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Surgical Strategy for T1 Duodenal Or Ampullary Carcinoma According To ANTICANCER RESEARCH 37 : 5277-5283 (2017) doi:10.21873/anticanres.11953 Surgical Strategy for T1 Duodenal or Ampullary Carcinoma According to the Depth of Tumor Invasion ATSUSHI KOHGA 1, YUSUKE YAMAMOTO 1, SHUSEI SANO 1, TEIICHI SUGIURA 1, YUKIYASU OKAMURA 1, TAKAAKI ITO 1, RYO ASHIDA 1, HIROTOSHI ISHIWATARI 2, HIROYUKI MATSUBAYASHI 2, KEIKO SASAKI 3 and KATSUHIKO UESAKA 1 Divisions of 1Hepato-Biliary-Pancreatic Surgery, 2Endoscopy, 3Pathology, Shizuoka Cancer Center, Shizuoka, Japan Abstract. Aim: To investigate the utility of local resection malignancies (5, 6). Recently, LR has been introduced as an (LR) for T1 duodenal carcinoma and T1 ampullary alternative, less-invasive procedure for the treatment of carcinoma. Patients and Methods: Between June 2002 and early-stage duodenal and ampullary carcinomas in select November 2014, a total of 64 patients with pathological T1 patients, because PD carries a high risk of morbidity and (pT1) ampullary carcinoma (25 patients) and pT1 duodenal mortality (11-13). However, its indication for the treatment carcinoma (39 patients) were treated. Of these, 33 patients for early-stage carcinoma remains unclear because duodenal underwent local resection (LR group), while the other 31 or ampullary carcinoma is an uncommon disease, and the patients underwent pancreatoduodenectomy (PD group). rate of lymph node metastasis, which usually depends on the Results: The LR group had 31 patients with pT1a and 2 depth of tumor invasion, also remains unclear. Furthermore, patients with pT1b. PD group had 18 patients with pT1a and it is difficult to preoperatively assess the accurate depth of 13 patients with pT1b. One patient with pT1b duodenal invasion in patients with ampullary carcinoma, in carcinoma (20.0%) and one patient with pT1b ampullary particularly whether the sphincter of Oddi is involved (14). carcinoma (10.0%) developed lymph node metastasis, while The aim of the present study was to review a cohort of none of the patients with pT1a disease developed metastases. patients with early-stage duodenal and ampullary carcinomas Conclusion: LR may be considered in the patients and identify the clinicopathological factors that indicate a preoperatively diagnosed with T1a duodenal carcinoma and possible benefit in LR by comparing the results to those of T1a ampullary carcinoma. patients who underwent PD for early-stage duodenal and ampullary carcinomas. Tumors of the duodenum or the ampulla of Vater represent a small portion of gastrointestinal tumors, accounting for less Patients and Methods than 1% of all gastrointestinal malignancies (1-4). Complete Study population. Between June 2002 and November 2014, 76 resection is the only potential curative procedure for patients with ampullary carcinoma and 70 patients with duodenal duodenal or ampullary carcinoma, and various techniques carcinoma underwent macroscopic curative resection at the Division have been proposed for its management ranging from local of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center. Of resection (LR) to pancreatoduodenectomy (PD) (5-8). The these patients, 25 patients had pathological T1 (pT1) ampullary method of resection typically depends on the depth of tumor carcinoma and 39 patients had pT1 duodenal carcinoma according invasion for the treatment of various gastrointestinal tract to the TNM classification (7th edition) of the American Joint cancers (9, 10). In the field of duodenal and ampullary Committee on Cancer (AJCC) (12). Overall, 64 patients with pT1 ampullary and duodenal carcinomas were enrolled in this study. Of carcinomas, PD is standard treatment for advanced invasive these, 31 patients underwent PD (PD group) and 33 patients underwent LR (LR group); 4 patients underwent pancreas-sparing duodenectomy, 1 patient underwent segmental resection of the duodenum, 24 patients underwent partial resection of the duodenum, Correspondence to: Yusuke Yamamoto, MD, Division of Hepato- and 4 patients underwent ampullectomy. Patients with benign Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007, Shimo- lesions, gastrointestinal stromal tumors or neuroendocrine tumors Nagakubo, Sunto-Nagaizumi, Shizuoka 4118777, Japan. Tel: +81 were excluded from this study. 