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Focal early stage cancer in ampullary adenoma: surgery or endoscopic papillectomy?
Soon Man Yoon1, Myung-Hwan Kim, Mi Jung Kim
1Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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.
