Transduodenal ampullectomy (TDA) has lower peri-operative morbidity and mortality than PD and has been suggested as an alternative surgical treatment for ampullary adenoma and early AoV cancer.
1. Introduction
Ampulla of Vater (AoV) cancer is a malignant neoplasm that develops from the ampulla of Vater complex, which lies between the area distal to the confluence of the pancreatic duct and the distal common bile duct (CBD) and the duodenal opening. AoV cancer is a rare disease that constitutes roughly 7% of peri-ampullary tumors
[1][2]. Although AoV cancer is a peri-ampullary tumor, it has a better prognosis than other peri-ampullary tumors such as pancreatic cancer and distal CBD cancer
[3][4][5]. Approximately half of patients with AoV cancer present at an advanced stage. For those who present at an early stage, pancreaticoduodenectomy (PD) or pylorus-preserving pancreaticoduodenectomy (PPPD) are recognized as standard treatments
[6][7][8]. Because the disease generally presents in patients whose age makes surgical procedures risky, only 40% of AoV patients undergo surgical resection
[9].
Transduodenal ampullectomy (TDA) has lower peri-operative morbidity and mortality than PD and has been suggested as an alternative surgical treatment for ampullary adenoma and early AoV cancer
[10][11][12]. However, TDA presents a higher chance of recurrence due to limited resection and insufficient lymph node dissection, and its oncological safety has been controversial
[13]. Therefore, TDA is used only in patients with high surgical co-morbidity factors, small cancer with good cell differentiation, and staging equivalent to or less than T1. The indications for TDA differ among institutes, and no clear guidelines have been established
[14][15]. Some previous studies have compared the oncologic outcomes of PD and TDA in early AoV cancer. Winter et al. from the Johns Hopkins group reported no statistical differences (
p = 0.150) in postoperative complications between PD (
n = 435) and TDA (
n = 15). They noticed a high incidence of lymph node metastasis (28.0%) in T1 cancer and concluded that PD should be preferred, even in early AoV cancer
[16]. A retrospective single-institution study of early AoV cancer in China (PD:
n = 21, TDA:
n = 22) reported no statistical differences between the two groups in 5-year survival outcomes and a lower complication rate in the TDA group
[17]. A retrospective single-institution study in Korea evaluated the clinicopathologic characteristics, disease-free survival (DFS), and recurrence rate in 137 patients (PD:
n = 119, TDA:
n = 18) with early AoV cancer (Tis or T1). Those authors reported no statistical differences in postoperative complications or DFS between the two groups; however, among patients with T1 cancer, the TDA group showed a statistically higher recurrence rate than the PD group
[18].
2. Clinicopathologic Characteristics of the PPPD, TDA+LND, and TDA-Only Groups with T1 Stage Disease
Because patients with T1 disease had better DFS following PPPD than TDA (84.8% vs. 66.6%,
p = 0.040), we analyzed differences in the clinicopathologic characteristics of the T1 stage patients in both groups. For this analysis, we divided surgical methods into three groups: PPPD, TDA+LND, and TDA-only. The PPPD and TDA+LND groups did not differ in age, sex, tumor size, N stage, cell differentiation, LVI, PNI, or adjuvant treatment. However, the R0 resection rate was higher in the PPPD group than in the TDA+LND group (100% vs. 84.6%,
p = 0.004). In the comparison between the PPPD and TDA-only groups, the tumors were significantly larger (1.8 vs. 1.2 cm,
p = 0.025), and cell differentiation was worse in the PPPD group than in the TDA-only group (
p = 0.008) (
1).
Table 21. Comparison of clinicopathologic characteristics and recurrence according to the operation type in patients with T1 stage disease.
|
Operation |
p-Value |
|
1. PPPD (188) |
2. TDA + LND (13) |
3. TDA-Only (18) |
1 vs. 2 |
1 vs. 3 |
2 vs. 3 |
Total |
Age (years) |
63.07 ± 9.03 |
62.15 ± 11.66 |
59.39 ± 16.17 |
0.729 |
0.354 |
0.584 |
0.319 |
Male (%) |
86 (45.7%) |
6 (46.2%) |
9 (50.0%) |
0.977 |
0.729 |
0.833 |
0.942 |
Size (cm) |
1.81 ± 1.09 |
1.76 ± 0.68 |
1.20 ± 0.79 |
0.866 |
0.025 |
0.049 |
0.073 |
N staging |
|
|
|
|
|
|
|
Nx |
6 (3.2%) |
|
18 (100.0%) |
1.000 |
<0.001 |
<0.001 |
<0.001 |
N0 |
161 (85.6%) |
12 (92.3%) |
|
N1 |
21 (11.2%) |
1 (7.7%) |
|
Differentiation |
|
|
|
|
|
|
|
Well |
113 (62.1%) |
8 (72.7%) |
14 (82.4%) |
0.845 |
0.008 |
0.253 |
0.017 |
Moderate |
61 (33.5%) |
3 (27.3%) |
1 (5.9%) |
Poorly |
6 (3.3%) |
0 (0.0%) |
0 (0.0%) |
Undiff. |
0 (0.0%) |
0 (0.0%) |
0 (0.0%) |
Etc. |
2 (1.1%) |
0 (0.0%) |
2 (11.8%) |
LVI (+) |
35 (22.9%) |
0 (0.0%) |
0 (0.0%) |
0.349 |
0.576 |
− |
0.202 |
PNI (+) |
22 (14.4%) |
0 (0.0%) |
0 (0.0%) |
0.595 |
1.000 |
− |
0.340 |
Adj. Tx |
18 (9.6%) |
1 (7.7%) |
0 (0.0%) |
1.000 |
0.377 |
0.419 |
0.383 |
R status |
|
|
|
|
|
|
|
R0 |
188 (100.0%) |
11 (84.6%) |
18 (100.0%) |
0.004 |
− |
0.168 |
<0.001 |
R1 |
0 (0.0%) |
2 (15.4%) |
0 (0.0%) |
Recurrence |
20 (10.6%) |
3 (23.1%) |
5 (27.8%) |
0.174 |
0.050 |
1.000 |
0.019 |
Recurrence pattern |
|
|
|
0.249 |
0.016 |
1.000 |
0.004 |
Local |
1 (0.5%) |
1 (7.7%) |
3 (16.7%) |
|
|
|
|
Systemic |
19 (10.1%) |
2 (15.4%) |
2 (11.1%) |
|
|
|
|