Clinicopathologic analysis of early ampullary cancers with a focus on the feasibility of ampullectomy

Abstract

Objective: The purpose of this study was to evaluate whether ampullectomy can substitute for pancreatoduodenectomy (PD) in early ampullary cancer by clinicopathologic study.

Summary background data: Although ampullectomy has been attempted in early ampullary cancer (pTis, pT1), the indication and extent of resection have not been established.

Methods: Of 201 patients who had undergone PD for ampullary cancer between 1986 and 2002, 67 patients with a histologic diagnosis of pTis (n = 5) or pT1 (n = 62) cancer were analyzed retrospectively. Pathologic PD specimens were reviewed to analyze the cancer spread pattern, and medical records were reviewed for clinical outcomes.

Results: The 5-year survival rate of the 66 patients with early ampullary cancer (excluding one mortality) was 83.7%. Recurrence was confirmed in 12 patients (18.2%) and all died because of the recurrence. Pathologic review showed that 22 patients (32.8%) had at least one risk factor for failure after ampullectomy: lymph node metastasis (n = 6, 9.0%), perineural invasion (n = 1), or mucosal tumor infiltration along the CBD or P-duct (n = 15, 22.4%). Mean lengths of invasion into the CBD or the P-duct beyond the sphincter of Oddi were 7.7 mm (range, 1-25 mm) or 6.3 mm (range, 2-18 mm), respectively. Moreover, these risk factors were not correlated with tumor size, histologic grade, or the gross morphology of the primary tumor, although pTis cancer or pT1 cancer sized 1.0 cm or less was found to be least associated with risk factors.

Conclusions: Ampullectomy for early ampullary cancer should not be considered an alternative operation to PD because of the high possibility of recurrence. PD should be preferably performed for adequate radical resection, even in early ampullary cancer, and ampullectomy should be reserved for those who have pTis or pT1 cancer sized 1.0 cm or less with high operative risk.

FIGURE 1. A, Surgical specimen after PD, which was resected for CBD and P-duct visualization at the same cross section. B, Schematic drawing of the rectangular area in A, showing mucosal tumor infiltration into the CBD and the P-duct of early ampullary cancer. One expert pathologist measured the length from the proximal end of the sphincter of Oddi to the upper limit of the mucosal tumor (*arrows).

FIGURE 2. Overall survival of 199 patients with ampullary cancer after pancreatoduodenectomy (analysis excluded 2 operative mortality cases).

FIGURE 3. Comparison of survival according to the depth of invasion. Significant differences were found between early ampullary cancers (pTis, pT1) and other T stage cancers (pT2, pT3, pT4) (P < 0.001).

FIGURE 4. Photomicrograph showing pT1 ampullary cancer extending proximally along the mucosal layer of the CBD. Arrows indicate the extent of tumor infiltration and the arrowhead shows the end of the sphincter of Oddi.