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Shin DW, Lee JM, Lee JC, Lee HS, Yoon SB, Jang DK, Park JK, Jung MK, Lee YS, Hwang JH. Adjuvant Chemotherapy and Effect on Long-Term Survival in Ampullary Adenocarcinoma: A Multicenter Cohort Study. J Am Coll Surg 2023; 237:501-512. [PMID: 37222437 DOI: 10.1097/xcs.0000000000000769] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND The role of adjuvant chemotherapy (AC) in patients with ampullary adenocarcinoma (AA) remains controversial. This study aimed to determine if AC could improve the prognosis of patients with resected AA. STUDY DESIGN This study enrolled patients diagnosed with AA at 9 tertiary teaching hospitals. Patients who did and did not receive AC were matched 1:1 using propensity score. The overall survival (OS) and recurrence-free survival (RFS) were compared between the 2 groups. RESULTS Of the 1,057 patients with AA, 883 underwent curative-intent pancreaticoduodenectomy, and 255 received AC. Because patients with advanced-stage AA received AC more frequently, the no AC group unexpectedly had a longer OS (not reached vs 78.6 months; p < 0.001) and RFS (not reached vs 18.7 months; p < 0.001) than did the AC group in the unmatched cohort. In the propensity score-matched cohort (n = 296), no difference between the 2 groups in terms of OS (95.9 vs 89.8 months, p = 0.303) and RFS (not reached vs 25.5 months; p = 0.069) was found. By subgroup analysis, patients with advanced stage (pT4 or pN1-2) showed longer OS in the AC group than in the no AC group (not reached vs 15.7 months, p = 0.007: 89.8 vs 24.2 months, p = 0.006, respectively). There was no difference in RFS according to AC in the propensity score-matched cohort. CONCLUSIONS Given its favorable long-term outcomes, AC can be recommended for patients with resected AA, especially those in the advanced stage (pT4 or pN1-2).
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Affiliation(s)
- Dong Woo Shin
- From the Division of Gastroenterology, Department of Internal Medicine, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, Republic of Korea (Shin)
| | - Jae Min Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea (JM Lee)
| | - Jong-Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea (JC Lee, Hwang)
| | - Hee Seung Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (HS Lee)
| | - Seung Bae Yoon
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (Yoon)
| | - Dong Kee Jang
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea (Jang)
| | - Joo Kyung Park
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (Park)
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea (Park)
| | - Min Kyu Jung
- Division of Gastroenterology, Department of Internal Medicine, Kyungpook National University School of Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea (Jung)
| | - Yoon Suk Lee
- Division of Gastroenterology, Department of Internal Medicine, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Gyeonggi-do, Republic of Korea (YS Lee)
| | - Jin-Hyeok Hwang
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea (JC Lee, Hwang)
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Shin DW, Kim S, Jung K, Jung JH, Kim B, Ahn J, Kim J, Hwang JH, Lee JC. Impact of histopathological type on the prognosis of ampullary carcinoma: A systematic review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:306-315. [PMID: 36272870 DOI: 10.1016/j.ejso.2022.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 08/27/2022] [Accepted: 10/05/2022] [Indexed: 02/23/2023]
Abstract
Histologically, ampullary carcinomas (ACs) can be classified into intestinal (INT-AC) and pancreatobiliary (PB-AC) subtypes. However, the prognostic implications of these subtypes remain unclear. This study aimed to evaluate the impact of the histopathologic phenotype of ACs on survival following pancreaticoduodenectomy. We searched PubMed, Embase, and Medline for studies published in English from 1994 to 2021. A meta-analysis was performed using Review Manager 5.3. The primary endpoint was overall survival (OS). We identified 3,890 articles; of these, 37 articles involving 3,455 participants (1,659 INT-ACs and 1,796 PB-ACs) were included. Patients in the PB-ACs group had significantly shorter OS than those in the INT-ACs group (hazard ratio [HR]: 1.79, 95% confidence interval [95% CI]: 1.51-2.13, p < 0.001, I2 = 61%). A similar tendency was observed in the immunohistochemistry staining group (HR: 1.76, 95% CI: 1.33-2.33, p < 0.001, I2 = 67%), which included 24 studies and 1,638 patients, and the non-immunohistochemistry group (HR: 1.84, 95% CI: 1.53-2.22, p = 0.04, I2 = 46%), which included 13 studies and 1,817 patients. Subgroup analysis revealed that patients with PB-AC had higher frequencies of advanced (III, IV) and pT3-4 stage AC, lymph node metastasis, poorly differentiated tumor, positive surgical margins, lymphovascular invasion, and perineural invasion, than those with INT-AC. Patients with PB-AC had a significantly shorter OS than those with INT-AC due to a higher aggressiveness. Because the histopathologic subtype is a major prognostic factor in patients with resected AC, routine histopathologic classification should be considered even in clinical settings without immunohistochemistry.
