AMPULLA OF VATER (ICD‐O‐3 C24.1) (FIG. 229)

Rules for Classification

The classification applies only to carcinomas. There should be histological confirmation of the disease.

Regional Lymph Nodes (Fig. 230)

The regional lymph nodes are the same as for the head of the pancreas and are the lymph nodes along the anterior and posterior pancreaticoduodenal vessels the superior mesenteric vein and right lateral wall of the superior mesenteric artery, proximal mesenteric vessels, the common hepatic artery, coeliac axis, pyloric, infrapyloric, subpyloric vessels, portal vein and common bile duct (not shown).

Schematic illustration of ampulla of vater. — **Fig. 229**

Schematic illustration of the lymph nodes along the anterior and posterior pancreaticoduodenal vessels the superior mesenteric vein and right lateral wall of the superior mesenteric artery, proximal mesenteric vessels, the common hepatic artery, coeliac axis, pyloric, infrapyloric, subpyloric vessels. — **Fig. 230**

Source: From F. Charles Brunicardi et al. (2015) *Schwartz’s Principles of Surgery,* 10th edition, McGraw Hill Education. © 2015 McGraw Hill Education.

Note

The splenic lymph nodes and those of the tail of the pancreas are not regional; metastases to these lymph nodes are coded M1.

TNM Clinical Classification

T – Primary Tumour

TX	Primary tumour cannot be assessed
T0	No evidence of primary tumour
Tis	Carcinoma in situ
T1a	Tumour limited to ampulla of Vater or sphincter of Oddi (Fig. 231)
T1b	Tumour invades beyond the sphincter of Oddi (perisphincteric invasion) and/or into the duodenal submucosa (Fig. 232)
T2	Tumour invades the muscularis propria of the duodenum
T3	Tumour invades pancreas or peripancreatic tissue (Fig. 233)
	T3a	Tumour invades no more than 0.5 cm into the pancreas
	T3b	Tumour invades more than 0.5 cm into the pancreas or extends into peripancreatic tissue or duodenal serosa, but without involvement of the coeliac axis or the superior mesenteric artery
T4	Tumour with vascular involvement of the superior mesenteric artery or coeliac axis, or portal venous involvement that cannot be reconstructed (Fig. 234)

Schematic illustration of tumour limited to ampulla of Vater or sphincter of Oddi. — **Fig. 231**

Schematic illustration of tumour invades beyond the sphincter of Oddi and into the duodenal submucosa. — **Fig. 232**

Schematic illustration of tumour invades pancreas or peripancreatic tissue. — **Fig. 233**

Schematic illustration of tumour with vascular involvement of the superior mesenteric artery or coeliac axis, or portal venous involvement that cannot be reconstructed. — **Fig. 234**

N – Regional Lymph Nodes

NX	Regional lymph nodes cannot be assessed
N0	No regional lymph node metastasis
N1	Metastasis in 1 or 3 regional lymph nodes (Fig. 235)
N2	Metastasis in 4 or more regional lymph nodes (Fig. 236)

M – Distant Metastasis

M0	No distant metastasis
M1	Distant metastasis (Fig. 237)

Schematic illustration of Metastasis in 1 or 3 regional lymph nodes. — **Fig. 235**

Schematic illustration of Metastasis in 4 or more regional lymph nodes. — **Fig. 236**

Schematic illustration of Distant metastasis. — **Fig. 237**

TNM Pathological Classification

The pT and pN categories correspond to the T and N categories.

pM1	Distant metastasis microscopically confirmed

Note

pM0 and pMX are not valid categories.

pN0

Histological examination of a regional lymphadenectomy specimen will ordinarily include 10 or more lymph nodes. If the lymph nodes are negative, but the number ordinarily examined is not met, classify as pN0.