Introduction:
Ampullary adenomas (AAs) can occur in a sporadic setting (SA) or genetic conditions, such as FAP and HNPCC. We aim to share the long-term follow-up data on observation without intervention, endoscopic intervention, and surgical intervention.
Methods:
This is a retrospective study of all patients with pathology-confirmed AAs from 1987 to 2023 at a tertiary cancer center.
Results:
Of 289 patients with AAs (207 FAP/HNPCC and 82 SA) with a mean follow-up of (MFU) 7.72 (+ 5.53) y, 187 were under observation (162 FAP/HNPCC, 25 SA) with MFU 4.50 (+ 6.00) y, 68 underwent endoscopic intervention [67 endoscopic papillectomy (EP) and 1 argon plasma coagulation (APC)] with MFU 5.40 (+ 7.01) y, and 34 surgery [30 pancreaticoduodenectomy (PD) with MFU 4.22 (+ 7.35) y and 4 surgical ampullectomy with MFU of 7.64 (+ 6.87) y. During the follow-up period, none of our 256 patients died from AAs. None of the 187 patients in the observation group developed cancer during the follow-up although 12% underwent endoscopic or surgical intervention due to progression of advanced adenomas.
For EP, the mean size of ampullary mass was 40.28 + 7.00 mm. The technical success rate of EP was 67/68 (98.5%) with en bloc resection rate 10/68 (14.7%). In en bloc resection, deep and lateral margins were negative in 80.0. Pancreatic duct stent was placed in all patients who underwent EP. The complications of EPs include mild pancreatitis in 4 (5.8%) and cholangitis 1 (1.5%). Surveillance endoscopy post EP was done at 3 months, at 1 year, and then yearly thereafter. The recurrence AAs after EPs were 13/68 (19.1%) in 352(21-4,001)d.
Secondary intervention of EP for development of HGD was performed in 3 (2 from EP and 1 from surgical ampullectomy), APC treatment in 7 (all from EP), and PD in 10 (8 from EP and 2 from surgical ampullectomy), and two excisions by biopsy (all from EP) in 695 d (102-3013)d.
Of the 4 surgical ampullectomies, 3 patients required secondary intervention with EP in 1 and PD in 2.
Complications of surgical intervention were noted in 12/34 (43.5%) patients, including 4 pancreatic leak, 1 bile leak, 3 abscesses/infections, 1 chylous leak, 1 atelectasis, 1 respiratory insufficiency, and 1 pancreatitis.
Discussion:
When observation was chosen for AAs in FAP/HNPCC, progression of adenoma that needed intervention occurred within 5 years without observing any developing adenocarcinoma. EP had a high technical success rate with a low adverse event, but with a high recurrence rate. Surgical intervention had a low recurrence rate but a high adverse event rate. These findings should be considered when managing AAs, especially in hereditary conditions.

Ingrid Schwartz

The University of Texas MD Anderson Cancer Center

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