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Affiliation(s)
- Dong Woo Shin
- Department of Internal Medicine, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, Republic of Korea
| | - Sihyun Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
| | - Kwangrok Jung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
| | - Jae Hyup Jung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
| | - Bomi Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
| | - Jinwoo Ahn
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea
| | - Jaihwan Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jong-Chan Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Xu SB, Jia CK, Liu L, Zhu HZ. The net parenchymal thickness predicts pancreatic fistula after pancreaticoduodenectomy: a retrospective cohort study of objective data. ANZ J Surg 2022; 92:1097-1104. [PMID: 35388582 DOI: 10.1111/ans.17673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/11/2022] [Accepted: 03/13/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The clinically relevant postoperative pancreatic fistula (CR-POPF) is still a challenging complication of pancreaticoduodenectomy (PD). This study aims to explore the predictors of CR-POPF after PD, including net parenchymal thickness (NPT) of pancreatic neck. METHODS The consecutive patients who underwent PD at a tertiary hospital were retrospectively reviewed. Univariate and multivariate analyses were conducted on the perioperative data, which was mainly extracted from the objective data, containing the results from the laboratory tests and the imaging examination. NPT refers to the total thickness of pancreatic gland excluding main pancreatic duct (MPD) at the CT film. RESULTS Univariate analyses showed that total serum bilirubin (TBiL) and albumin (ALB) levels, MPD size and NPT were significantly different between the patients with and without CR-POPF. The white blood cell count, the rate of intra-abdominal infection (IAI) and the postoperative length of hospital stay (LOS) were associated with the incidence of CR-POPF. The proportion of patients with pancreatic adenocarcinoma or chronic pancreatitis was significantly lower in the CR-POPF group than in the non-CR-POPF group. Multivariate analyses manifested that ALB ≤35 g/L and NPT >10 mm were two of the independent risk factors for CR-POPF. CONCLUSION Preoperative ALB ≤35 g/L and NPT > 10 mm were both the independent predictors of CR-POPF. CR-POPF was associated with the higher IAI rate and the extended LOS.
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Affiliation(s)
- Sun-Bing Xu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Chang-Ku Jia
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Ling Liu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Han-Zhang Zhu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
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Market M, Tennakoon G, Auer RC. Postoperative Natural Killer Cell Dysfunction: The Prime Suspect in the Case of Metastasis Following Curative Cancer Surgery. Int J Mol Sci 2021; 22:ijms222111378. [PMID: 34768810 PMCID: PMC8583911 DOI: 10.3390/ijms222111378] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 12/12/2022] Open
Abstract
Surgical resection is the foundation for the curative treatment of solid tumors. However, metastatic recurrence due to the difficulty in eradicating micrometastases remain a feared outcome. Paradoxically, despite the beneficial effects of surgical removal of the primary tumor, the physiological stress resulting from surgical trauma serves to promote cancer recurrence and metastasis. The postoperative environment suppresses critical anti-tumor immune effector cells, including Natural Killer (NK) cells. The literature suggests that NK cells are critical mediators in the formation of metastases immediately following surgery. The following review will highlight the mechanisms that promote the formation of micrometastases by directly or indirectly inducing NK cell suppression following surgery. These include tissue hypoxia, neuroendocrine activation, hypercoagulation, the pro-inflammatory phase, and the anti-inflammatory phase. Perioperative therapeutic strategies designed to prevent or reverse NK cell dysfunction will also be examined for their potential to improve cancer outcomes by preventing surgery-induced metastases.
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Affiliation(s)
- Marisa Market
- Faculty of Medicine, University of Ottawa, Ottawa, ON K1G 8M5, Canada; (M.M.); (G.T.)