559895222, Fax: +81 559895783, e-mail: [email protected] Imaging diagnostic modality. Among 64 patients examined, all Key Words: Local resection, duodenal carcinoma, ampullary patients underwent computed tomography (CT) and esophagogastro- carcinoma. duodenoscopy for diagnostic purposes. Thirty-nine patients 5277 ANTICANCER RESEARCH 37 : 5277-5283 (2017) Figure 1. The T1a and T1b defined the patients with ampullary carcinoma as bellow, according to the Japanese classification for biliary tract cancers. A) T1a: invasion to only the mucosa. B) T1b: invasion to the sphincter of Oddi. BD, Bile duct; PD, pancreatic duct. underwent preoperative endoscopic ultrasonography (EUS) and 11 complications were considered to be significant. None of the patients underwent intraductal ultrasonography (IDUS) in order to patients received adjuvant chemotherapy, radiotherapy, or diagnose the depth of tumor invasion. chemoradiotherapy. All patients were examined in the outpatient clinic where abdominal ultrasound, CT, and the measurement of the Surgical strategy and surgical procedures for ampullary and CEA and CA19-9 levels was performed every 3-6 months after duodenal carcinomas. In our institution, PD with regional lymph surgery. node dissection was routinely performed for advanced ampullary and duodenal carcinomas. For the patients with clinical T1a Statistical analysis of the surgical outcomes and clinicopathological duodenal carcinoma, LR was planned. For the patients with clinical factors. The clinicopathological factors of the patients treated using T1b duodenal carcinoma, PD with regional lymph node dissection LR were compared with those treated using PD. was indicated. In the patients with clinical T1 ampullary carcinoma, Pearson’s Chi-square test and Fisher’s exact test were used to PD was initially planned. For the patients with T1 ampullary assess nominal variables, and continuous data were compared using carcinoma, the following conditions were considered to be the Mann-Whitney U- test. All statistical analyses were performed candidates for LR: 1) the tumor was located only in the mucosa, 2) using the Software Package for Social Sciences, version 11.5J for there was no apparent lymph node metastasis or distant metastasis, Windows 1 software program (SPSS, Chicago, IL, USA). A p-value and 3) the tumor was small enough to be completely resected using of <0.05 was considered significant. We performed Yates’ correction LR. In the patients with ampullary carcinomas who underwent for calculating the p- value using a two-by-two contingency table. ampullectomy, frozen sections of the cut end of the specimen were examined. We performed PD when the examination of a frozen Results section revealed tumor involvement at the resection margin. The LR group (n=33) included 31 patients with pT1a lesions Clinicopathological findings. We reviewed the following (4 ampullary and 27 duodenal carcinoma) and 2 patients with clinicopathological findings of the patients: demographic parameters (gender and age), preoperative carcinoembryonic antigen (CEA) pT1b duodenal cancer. The PD group (n=31) included 18 level and carbohydrate antigen 19-9 (CA19-9) level, pathological patients with pT1a lesions (11 ampullary and 7 duodenal factors (tumor size, depth of tumor, histologic grade and lymph carcinoma) and 13 patients with pT1b lesions (10 ampullary node metastasis), perioperative factors (operation time, blood loss, and 3 duodenal carcinoma). One patient with pT1b duodenal postoperative length of days, postoperative complication), and long- carcinoma (20.0%) and one patient with pT1b ampullary term outcomes (recurrence and survival). carcinoma (10%) developed lymph node metastasis (Table In principle, the T classifications of duodenal and ampullary I). On the other hand, none of the patients with pT1a carcinoma (T1-T4) were defined with reference to the TNM classification (7th edition) of the American Joint Committee on developed lymph node metastasis. Cancer (AJCC) (15). In addition, for the finer division of T1 Five patients with pT1 ampullary carcinoma were ampullary carcinoma, we also referred to the Japanese classification scheduled to undergo LR. Of these patients, two were found for biliary tract cancers (16), and divided the T1 lesions of to have positive margins according to the findings from ampullary carcinoma into T1a and T1b as follows: T1a, invasion to frozen section samples. One of the patients converted to PD, only the mucosa in both ampullary and duodenal carcinoma; T1b, while the other could not convert to PD due to old age. Four invasion to the submucosa in patients with duodenal carcinoma or patients with pT1 ampullary carcinoma were treated by LR invasion to the sphincter of Oddi in patients with ampullary carcinoma (Figure 1A and B). alone (Table II). Three patients with pT1a duodenal carcinoma (7.7%) and one patient with pT1a ampullary Postsurgical management. Complications were classified according carcinoma (4%) had previous histories of familial to the grading system of Dindo et al. (17), and grade III or further adenomatous polyposis. 5278 Kohga et al : Resection for T1 Duodenal or Ampullary Carcinoma Table I. Clinical characteristics of the patients pathologically diagnosed to have lymph node metastasis. Case Gender/ Disease/ No. of Lymph nodes Size Depth
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