The Value Of Pathological Classification Of Duodenal Papillary Adenoma In Clinical Diagnosis And Treatment

Background and objective:Duodenal papillary adenomas are clinically important because of their premalignant potential,which can be excised either surgically or endoscopically.Compared to surgery,endoscopic treatment was associated with fewer complications and higher recurrence rate.Even if expertise in the therapeutic endoscopic arts is evolving,the recurrence almost remains.It is well known that the pathological classification of duodenal papillary adenocarcinoma carcinomas has play a vital role in the prognosis;however,it is not fully known to all that duodenal papillary adenomas have their own pathological classification,but the relationship between the pathological classification and recurrence is not clear.We studied the clinicopathological characteristics of duodenal papillary adenoma with different pathological types,and conducted a long-term follow-up to explore the prognosis of duodenal papillary adenoma by endoscopic papillectomy(EP),for the aim to find the suitable management for duodenal papillary adenomas clinically.Methods:A total of 95 patients with duodenal papillary adenoma confirmed by postoperative pathology were collected in DrumTower Hospital,of which 58 lesions were treated by endoscopic papillectomy(EP)and 37 cases were resected by pancreatoduodenectomy(PD).According to histopathology and location of endoscopic features,all subjects were classified into 3 types of macrotypes and 2 types of histology,and we summarized and compared the clinicopathologic features of duodenal papillary adenomas with different pathological types in all patiens.Furthermore,we investigated the factors associated with recurrence among subgroup of patients who uderwent EP.Results:Duodenal papillary adenomas(DPA)were classified into 3 types of macrotypes,called periampullary duodenal papillary adenoma(peri-DPA),intra-ampullary duodenal papillary adenoma(intra-DPA)and mixed-DPA.In histology,91.3%(42/46)peri-DPA and 84.6%(11/13)mixed-DPA comprised the intestinal type,however,the intra-DPA was composed of 66.7%(24/36)pancreatobiliary and 33.3%(12/36)intestinal histomorphological types.There is a significant positive correlation between the type of giant examination and histological classification(Pearson,r=0.562,p<0.001).Compared to PD,EP was associated with fewer complications(32.8%vs 75%,p<0.001),however,the R0 rate was obviously lower and the recurrence rate of EP was significantly higher than PD(72.4%vs 100.0%,p<0.001;16.3%vs 0.0%,p<0.001).Among 8 patients with recurrence after EP,the intra-DPA got six(75%),while the peri-DPA and the mixed-DPA accounted for 12.5%respectively.The DFS after EP was correlated with the macrotype of adenoma(the intra-DPA)(p<0.001),the grade of hyperplasia(HGIN)(p=0.003),incomplete resection(R1)(p<0.001),MUC2 negative,preoperative evaluation of bile duct dilatation(p=0.041),preoperative AKP/TB/DB higher than normal(p=0.015,p=0.034,p=0.024),the increase of preoperative tumor markers(CA-199,CA-242)(p=0.010,p=0.003)by univariate analysis.We enrolled the risk factors above into the multivariate analysis,which showd the incomplete resection(R1)and MUC2 negative were independent risk factors for adenoma recurrence after EP(HR 23.67,95%CI 6.42-87.27,p<0.001.HR 3.47,95%CI 1.16-10.40,p=0.026).In general,there was no statistically significant difference in the choice of endoscopic or surgical resection of duodenal papillary adenomas with different pathological types.However,the endoscopic complete resection rate of intra-DPA was significantly lower than peri-DPA(61.1%vs 97.8%,p<0.001),and the local recurrence rate of EP of the intra-DPA was significantly higher than that of the periampullary type(HR 18.43,95%CI 2.20-154.06,p=0.007).In addition,the intestinal histomorphological adenoma had a significantly higher complete resection rate than that of the pancreatobiliary type(92.3%vs 63.3%,p<0.001),yet the DFS of the two histomorphological type was no statistically significant.Conclusions:Our study confirms that there are different pathological types of duodenal papillary adenoma,and different pathological types of duodenal papillary adenoma have different clinicopathological features.The R0 resection rate is low while the residual(recurrence within 6 months after operation)rate is high of the intra-DPA and the pancreatobiliary DPA,in addition,the the rucurrence(relapse after 6 months postoperatively)rate of the intra-DPA is high,which suggests that the intra-DPA is more suitable for surgical treatment.This study exhibits that pathological classification of DPA,especially the macrotype,may be a good strategy for the choice of endoscopic or surgical treatment.