- The Ottawa Hospital Research Institute, Ottawa, ON K1G 4E3, Canada
| | - Gayashan Tennakoon
- Faculty of Medicine, University of Ottawa, Ottawa, ON K1G 8M5, Canada; (M.M.); (G.T.)
| | - Rebecca C. Auer
- The Ottawa Hospital Research Institute, Ottawa, ON K1G 4E3, Canada
- Department of General Surgery, The Ottawa Hospital, Ottawa, ON K1Y 4E9, Canada
- Correspondence: ; Tel.: +1-613-722-7000
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5
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Survival Benefit of Adjuvant Chemotherapy After Pancreatoduodenectomy for Ampullary Adenocarcinoma: a Propensity-Matched National Cancer Database (NCDB) Analysis. J Gastrointest Surg 2021; 25:1805-1814. [PMID: 33230687 PMCID: PMC8275534 DOI: 10.1007/s11605-020-04879-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 11/10/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The benefit of adjuvant chemotherapy (AC) after pancreatoduodenectomy (PD) for ampullary adenocarcinoma is uncertain. We aimed to evaluate the association of AC with survival in patients with resected ampullary adenocarcinoma. METHODS Using the National Cancer Database (NCDB) data from 2004 to 2016, patients with non-metastatic ampullary adenocarcinoma who underwent PD were identified. Patients with neoadjuvant radiotherapy and chemotherapy and survival < 6 months were excluded. Propensity score matching was used to account for treatment selection bias. A multivariable Cox proportional hazards model was then used to analyze the association of AC with survival. RESULTS Of 3186 (43%) AC and 4172 (57%) no AC (noAC) patients, 1720 AC and 1720 noAC patients remained in the cohort after matching. Clinicopathologic variables were well balanced after matching. After matching, AC was associated with improved survival (median 47.5 vs 39.6 months, p = 0.003), which remained after multivariable adjustment (HR: 0.83, CI95%: 0.76-0.91, p < 0.001). Multivariable interaction analyses showed that this benefit was seen irrespective of nodal status: N0 (HR: 0.81, CI95%: 0.68-0.97, p < 0.001), N1 (HR: 0.65, CI95%: 0.61-0.70, p < 0.001), N2 (HR: 0.73, CI95%: 0.59-0.90, p = 0.003), N3 (HR: 0.59, CI95%: 0.44-0.78, p < 0.001); and margin status: R0 (HR: 0.85, CI95%: 0.77-0.94, p < 0.001), R1 (HR: 0.69, CI95%: 0.48-1.00, p < 0.001). Stratified analyses by nodal and margin status demonstrated consistent results. CONCLUSION In this large retrospective cohort study, AC after resected ampullary adenocarcinoma was associated with a survival benefit in patients, including patients with node-negative and margin-negative disease.
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Histopathologic Predictors of Survival and Recurrence in Resected Ampullary Adenocarcinoma: International Multicenter Cohort Study. Ann Surg 2020; 272:1086-1093. [PMID: 30628913 DOI: 10.1097/sla.0000000000003177] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of the study was to define histopathologic characteristics that independently predict overall survival (OS) and disease-free survival (DFS), in patients who underwent resection of an ampullary adenocarcinoma with curative intent. SUMMARY BACKGROUND DATA A broad range of survival rates have been described for adenocarcinoma of the ampulla of Vater, presumably due to morphological heterogeneity which is a result of the different epitheliums ampullary adenocarcinoma can arise from (intestinal or pancreaticobiliary). Large series with homogenous patient selection are scarce. METHODS A retrospective multicenter cohort analysis of patients who underwent pancreatoduodenectomy for ampullary adenocarcinoma in 9 European tertiary referral centers between February 2006 and December 2017 was performed. Collected data included demographics, histopathologic details, survival, and recurrence. OS and DFS analyses were performed using Kaplan-Meier curves and Cox proportional hazard models. RESULTS Overall, 887 patients were included, with a mean age of 66 ± 10 years. The median OS was 64 months with 1-, 3-, 5-, and 10-year OS rates of 89%, 63%, 52%, and 37%, respectively. Histopathologic subtype, differentiation grade, lymphovascular invasion, perineural invasion, T-stage, N-stage, resection margin, and adjuvant chemotherapy were correlated with OS and DFS. N-stage (HR = 3.30 [2.09-5.21]), perineural invasion (HR = 1.50 [1.01-2.23]), and adjuvant chemotherapy (HR = 0.69 [0.48-0.97]) were independent predictors of OS in multivariable analysis, whereas DFS was only adversely predicted by N-stage (HR = 2.65 [1.65-4.27]). CONCLUSIONS Independent predictors of OS in resected ampullary cancer were N-stage, perineural invasion, and adjuvant chemotherapy. N-stage was the only predictor of DFS. These findings improve predicting survival and recurrence after resection of ampullary adenocarcinoma.
