Assessment of survival advantage in ampullary carcinoma in relation to tumour biology and morphology G. Morris-Stiff a , E. Alabraba a , Y.-M. Tan a , I. Shapey a , C. Bhati a , P. Tanniere b , D. Mayer a , J. Buckels a , S. Bramhall a , D.F. Mirza a, * a Hepato-biliary Pancreatic Surgery Unit, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom b Department of Histopathology, Queen Elizabeth Hospital, Edgbaston, Birmingham, United Kingdom Accepted 10 October 2008 Available online 23 January 2009 Abstract Introduction: Carcinoma of the ampulla of Vater is said to carry a significantly better prognosis than pancreatic ductal adenocarcinomas arising in the pancreatic head. However, it is uncertain as to whether this is due to the fact that they have differing oncological character- istics or simply an earlier presentation as a result of the exophytic morphology of ampullary lesions causing obstruction of the bile ducts. Methods: All patients undergoing pancreaticoduodenectomy between January 1998 and December 2004 were identified from a prospectively maintained database. Patients with a pathologically confirmed ampullary (AMP) tumour were compared to those with a carcinoma of the head of the pancreas (HOP). Tumour characteristics including size, stage and degree of differentiation were analysed as were survival data. Results: 71 AMP and 144 HOP tumours were resected during the period studied and had full histology reports available for assessment. The median diameter of the AMP tumours was significantly less than those of the HOP (2 cm vs. 3 cm; p ¼ 0.04). The T stage distribution differed significantly between the AMP and HOP tumours in favour of the former (Stages I e 10 vs. 0( p ¼ 0.03); II e 29 vs. 13 ( p ¼ 0.04); III e 25 vs. 121 ( p ¼ 0.01); IV e 7 vs. 10). The number of resection specimens with positive lymph nodes was lower in the AMP group (31 vs. 121; p ¼ 0.03) as was the prevalence of vascular invasion (33 vs. 114; p ¼ 0.006) and neural invasion (23 vs. 134; p ¼ 0.009). There was no difference in the degree of differentiation of the AMP and HOP tumours. The 5-year survival rates were significantly better in the AMP group at 60% vs. 20% ( p ¼ 0.008). Subdivision of AMP carcinoma into polypoid (60%) and ulcerating (40%) lesions revealed a non-significant survival advantage in favour of polypoid tumours at (64% vs. 60%; p ¼ 0.07) at 5 years. Conclusions: The outcome of resection for AMP is significantly better than for pancreatic ductal adenocarcinomas arising in the periam- pullary region. Although the anatomical position of AMP tumours may contribute to this survival advantage, the HOP tumours exhibit more adverse histological features suggesting that they are different diseases and hence the difference in survival. Ó 2008 Elsevier Ltd. All rights reserved. Keywords: Ampullary carcinoma; Resection; Survival Introduction A periampullary carcinoma e one arising in the region of the ampulla of Vater, may be from one of four potential ori- gins e pancreas, bile duct, the ampulla itself or the periam- pullary duodenum. A carcinoma of the ampulla of Vater (AMP) is the second most common of the four tumours following carcinoma of the head of pancreas (HOP), representing around 10% 1 of all periampullary tumours but up to 46.6% of those undergoing resection. 2 Resection rates in excess of 80% are frequently reported for AMP which is far superior to the 20% reported for HOP lesions. 1,3 Distinction as to the origin of the tumour is of vital impor- tance since although the presentation is similar there is a sig- nificant difference in outcome. Riall et al. reported long-term follow-up data from the John’s Hopkins series of pancreati- coduodenectomy (PD) which indicated that the 5-year sur- vival ranged from 59% for duodenal tumours, through 39% for ampullary carcinomas, 27% for cholangiocarcinoma of the distal bile duct down to 15% for the most frequently seen lesion, carcinoma of the head of the pancreas. 1 * Corresponding author. Hepato-biliary Pancreatic Surgery Unit, Nuffield House, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom. Tel.: þ44 0121 6178927. E-mail address: darius.mirza@uhb.nhs.uk (D.F. Mirza). 0748-7983/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ejso.2008.10.010 Available online at www.sciencedirect.com EJSO 35 (2009) 746e750 www.ejso.com