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

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.