Prognostic analysis of carcinoma of the ampulla of Vater: pancreaticoduodenectomy versus local resection.

BACKGROUND AND AIM: Pancreaticoduodenectomy (PD) is considered to be the optimal treatment for carcinoma of the ampulla of Vater, but the trauma caused by PD is often severe and extensive. Local resection (LR) for ampullary tumors has been performed for a century but remains controversial. The use of this procedure for benign conditions is clear, but its place, if any, in the management of ampullary carcinoma is debated. The aim of this study was to investigate the outcomes and analyse the prognostic factors of LR of carcinoma of the ampulla of Vater by comparison with PD. PATIENTS AND METHODS: A retrospective analysis of 71 patients of carcinoma of the ampulla of Vater was conducted at Zhejiang Cancer Hospital from January 1995 to December 2005. We investigated the differences of the baseline characteristics and the intra- and postoperative data of patients who underwent PD and LR. Prognostic factors for recurrence and survival of carcinoma of the ampulla of Vater between PD and LR was also analysed.
RESULTS: Among the 71 patients of ampullary carcinoma who underwent surgical resection, a PD was performed in 46 (64.8%) patients while a LR was performed in 25 (35.2%) patients. The 30-day mortality rate associated with PD (6.5%) was not different from that with LR (0%; p=0.547) while the morbidity following PD (30.4%) and LR (8.0%) was statistically different (p=0.031). The complications were also significantly higher in the PD group than the LR group (34.8% vs 6.5%; p=0.013). In a univariate Cox regression analysis of survival, there were significant differences in tumor size (p=0.031), TNM (Tumor Node Metastasis) stage (p=0.000), pT (pathologic Tumor) stage (p=0.010), pN (pathologic Node) stage (p=0.000), differentiation (p=0.026), and surgical margin (p=0.031). Multivariate Cox regression analysis showed that TNM stage (HR=3.640, 95% CI 1.428~9.282; p=0.007), pT stage (HR=3.090, 95% CI 1.230~7.762; p=0.016), and pN stage (HR=4.479, 95% CI 1.524~013.161; p=0.005) remained as independent predictors of survival rates. According to the method of Kaplan-Meier, the five-year survival rate in the PD group was 53.5% and that in the LR group was 48.0%, no significant differences were found between the two groups in overall survival rates (p=0.540). Compared with the PD, the 5-year survival of patients with the TNM stage-III/IV who undergoing LR was statistically lower (11.1% vs 38.1%; p=0.040). As expected, the overall survival were signicant differences between the two groups in pT stage-T3/T4 (47.4% vs 18.2%, p=0.018) and pN stage-N1 (36.8% vs 11.1%, p=0.004), respectively. Tumor recurrence was diagnosed in 10/43 (23.3%) patients after PD and 12/25 (48.0%) patients after LR (p=0.035). Logistic regression analysis of recurrence showed that TNM stage-III/IV (p=0.004), pT stage-T3/T4 (p=0.034), and pN stage-N1 (p=0.007) were associated with a 2.444, 1.943, and 2.111-fold increased risk of recurrence, respectively.
CONCLUSIONS: PD is the preferred operation for carcinoma of the ampulla of Vater. LR is less mortal and morbid than PD, which is a suitable treatment in patients with a low-risk cancer in stages I/II or pT1/T2 N0 with a maximum diameter of 2 cm or less. TNM stage, pT stage, and pN stage remained as independent predictors of survival rates.