Combined excision and ablation of ampullary tumors with biliary or pancreatic intraductal extension is effective even in malignant neoplasms

Abstract

Background: The feasibility and outcome of endoscopic resection in ampullary tumors with intraductal growth remains unclear. Objective: To assess the safety, feasibility and outcomes of these patients treated by thermal ablation. Methods: Retrospective observational study. All consecutive patients who underwent an endoscopic snare papillectomy with a 6-month minimum follow-up were included. Ablation was performed with cystotomes and soft/forced coagulation. Successful endoscopic treatment was defined as no adenomatous residual tissue or recurrence observed at follow-up. Results: Of 86 patients presenting with an ampullary tumor, 73 (58 AE 14 years old, 49% men, 34% familial adenomatous polyposis) (median tumor size: 20 mm, range: 8-80) were included. En bloc and curative resection rates were achieved in 46.6% and 83.6%, respectively. Intraductal ingrowth was seen in 18 (24.7%) patients and histologically confirmed in 12 (16.4%). Intraductal ablation achieved a 100% success rate, with a 20-month median follow-up. Most of these patients had malignant forms (n ¼ 8, 66.7%), with a higher adenocarcinoma rate (33.3% versus 3.3%, p ¼ 0.001) compared to extraductal tumors. Overall, there was a 20.5% complication rate with no significant differences between both groups (p ¼ 0.676). Conclusions: Intraductal ablation achieves a high therapeutic success rate in ampullary tumors with 20 mm ductal extension, even in malignant forms or biliary and pancreatic involvement. The technique is feasible, cheap and safe and may avoid major surgery. Key summary1. Summary of the established knowledge on this subject . Endoscopic papillectomy can offer a curative resection in 67-92% of cases.. Intraductal extension has been described as a relative contraindication for endoscopic resection and is associated with lower curative resection rates and incomplete adenoma removal. . There is no consensus on the indications for endoscopic papillectomy in intraductal extension of ampullary neoplasms and the maximum intraductal involvement able to be resected endoscopically is unknown.

Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

“…Papillary tumors can be limited to the ampullary mound, present with an extrapapillary component in 6.9 %-43.8 % of cases, and/or have an intraductal presentation [19][20][21][22][23][24]. Laterally spreading lesions of the papilla may have an extrapapillary component and may have characteristics in common with superficial nonampullary duodenal tumors [23].…”

“…Tumor size may guide therapy and predict endoscopic outcomes, but studies to date have conflicting results. Larger tumor sizes (mainly with a cutoff of 20 mm) have been associated with malignancy [24,27,28] or residual disease/recurrence in observational studies [21].…”

“…Nevertheless, two endoscopic complementary destruction techniques are available and have recently been evaluated. Pérez-Cuadrado-Robles et al [24] proposed the use of endoscopic thermal ablation by a wire-guided cystotome combined with endoscopic papillectomy (73 patients overall including 18 with ≤ 20-mm intraductal extension). No difference in curative resection rates was observed after a mean follow-up of 20 months (100 % for patients with intraductal extension vs. 80.3 % for those without; P = 0.093).…”

Systematic Review with Meta-Analysis: Endoscopic and Surgical Resection for Ampullary Lesions

“…EA is usually performed for smaller lesions without any sign of invasive carcinoma, clear margins, soft tissue and absence of ulceration [10]. In contrast, recent studies describe the feasibility of "piece-meal" EA [11], even in large laterally spreading lesions, with deep ductal invasion [12] and supposed node-negative T1 adenocarcinoma [13]. Additionally, EA could be used as a "macrobiopsy" for tumor staging and as a bridge to surgery [14].…”

Synchronous Periampullary Tumors in a Patient With Pancreas Divisum and Neurofibromatosis Type 1

“…Ampullary neoplasms are rare, comprising 7% of all periampullary malignancies (Adsay et al, 2012), and association of theses tumors with pancreas divisum is considered an episodic event (Singh et al, 2003;Outtas et al, 2004;Kim et al, 2010). Their occurrence has been reported in families with hereditary cancer syndromes, such as Familial Adenomatous Polyposis (Pérez-Cuadrado-Robles et al, 2019) and Neurofibromatosis type 1 (NF1) (Tewari et al, 2014).…”