Is local resection adequate for T1 stage ampullary cancer?
BACKGROUND
Concerns for morbidity after a pancreaticoduodenectomy (PD) has led to practitioners adopting endoscopic resection or ampullectomy in the treatment of T1 ampullary cancer (AC). It was hypothesized that survival for patients undergoing local resection of AC was inferior to those undergoing a PD.


METHODS
All the data of patients with AC reported in the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2010 were collected. Five-year survival rates according to nodal disease and histological type were compared.


RESULTS
There were 1916 cases of AC; 421 (22%) had T1 disease. Among those with T1 disease, 217 (51%) received endoscopic surveillance, 21 (5%) underwent local resection/ampullectomy, 20 (5%) underwent ampullectomy with regional lymphadenectomy and 163 (39%) underwent PD. For patients with complete nodal staging (PD, n = 163), 35 (22%) had metastatic disease in the nodes. Grade was significantly associated with node positivity (P = 0.007). In multivariate models, survival was improved with either an ampullectomy with regional lymphadenectomy [hazard ratio (HR) 0.19; 95% confidence interval (CI) 0.05-0.61, P < 0.005] or a PD (HR 0.23; 95% CI 0.15-0.36, P < 0.001).


CONCLUSIONS
Patients with T1 AC have a high risk for nodal metastases especially if they are higher-grade lesions. Nodal clearance with a lymphadenectomy or a PD is essential for long-term survival in these patients.
Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
Albert
A
Amini
John T
JT
Miura
Thejus T
TT
Jayakrishnan
Fabian M
FM
Johnston
Susan
S
Tsai
Kathleen K
KK
Christians
T Clark
TC
Gamblin
Kiran K
KK
Turaga
D000230:Adenocarcinoma / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater / Q000473:pathology / Q000601:surgery*; D003138:Common Bile Duct Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016145:Endoscopy, Digestive System; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008197:Lymph Node Excision / Q000009:adverse effects / Q000401:mortality; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000401:mortality; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D018426:SEER Program; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D057832:Watchful Waiting