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7
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Tashiro K, Kuroki N, Einama T, Iwasaki T, Miyata Y, Aosasa S, Inoue Y, Takahashi Y, Ogata S, Ueno H, Hase K, Yamamoto J, Kishi Y. Prognostic significance of regional lymph node metastasis according to station in ampullary carcinoma. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:712-720. [PMID: 32578342 DOI: 10.1002/jhbp.791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/08/2020] [Accepted: 06/18/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The TNM (Tumor, Node, Metastasis) classification of the 8th Union for International Cancer Control and the 6th Japanese classification of biliary tract cancer were made on the premise that the prognostic effect of each regional lymph node station is similar. However, some studies have reported different effects of lymph node metastasis location on post-resection prognosis. This study aimed to investigate outcome following radical resection of ampullary carcinoma according to station of lymph node metastasis. METHODS Patients who underwent surgical resection for ampullary carcinoma between January 2007 and December 2017 at two separate Japanese institutions were included. Regional lymph nodes were subclassified as follows: Pancreatoduodenal lymph nodes (PD) and others (OT). RESULTS Of the 101 patients analyzed, 34 had regional lymph node metastasis. OT metastasis was found in eight patients. Significant differences were found in relapse-free survival (RFS) and overall survival (OS) between the three study groups (no nodal metastasis, only PD metastasis and OT metastasis; P < .001 for both). OT metastasis was an independent prognostic factor in the multivariate analysis for RFS (hazard ratio [HR] 17.14; 95% confidence interval [CI], 6.33-43.93) and OS (HR 11.06; 95% CI, 3.7-32.99). CONCLUSION The poor prognosis of ampullary carcinoma patients with OT metastasis suggests that regional lymph nodes should not be categorized equally into one group.
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Affiliation(s)
- Keita Tashiro
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Naomi Kuroki
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Koto, Tokyo, Japan
| | - Takahiro Einama
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Toshimitsu Iwasaki
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Yoichi Miyata
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Suefumi Aosasa
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan.,Department of Surgery, Shin-Kuki General Hospital, Kuki, Saitama, Japan
| | - Yosuke Inoue
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Koto, Tokyo, Japan
| | - Yu Takahashi
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Koto, Tokyo, Japan
| | - Sho Ogata
- Department of Pathology and Laboratory Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hideki Ueno
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Kazuo Hase
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
| | - Junji Yamamoto
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan.,Department of Gastrointestinal Surgery, Ibaraki Prefectural Central Hospital, Kasama, Ibaraki, Japan
| | - Yoji Kishi
- Department of Surgery, National Defense Medical College Hospital, Tokorozawa, Saitama, Japan
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Development and external validation of a prediction model for survival in patients with resected ampullary adenocarcinoma. Eur J Surg Oncol 2020; 46:1717-1726. [PMID: 32624291 DOI: 10.1016/j.ejso.2020.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/26/2020] [Accepted: 04/09/2020] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Ampullary adenocarcinoma (AAC) is a rare malignancy with great morphological heterogeneity, which complicates the prediction of survival and, therefore, clinical decision-making. The aim of this study was to develop and externally validate a prediction model for survival after resection of AAC. MATERIALS AND METHODS An international multicenter cohort study was conducted, including patients who underwent pancreatoduodenectomy for AAC (2006-2017) from 27 centers in 10 countries spanning three continents. A derivation and validation cohort were separately collected. Predictors were selected from the derivation cohort using a LASSO Cox proportional hazards model. A nomogram was created based on shrunk coefficients. Model performance was assessed in the derivation cohort and subsequently in the validation cohort, by calibration plots and Uno's C-statistic. Four risk groups were created based on quartiles of the nomogram score. RESULTS Overall, 1007 patients were available for development of the model. Predictors in the final Cox model included age, resection margin, tumor differentiation, pathological T stage and N stage (8th AJCC edition). Internal cross-validation demonstrated a C-statistic of 0.75 (95% CI 0.73-0.77). External validation in a cohort of 462 patients demonstrated a C-statistic of 0.77 (95% CI 0.73-0.81). A nomogram for the prediction of 3- and 5-year survival was created. The four risk groups showed significantly different 5-year survival rates (81%, 57%, 22% and 14%, p < 0.001). Only in the very-high risk group was adjuvant chemotherapy associated with an improved overall survival. CONCLUSION A prediction model for survival after curative resection of AAC was developed and externally validated. The model is easily available online via www.pancreascalculator.com.
