Impact of grade of dysplasia in villous adenomas of vater’s papilla

Abstract

Therapeutic strategies for villous adenoma of the papilla of Vater remain controversial. This study evaluates the accuracy of preoperative histopathologic diagnosis and the impact of the grade of dysplasia on recurrence as well as on potential alteration of the surgical approach. A series of 32 patients with an adenoma of Vater's papilla who underwent local resection or pylorus-preserving pancreaticoduodenectomy between January 1990 and August 2000 were reviewed retrospectively. Multiple endoscopic biopsies had been performed preoperatively. The histopathology of the preoperatively obtained biopsy specimens and subsequent surgical specimens were evaluated for grade of dysplasia by two pathologists and correlated with the clinical course after operative treatment. Altogether, 3 of 11 patients (27%) with a low-grade (LG) dysplasia adenoma and 6 of 21 patients (29%) with a high-grade (HG) dysplasia adenoma in the initial endoscopic biopsy specimens exhibited invasive carcinoma at the postoperative histologic examination (NS). Recurrence was not observed in the 6 patients from the LG dysplasia adenoma group following local resection and benign postoperative histology. In contrast, recurrence of villous adenoma was discovered in 2 of 12 patients (17%) and development of invasive carcinoma in 5 of 12 patients (42%) from the preoperative HG dysplasia group (p <0.05). The overall risk of carcinoma after primary diagnosis of an HG dysplasia adenoma was 44% (14/32). Adenoma of the papilla of Vater including HG dysplasia appears to be associated with a high risk of exhibiting invasive carcinoma postoperatively and a high rate of recurrence. Therefore pylorus-preserving pancreaticoduodenectomy should be offered to patients with an HG dysplasia adenoma.

Is Endoscopic Papillectomy Safe for Ampullary Adenomas with High-Grade Dysplasia?

“…Meneghetti et al and Heidecke et al reported the rate of coexistence of cancer in patients with pre-HGD as 100% and 44%, respectively. 23,24 For recurrence of pre-HGD in 12 patients with benign lesions, 3 patients with moderate-or high-grade dysplasia encountered recurrence. 25 On the other hand, some authors reported no recurrence in patients with pre-HGD, and one study including pre-HGD did not describe detailed outcomes.…”

An approach to duodenal biopsies

“…The overall risk of carcinoma after primary diagnosis of a high-grade dysplasic adenoma was 44% (14/32). 105 Carcinomas of this region are differentiated into intestinal type, pancreatobiliary type and an unusual type, which includes signet-ring cell carcinoma and undifferentiated adenocarcinoma. Immunohistochemical expression of apomucin MUC2 helps in the distinction between intestinal and pancreatobiliary types.…”

Large periampullary villous tumor of the duodenum

“…The incidence of malignancy, in a series of 241 adenomas reviewed from the literature, was about 50% (with an increased risk for periampullary localization), which was worse than the malignant propensity of villous adenomas of the colon‐rectum (approximately 30%) . Villous adenomas with low‐grade dysplasia are associated with a lower incidence of malignancy (27%) as compared to the high‐grade dysplasia tumors (52%) . On the other hand, an endoscopic biopsy that reveals a low‐grade dysplasia adenoma does not exclude the possibility of areas of high‐grade dysplasia or invasive carcinoma.…”