Comparative study of the radical and standard lymphadenectomy in the surgical treatment of adenocarcinoma of the ampula of Vater

Prognostic Factors of Long-term Survival Following Radical Resection for Ampullary Carcinoma

BACKGROUND

The incidence of adenocarcinoma of the ampulla of Vater has been increasing over the past years. Nevertheless, it is still a rare disease and the prognostic factors predicting long-term survival are not sufficiently clarified. This study aims to evaluate the association between histopathological characteristics and long-term survival of patients with ampullary cancer after curative resection, as well as the efficiency of immunohistochemical expression of CK7, CK20, and CDX2 to distinguish the histopathological (intestinal or pancreaticobiliary) patterns.

METHODS

Demographic, histopathological data, pTNM stage, and immunohistochemical expression patterns were collected from 65 patients with adenocarcinoma of the ampulla of Vater. Five and 10-year overall and disease-free survival rates after curative resection were determined.

RESULTS

Of the 65 patients with ampullary carcinoma, 47 (72%) underwent radical resection. The 5- and 10-year overall survival rate was 46% and 37%, respectively. Our results demonstrate that the main prognostic factors were the presence and number of lymph node metastases, lymph node ratio (LNR), differentiation grade, and lymphovascular invasion. After multivariate analysis, only lymph node ratio ≥ 20% remained an independent prognostic factor of survival (HR: 2.63 95% CI: 1.05-6.61; p = 0.039).

CONCLUSION

Here, we demonstrated more evidence that the lymph node metastases are associated with poor prognosis in ampullary carcinoma. Particularly, the relation between the number of metastatic lymph nodes and the number of harvested lymph node (LNR) should be considered a major prognostic factor.

[Moderately differentiated adenocarcinoma of the third duodenal portion]

BACKGROUND

Duodenal carcinoma is very rare. It represents 33-45% of the all tumours of the small bowel. The symptoms are non-specific, and the diagnosis is often accidental.

CLINICAL CASE

A 35-year old man was admitted to our hospital with post-prandial abdominal pain. Upper gastrointestinal examination revealed a tumour of the third duodenal portion, which was diagnosed, using endoscopic biopsy, as a tubular adenoma with high grade dysplasia. The computed axial tomography scan, the magnetic resonance imaging, and the endoscopic ultrasound showed the neoplasia of the third duodenal portion with no lymph node or peritoneal metastases. Partial resection of the duodenum was performed. The definitive histopathological diagnosis was primary adenocarcinoma of the third duodenal portion. pT2 N0M0, originated in a tubular adenoma.

CONCLUSIONS

Primitive neoplasia of the duodenum is very rare. Duodeno-cephalo-pancreatectomy is recommended in proximally located tumours, while segmental resection of the duodenum is appropriate for distal locations, with the same survival.

Management of ampullary neoplasms: A tailored approach between endoscopy and surgery

Ampullary neoplasms, although rare, present distinctive clinical and pathological features from other neoplastic lesions of the periampullary region. No specific guidelines about their management are available, and they are often assimilated either to biliary tract or to pancreatic carcinomas. Due to their location, they tend to become symptomatic at an earlier stage compared to pancreatic malignancies. This behaviour results in a higher resectability rate at diagnosis. From a pathological point of view they arise in a zone of transition between two different epithelia, and, according to their origin, may be divided into pancreatobiliary or intestinal type. This classification has a substantial impact on prognosis. In most cases, pancreaticoduodenectomy represents the treatment of choice when there is an overt or highly suspicious malignant behaviour. The rate of potentially curative resection is as high as 90% and in high-volume centres an acceptable rate of complications is reported. In selected situations less invasive approaches, such as ampullectomy, have been advocated, although there are some concerns mainly because of a higher recurrence rate associated with limited resections for invasive carcinomas. Importantly, these methods have the drawback of not including an appropriate lymphadenectomy, while nodal involvement has been shown to be frequently present also in apparently low-risk carcinomas. Endoscopic ampullectomy is now the procedure of choice in case of low up to high-grade dysplasia providing a proper assessment of the T status by endoscopic ultrasound. In the present paper the evidence currently available is reviewed, with the aim of offering an updated framework for diagnosis and management of this specific type of disease.

Adenocarcinoma of the third duodenal portion: Case report and review of literature

We focus on the diagnostic and therapeutic problems of duodenal adenocarcinoma, reporting a case and reviewing the literature. A 65-year old man with adenocarcinoma in the third duodenal portion was successfully treated with a segmental resection of the third part of the duodenum, avoiding a duodeno-cephalo-pancreatectomy. This tumor is very rare and frequently affects the III and IV duodenal portion. A precocious diagnosis and the exact localization of this neoplasia are crucial factors in order to decide the surgical strategy. Given a non-specificity of symptoms, endoscopy with biopsy is the diagnostic gold standard. Duodeno-cephalo-pancreatectomy (DCP) and segmental resection of the duodenum (SRD) are the two surgical options, with overlapping morbidity (27% vs 18%) and post operative mortality (3% vs 1%). The average incidence of postoperative long-term survival is 100%, 73.3% and 31.6% of cases after 1, 3 and 5 years from surgery, respectively. Long-term survival is made worse by two factors: the presence of metastatic lymph nodes and tumor localization in the proximal duodenum. The two surgical options are radical: DCP should be used only for proximal localizations while SRD should be chosen for distal localizations.