are only anecdotal reports of endoscopic management of “focal” T1 ampullary cancer (T1 cancer), and radical surgery is still considered the only accepted treatment modality.

Objective

To assess the possibility of endoscopic papillectomy as an alternative to radical surgery for the treatment of ampullary adenoma with HGIN/Tis or focal T1 cancer.

Design

Retrospective evaluation of case series of our hospital from 1996 to 2006.

Setting

Tertiary-care university teaching hospital.

Patients

Twenty-three patients who had HGIN/Tis or focal T1 cancer in ampullary adenoma resected by endoscopic papillectomy and 60 patients who initially underwent radical surgery for HGIN/Tis or T1 cancer of the ampulla of Vater. “Focal” was defined as a lesion involving only mucosa, with a size less than a fourth the diameter of main adenoma.

Interventions

Review of medical records and analysis of surgically or endoscopically resected specimens of ampullary tumors.

Main Outcome Measurements

Locoregional extension and follow-up data.

Results

Patients with HGIN/Tis of the ampulla of Vater had no lymphovascular invasion or lymph-node metastasis, and there were no occurrences of cancer or deaths during a mean (standard error [±SE]) 27.1 ± 5.9 months after endoscopic papillectomy. T1 cancer was shown to have lymphovascular invasion and/or lymph-node metastasis in 10.7% and duct mucosal involvement in another 17.9%. Among them, patients with focal T1 cancer showed no lymphovascular invasion or lymph-node metastasis and no ductal involvement, and none of the patients who underwent endoscopic papillectomy alone had cancer recurrence or disease-related death for mean (±SE) 32.2 ± 6.7 months.

Limitations

Single-center, retrospective study, small number of patients, and medium-term follow-up period.

Conclusions

Endoscopic papillectomy may be a curative treatment for ampullary adenoma with HGIN/Tis and should also be considered as an alternative to surgery in focal T1 cancer in ampullary adenoma.

Section snippets

Patients and methods

From the computerized database of our institution, we identified 439 patients with adenoma or carcinoma of the ampulla of Vater diagnosed and treated between April 1996 and March 2006. Of these 439 patients, 371 patients underwent surgery and 68 patients underwent endoscopic papillectomy.

Of the 68 patients who underwent endoscopic papillectomy for ampullary adenoma, 23 patients were found to have HGIN/Tis or focal T1 cancer in the endoscopically resected specimens. Seven patients underwent

Histopathologic findings

In the 13 patients who had focal HGIN/Tis in resected adenoma after endoscopic papillectomy, all patients had clear resection margins and the mean (±SE) tumor size was 1.8 ± 0.3 cm. Of these 13 patients, 3 patients who underwent additional surgery showed no signs of residual adenoma or cancer, as well as an absence of lymphovascular invasion or lymph-node metastasis in the surgically resected specimens.

Eight patients who initially underwent surgery for HGIN/Tis also had no evidence of

Discussion

Currently, much evidence has already accumulated to suggest that endoscopic papillectomy can be used as a first-line therapy for adenoma of the ampulla of Vater.1, 2, 3, 4, 5, 6, 8, 14, 15 In addition, for patients with ampullary adenoma that contains HGIN/Tis, endoscopic papillectomy is increasingly being regarded as the curative therapeutic approach in place of surgical resection, although data supporting it are not yet numerous.² For ampullary adenoma that contains focal T1 cancer, however,

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Original Article: Clinical EndoscopyFocal early stage cancer in ampullary adenoma: surgery or endoscopic papillectomy?

Background

Objective

Design

Setting

Patients

Interventions

Main Outcome Measurements

Results

Limitations

Conclusions

Section snippets

Patients and methods

Histopathologic findings

Discussion

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc Clin N Am

Gastrointest Endosc

Gastrointest Endosc

Eur J Surg Oncol

Gastrointest Endosc

Gastrointest Endosc

Indication of endoscopic papillectomy for tumors of the papilla of Vater and its problems

Dig Endosc

Still any role for transduodenal local excision in tumors of the papilla of Vater?

J Hepatobiliary Pancreat Surg

Endoscopic resection for neoplastic diseases of the papilla of Vater

J Hepatobiliary Pancreat Surg

Endoscopic resection of benign tumors of the papilla of Vater

Endoscopy

Ampullary tumors: endoscopic versus operative management

Surg Innov

Original Article: Clinical Endoscopy
Focal early stage cancer in ampullary adenoma: surgery or endoscopic papillectomy?