背景:壶腹肿瘤(AT)的治疗由于科学证据水平低而具有挑战性。本文件是法国关于AT管理的集团间准则的摘要,腺瘤(AA)或癌(AC),2023年7月出版,可在法国胃肠病学会(SNFGE)网站上查阅(www.tncd.org)。
方法:在法国医学的主持下进行了一项协作工作,内窥镜,参与AT管理的肿瘤和外科学会。建议基于最近的文献综述和专家意见,分为三类(A,B,C),根据证据的质量。
结果:AT的准确诊断至少需要十二指肠镜检查和EUS。所有患者治疗前应在多学科肿瘤委员会讨论。只能对家族性腺瘤性息肉病中的小AA进行监测。对于AA,只有在可以实现R0切除的情况下,内镜下乳头切除术才是首选。如果不可能,应考虑手术乳头切除术。对于pT1aN0以外的AC,胰十二指肠切除术是首选方法。辅助单一化疗(吉西他滨,5FU)可以提议。对于侵袭性肿瘤(pT3/T4,pN+,R1,分化差的AC,胰胆管分化)具有高复发风险,6个月的综合化疗(CAPOX/FOLFOX用于肠道亚型,mFOLFIRINOX用于胰胆管或混合亚型)可能是有效的替代方案。建议临床和放射学随访5年。
结论:这些指南有助于在AA和AC的管理中均匀化和突出未满足的需求。每个个案都应由多学科小组讨论。
BACKGROUND: Management of ampullary tumors (AT) is challenging because of a low level of scientific evidence. This document is a summary of the French intergroup
guidelines regarding the management of AT, either adenoma (AA) or carcinoma (AC), published in July 2023, available on the website of the French Society of Gastroenterology (SNFGE) (www.tncd.org).
METHODS: A collaborative work was conducted under the auspices of French medical, endoscopic, oncological and surgical societies involved in the management of AT. Recommendations are based on recent literature review and expert opinions and graded in three categories (A, B, C), according to quality of evidence.
RESULTS: Accurate diagnosis of AT requires at least duodenoscopy and EUS. All patients should be discussed in multidisciplinary tumor board before treatment. Surveillance may only be proposed for small AA in familial adenomatous polyposis. For AA, endoscopic papillectomy is the preferred option only if R0 resection can be achieved. When not possible, surgical papillectomy should be considered. For AC beyond pT1a N0, pancreaticoduodenectomy is the procedure of choice. Adjuvant monochemotherapy (gemcitabine, 5FU) may be proposed. For aggressive tumors (pT3/T4, pN+, R1, poorly differentiated AC, pancreatobiliary differentiation) with high risk of recurrence, 6 months polychemotherapy (CAPOX/FOLFOX for the intestinal subtype and mFOLFIRINOX for the pancreatobiliary or the mixed subtype) may be a valid alternative. Clinical and radiological follow up is recommended for 5 years.
CONCLUSIONS: These
guidelines help to homogenize and highlight unmet needs in the management of AA and AC. Each individual case should be discussed by a multidisciplinary team.