CARCINOMA OF THE AMPULLA OF VATER - HISTOPATHOLOGIC ANALYSIS OF TUMORSPREAD IN WHIPPLE PANCREATICODUODENECTOMY SPECIMENS

Controversies exist regarding the application of the pylorus-preservin g pancreatoduodenectomy (PPPD) to malignancies. This study was intende d to disclose the pattern of spread of ampullary cancer and to substan tiate that tumor spread at resectable stages does not involve the tiss ues preserved by PPPD. We examined 40 consecutive Whipple pancreatoduo denectomy specimens: mucosal cancer, 4 cases; cancer invading (but not penetrating) the sphincter of Oddi, 1; cancer invading the submucosa of the duodenum, 12; cancer invading the proper muscle of the duodenum , 5; cancer invading the subserosal layer of the duodenum, 7; and canc er invading pancreatic parenchyma, 11. Five cases of mucosal cancer or cancer invading (but not penetrating) the sphincter spread locally wi thout nodal involvement and showed a 5-year survival of 80% without re currence, being better (p < 0.05) than the 40% survival for patients w ith more advanced cancers. Sixty-three percent of the remaining 35 cas es had metastasis to regional lymph nodes. The 5-year survival of 28% among those with cancer penetrating the proper muscle was worse (p < 0 .05) than the 59% survival for those with less advanced cancers. No ca ses had involved the anatomic structures that would have been preserve d by a PPPD. In three cases (7.5%), gastric cancer coexisted. In concl usion, ampullary cancer not penetrating the sphincter spreads locally. Once penetrating the sphincter, it often spreads regionally and cause s recurrence. Cancer penetrating the proper muscle of the duodenum bea rs a worse prognosis. PPPD is an attractive alternative to the Whipple operation for ampullary cancer because no involvement was found in th e tissue preserved by the PPPD. However, surgeons should be aware of a concomitant gastric cancer when doing a PPPD.