Is Endoscopic Papillectomy Safe for Ampullary Adenomas with High-Grade Dysplasia?

Abstract

Objectives. This study was designed to provide safe management guidelines for ampullary adenoma by analysis of clinicopathological features. Background. The treatment of ampullary cancer has been established; however, the indications for treatment of ampullary adenoma remain controversial. Methods. Between July 1997 and July 2008, a total of 33 patients were diagnosed with ampullary adenoma prior to procedures: 20 endoscopic papillectomies (ESP), 5 transduodenal resections (TDR), and 8 pancreatoduodenectomies (PD). Results. The false-negative rate of biopsy for cancer was 27.5% (8/29). Coexistence of cancer in patients with prehigh-grade dysplasia (HGD) was 50.0% (5/10), whereas it was 15.7% in pre-low-grade dysplasia (LGD). In addition, the rate of recurrence was 80% (8/10) in patients with pre-HGD. The size of tumor by final pathology was 1.27 ± 0.89 cm in LGD, 1.81 ± 0.99 cm in HGD, and 1.98 ± 1.08 cm in cancer group. There was a significant correlation between size of tumor and final pathology (P = 0.036). According to receiver operating characteristic (ROC) curve, criterion to predict HGD/cancer was tumor size larger than 1.5 cm; sensitivity and specificity were 55.6% and 80.0%, respectively, and likelihood ratio was 2.778. However, size of tumor was not associated with preprocedural pathology. Conclusions. Ampullary adenoma with preprocedural HGD was highly associated with coexistence of cancer and recurrence. Moreover, most of large tumors were treated by surgical procedures and proved to be cancer. Therefore, we suggest that ampullary adenoma with preprocedural HGD or more than 1.5 cm should not be managed with endoscopic papillectomy due to high associated rates of recurrence.Since 1935, pancreatoduodenectomy (PD) has been used as the treatment of choice for periampullary tumors.1,2 For the treatment of ampullary cancer, Beger et al. reported that oncological resection of ampullary cancer by means of PD is the surgical procedure of choice; the 3-and 5-year survival rates were 72% and 52%, respectively.3 Moreover, Yoon et al. reported that PD should preferably be performed even in early ampullary cancer. 4 The management criteria for ampullary cancer have already been established.As a noninvasive treatment, transduodenal resection (TDR) is usually indicated in patients with high operative risk.3 However, most surgeons have no great desire to try local resection of ampullary tumors, because of high recurrence rate and lack of established management criteria. Recently, endoscopic papillectomy (ESP) has been accepted as an alternative therapy to surgery in ampullary adenoma. According to some studies, the tumor size criterion for endoscopic papillectomy is up to 4-4.5 cm. [5][6][7] Nevertheless, ampullary adenoma is considered as a precancerous lesion, and the rate of development of carcinoma has been shown to be 30%. 8 Moreover, the coexistence of carcinoma within adenoma cannot be excluded by preprocedural biopsy. 9,10 As described above, the management strategies for ampulla adenoma are expanding...

Diagnostic Ability of Diffusion-weighted Magnetic Resonance Imaging to Discriminate Ampullary Neoplasms: A Preliminary Study of 15 Cases

“…We recognize that our current management algorithm for ampullary lesions, which includes EP, should be considered challenging at this stage because the occurrence rate of potentially life-threatening complications in patients receiving EP is reported to be markedly higher than in those who underwent endoscopic resection of gastric or colonic lesion, and the efficacy of EP remains unjustifiable [1][2][3][4] . Furthermore, it is uncertain which of the following should be applied for a salvage procedure when the ampullectomy margin is positive for tumor, i.e., repeat endoscopic resection, transduodenal resection, or PD [1][2][3][4] .…”

“…Furthermore, it is uncertain which of the following should be applied for a salvage procedure when the ampullectomy margin is positive for tumor, i.e., repeat endoscopic resection, transduodenal resection, or PD [1][2][3][4] . Thus it is difficult to state that EP is an established treatment procedure.…”

“…EP is obviously a more complicated procedure and thus considered to adversely affect the adjacent tissues more than biliary stenting alone, suggesting that PD following ampullectomy could be more technically difficult than PD without prior ampullectomy. Conversely, it is obviously excessive if PD is applied for localized adenoma with low-grade dysplasia [1][2][3][4] . In other words, an inappropriate choice of treatment procedure would have a markedly larger impact on the clinical course in patients with ampullary lesions than in patients with early gastric or colonic cancer, both of which are often treated endoscopically [1][2][3][4][16][17][18] ; thus, accurate preprocedural diagnosis is essential for avoiding such an inappropriate choice.…”

“…Ampullary neoplasms occur rarely and have a complex anatomy, making it difficult to accomplish accurate preprocedural diagnosis [1][2][3][4] . The primary cause of this difficulty is the diagnostic uncertainty of endoscopic biopsy for ampullary lesions ; i.e., false-negative findings for cancer are frequent in the ampulla of Vater [1][2][3][4] .…”

“…The primary cause of this difficulty is the diagnostic uncertainty of endoscopic biopsy for ampullary lesions ; i.e., false-negative findings for cancer are frequent in the ampulla of Vater [1][2][3][4] . Consequently, inappropriate treatment procedures are sometimes performed including pancreaticoduodenectomy PD for localized adenoma and ampullectomy for hyperplasia or invasive adenocarcinoma [1][2][3][4] . Therefore, a more reliable method of endoscopic biopsy and / or better supplemental diagnostic tools are needed to achieve more accurate preprocedural diagnoses of ampullary lesions.…”