The role of K-ras mutations in the progression of tumors of the ampulla of Vater is not well understood. To study the frequency and timing of K-ras mutations in ampullary tumors, areas of invasive carcinoma and adjacent adenomas were microdissected from paraffin blocks from 96 resected tumors. DNA was extracted, PCR amplification of K-ras exon 1 was performed, and PCR products were sequenced. Statistical analysis of K-ras mutations with respect to patient survival and clinicopathological factors was performed using the chi2 test, log-rank test, and Cox proportional hazard model. Thirty-four of 92 ampullary carcinomas (37.0%) and 25 of 46 adenomas (54.3%) had mutations in K-ras exon 1. Twenty-two of 23 (95.7%) adenomas adjacent to carcinomas with K-ras mutations also had K-ras mutations. The only clinicopathological factor significantly associated with K-ras mutation was tumor size >2 cm (P = = 0.035). Patient survival did not correlate with the K-ras mutation status (P = 0.31). We conclude that K-ras mutations are frequent in both adenomas and carcinomas of the ampulla of Vater and appear to occur as an early genetic event. The spectrum of mutations is similar to that observed in colorectal neoplasms, and these do not significantly correlate with patient survival.