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

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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.

Résumé

La stratégie thérapeutique vis-à-vis de l’adénome villeux de l’ampoule de Vater reste controversée. Cette étude évalue la précision du diagnostic préopératoire histopathologique et l’impacte du grade de la dysplasie sur la récidive ainsi que sur la tactique chirurgicale. 32 patients porteurs d’un adénome de l’ampoule de Vater ayant eu une résection locale ou une duodénopancréatectomie avec conservation du pylore entre janvier 1990 et août 2000 ont été revus rétrospectivement. De multiples biopsies endoscopiques ont été réalisées en préopératoire pour permettre à deux anatomopathologistes de déterminer le grade de dysplasie, corrélé ensuite à l’évolution clinique après traitement chirurgical. Trois des 11 patients (27%) ayant un adénome de bas grade de dysplasie et six des 21 patients (29%) ayant un adénome de haut grade de dysplasie lors des biopsies endoscopiques initiales ont développé carcinome invasif sur l’histologie de la pièce opératoire (différence non significative). On n’a observé aucun cas de récidive dans le groupe de six patients ayant un adénome de bas grade de dysplasie et une histologie définitive bénigne après résection locale. En revanche, on a noté une récidive d’adénome villeux chez deux (17%) et un carcinome invasif chez cinq (42%) des 12 patients du groupe de dysplasie de haut grade (p<0.05). Le risque global de carcinome après diagnostic primitif d’adénome de haut grade de dysplasie a été de 14 des 32 patients (44%). Les adénomes de l’ampoule de Vater avec à l’appui une biopsie montrant une dysplasie de haut grade apparaissent être associés à un haut risque de carcinome invasif en postopératoire ainsi qu’un risque élevé de récidive. Ainsi, en cas d’adénome avec dysplasie de haut grade, il faut préconiser une duodénopancréatectomie avec conservation du pylore.

Resumen

Las conductas terapéuticas en los papilomas vellosos de la papila de Vater siguen siendo motivo de controversia. El presente estudio tuvo como propósito evaluar la certeza del diagnóstico histopatológico preoperatorio y el impacto del grado de displasia sobre la recurrencia y sobre un cambio potencial en el abordaje quirúrgico. Se hizo la revisión retrospectiva de 32 pacientes con adenoma de la papila de Vater sometidos a resección local o a pancreatoduodenectomía con preservación del píloro en el periodo entre enero de 1990 y agosto de 2000. Se practicaron múltiples biopsias endoscópicas preoperatoriamente, las cuales fueron analizadas, junto con los subsiguientes especímenes quirúrgicos, en cuanto al grado de displasia por dos patólogos para establecer la correlación con la evolución clínica luego del tratamiento quirúrgico. Tres de 11 pacientes (27%) con adenoma con displasia de bajo grado y 6/21 (29%) con adenoma con displasia de alto grado en las biopsias endoscópicas iniciales exhibieron una carcinoma invasor en la histología postoperatoria (NS). No se observó recurrencia en los 6 pacientes en el grupo de los adenomas con displasia de bajo grado sometidos a resección local y que tuvieron histología postoperatoria benigna. Por el contrario, se registró recurrencia del adenoma velloso en 2/12 pacientes (17%) y el desarrollo de carcinoma invasor en 5/12 pacientes (42%) en el grupo con displasia de alto grado (p<0.05). El riesgo global de carcinoma luego del diagnóstico primario de adenoma con displasia fue de 44% (14/32 pacientes). El adenoma de la papila de Vater que incluye displasia de alto grado parece estar asociado con un riesgo elevado de hallazgo postoperatorio de carcinoma invasor, así como con una alta tasa de recurrencia. Por consiguiente, se debe proponer pancreatoduodenectomía a los pacientes con adenomas con displasia de alto grado.

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Authors and Affiliations

  1. Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstrasse 22, 81675, Munich, Germany

    Claus-Dieter Heidecke M.D., Robert Rosenberg M. D., Jürgen D. Roder M.D. & Jórg-Rüdiger Siewert M.D.

  2. Institut für Pathologie und Pathologische Anatomie, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstrasse 22, 81675, Munich, Germany

    Markus Bauer M.D. & Martin Werner M. D.

  3. II Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstrasse 22, 81675, Munich, Germany

    Norbert Weigert M.D.

  4. Institut für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar der Technischen Universität München, Ismaningerstrasse 22, 81675, Munich, Germany

    Kurt Ulm M.D.

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  1. Claus-Dieter Heidecke M.D.
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  2. Robert Rosenberg M. D.
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  3. Markus Bauer M.D.
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  4. Martin Werner M. D.
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  5. Norbert Weigert M.D.
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  6. Kurt Ulm M.D.
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  7. Jürgen D. Roder M.D.
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Published Online: March 26, 2002

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Heidecke, CD., Robert, R., Bauer, M. et al. Impact of grade of dysplasia in villous adenomas of vater’s papilla. World J. Surg. 26, 709–714 (2002). https://doi.org/10.1007/s00268-002-6215-x

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  • DOI: https://doi.org/10.1007/s00268-002-6215-x

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