A single-institution review of 157 patients presenting with benign and malignant tumors of the ampulla of Vater

Abstract

Background Although benign ampullary tumors are removed endoscopically, due to their potential to progress to malignant disease, the favored treatment for adenocarcinoma is pancreaticoduodenectomy. We reviewed our institution's experience in order to identify which patients were at highest risk of disease progression following surgical resection, as well as evaluate whether localized T1 tumors are best treated by pancreaticoduodenectomy.

Methods We retrospectively reviewed 157 patients who presented with an ampullary mass, from 2001 to 2010, and identified 51 with benign adenoma and 106 with adenocarcinoma.

Results Patients with malignant tumors most often presented with larger tumors and jaundice, which alone was predictive of survival (OR = 67). Forty-five percent of patients with pathologically confirmed T1 tumors had positive lymph nodes and median survival was modest at 60 months. Lymph node involvement was predictive of recurrence and decreased survival.

Conclusion Patients with malignant tumors often present with jaundice and larger tumors. These findings should warrant suspicion for cancer and expedited preoperative workup. Based on our finding that nearly half the patients with T1 tumors had positive lymph nodes, we recommend pancreaticoduodenectomy for any patient with biopsy proven adenocarcinoma who is a suitable candidate for surgery. With the exception of individuals with familial adenomatous polyposis (FAP), adenomas of the ampulla of Vater arise sporadically and rarely. These tumors necessitate removal because of their known progression to carcinoma and for relief of symptoms associated with blockage of the ampulla.1 Although they were traditionally treated surgically, advances in endoscopic technique has seen endoscopic papillectomy become an attractive alternative in the removal of benign ampullary adenomas.2 Ampullary adenocarcinomas are widely treated by pancreaticoduodenectomy (PD)3 because of their propensity to spread to lymph nodes and high incidence of recurrence. In some series preoperative endoscopic biopsy has a high rate of false negative results,4 prompting some researchers to recommend PD for all ampullary adenomas. Fit patients with tumors exhibiting high-grade dysplasia or adenocarcinoma are generally treated by PD with low recurrence rates.5 The perioperative mortality rate for PD has declined,6 and is widely accepted at academic care centers where the procedure is routinely performed. For ampullary adenocarcinoma postoperative survival rates are rising. Recent series report 5-year postoperative survival rates of 53–68%.7 Successful endoscopic removal of high-grade intraepithelial neoplasia, in situ tumors, and focal T1 cancers has been reported, but is not widely practiced.8, 9 and 10 For patients with slow-growing benign tumors, endoscopic resection is an attractive alternative with decreased cost and morbidity.11 and 12 Endoscopic papillectomy has a recurrence rate of 30% with 13.9% of endoscopically treated patients subsequently undergoing follow-up surgery. Success rates vary from 80% to 92% but have been high enough to prompt recommendation of endoscopic resection for benign ampullary tumors.13, 14 and 15 Endoscopic papillectomy's relatively low complication rate and the elimination of standard risks associated with surgery are advantageous. The high recurrence rate of the procedure is mitigated by follow-up endoscopic surveillance.2 Can the success of the endoscopic resection be extended to small localized T1 adenocarcinomas? Selection criteria have been suggested and small series and isolated cases in high risk individuals have been reported. Our institutional bias has been to surgically resect all patients with adenocarcinoma unless they are not acceptable surgical candidates. We anticipate that the debate on the roles of surgery and endoscopy in the treatment of small cancerous tumors will likely increase as experience with endoscopic resection increases. This study aims to evaluate the Washington University experience with tumors of the ampulla of Vater and present a strategy for optimal treatment of resectable tumors at the present time.