title: Endoscopic papillectomy and KRAS expression in the treatment of adenoma in the major duodenal papilla.
abstract: OBJECTIVE
  The use of endoscopic papillectomy for resecting adenomas in the major duodenal papilla is increasing. This study focuses on the following three issues: Can endoscopic papillectomy be performed as a safe diagnostic and/or therapeutic procedure in biopsy-verified or suspected ampullary adenoma? Does expression of mutated KRAS in resected adenomatous tissue predict long-term outcome? What other factors may affect long-term outcome and should, therefore, be considered in decision making prior to endoscopic papillectomy?
  
  
  METHODS
  Thirty-six prospectively collected patients who underwent endoscopic papillectomy at Karolinska University Hospital between 2005 and 2014 were analyzed.
  
  
  RESULTS
  The rate of exact agreement between the histomorphological grading of the endoscopic biopsies and the papillectomy specimens was low (48%). Obstructive jaundice at presentation increased the risk of undetected adenocarcinoma (RR = 3.98; 95% CI = 1.46-10.85, p = 0.007). Lesions with malignancies were significantly larger (mean 30.6 mm) than those where only adenomas were found (mean 14.4 mm, p = 0.001). Mutated KRAS was detected in 9 of the 36 post-papillectomy specimens, including 4 of the 5 cases of ampullary adenocarcinoma. Eighteen cases were endoscopically cured after a mean follow-up period of 47 months (range 16-92 months).
  
  
  CONCLUSIONS
  Endoscopic papillectomy is a valuable staging tool because of the limitations of endoscopic biopsy. Endoscopic papillectomy concomitantly offers a curative treatment for most patients with adenoma in the major duodenal papilla. Jaundice at presentation and large adenomas may indicate the presence of more advanced disease. Determination of mutated KRAS seems to be of limited value in predicting long-term outcome.
authors.affiliation: Centre for Digestive Diseases, Karolinska University Hospital and Division of Surgery, CLINTEC, Karolinska Institutet , Stockholm , Sweden.
authors.forename: Erik
authors.initials: E
authors.lastname: Haraldsson
authors.forename: Fredrik
authors.initials: F
authors.lastname: Swahn
authors.forename: Caroline
authors.initials: C
authors.lastname: Verbeke
authors.forename: Johanna S M
authors.initials: JS
authors.lastname: Mattsson
authors.forename: Lars
authors.initials: L
authors.lastname: Enochsson
authors.forename: Kjell-Arne
authors.initials: KA
authors.lastname: Ung
authors.forename: Lars
authors.initials: L
authors.lastname: Lundell
authors.forename: Rainer
authors.initials: R
authors.lastname: Heuchel
authors.forename: J-Matthias
authors.initials: JM
authors.lastname: Löhr
authors.forename: Urban
authors.initials: U
authors.lastname: Arnelo
mesh_terms: D000230:Adenocarcinoma / Q000235:genetics / Q000601:surgery*; D000236:Adenoma / Q000235:genetics / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater / Q000473:pathology / Q000601:surgery*; D001706:Biopsy; D002760:Cholangiopancreatography, Endoscopic Retrograde; D004379:Duodenal Neoplasms / Q000235:genetics / Q000601:surgery*; D005260:Female; D006801:Humans; D041781:Jaundice, Obstructive; D008297:Male; D008875:Middle Aged; D009154:Mutation; D016283:Proto-Oncogene Proteins p21(ras) / Q000235:genetics*; D016896:Treatment Outcome
chemical_list: C117307:KRAS protein, human; D016283:Proto-Oncogene Proteins p21(ras)
keywords: KRAS mutation; ampulla of vater; ampullectomy; endoscopic resection; endoscopic retrograde cholangiopancreatography