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Moekotte AL, Malleo G, van Roessel S, Bonds M, Halimi A, Zarantonello L, Napoli N, Dreyer SB, Wellner UF, Bolm L, Mavroeidis VK, Robinson S, Khalil K, Ferraro D, Mortimer MC, Harris S, Al-Sarireh B, Fusai GK, Roberts KJ, Fontana M, White SA, Soonawalla Z, Jamieson NB, Boggi U, Alseidi A, Shablak A, Wilmink JW, Primrose JN, Salvia R, Bassi C, Besselink MG, Abu Hilal M. Gemcitabine-based adjuvant chemotherapy in subtypes of ampullary adenocarcinoma: international propensity score-matched cohort study. Br J Surg 2020; 107:1171-1182. [PMID: 32259295 DOI: 10.1002/bjs.11555] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/14/2019] [Accepted: 01/23/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Whether patients who undergo resection of ampullary adenocarcinoma have a survival benefit from adjuvant chemotherapy is currently unknown. The aim of this study was to compare survival between patients with and without adjuvant chemotherapy after resection of ampullary adenocarcinoma in a propensity score-matched analysis. METHODS An international multicentre cohort study was conducted, including patients who underwent pancreatoduodenectomy for ampullary adenocarcinoma between 2006 and 2017, in 13 centres in six countries. Propensity scores were used to match patients who received adjuvant chemotherapy with those who did not, in the entire cohort and in two subgroups (pancreatobiliary/mixed and intestinal subtypes). Survival was assessed using the Kaplan-Meier method and Cox regression analyses. RESULTS Overall, 1163 patients underwent pancreatoduodenectomy for ampullary adenocarcinoma. After excluding 187 patients, median survival in the remaining 976 patients was 67 (95 per cent c.i. 56 to 78) months. A total of 520 patients (53·3 per cent) received adjuvant chemotherapy. In a propensity score-matched cohort (194 patients in each group), survival was better among patients who received adjuvant chemotherapy than in those who did not (median survival not reached versus 60 months respectively; P = 0·051). A survival benefit was seen in patients with the pancreatobiliary/mixed subtype; median survival was not reached in patients receiving adjuvant chemotherapy and 32 months in the group without chemotherapy (P = 0·020). Patients with the intestinal subtype did not show any survival benefit from adjuvant chemotherapy. CONCLUSION Patients with resected ampullary adenocarcinoma may benefit from gemcitabine-based adjuvant chemotherapy, but this effect may be reserved for those with the pancreatobiliary and/or mixed subtype.
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Affiliation(s)
- A L Moekotte
- Departments of Surgery, Southampton, UK.,Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - G Malleo
- Department of Surgery, University Hospital of Verona, Verona, Italy
| | - S van Roessel
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - M Bonds
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - A Halimi
- Pancreatic Surgery Unit, Division of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - L Zarantonello
- Pancreatic Surgery Unit, Division of Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - N Napoli
- Department of Surgery, Pisa University Hospital, Pisa, Italy
| | - S B Dreyer
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - U F Wellner
- Department of Surgery, University Medical Centre Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - L Bolm
- Department of Surgery, University Medical Centre Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - V K Mavroeidis
- Department of Hepatobiliary and Pancreatic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Robinson
- Department of Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - K Khalil
- Faculty of Medicine, University of Birmingham, Birmingham, UK
| | - D Ferraro
- Department of Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - M C Mortimer
- Department of Surgery, Morriston Hospital, Swansea, UK
| | - S Harris
- Medical Statistics, Faculty of Medicine, University of Southampton, Southampton, UK
| | - B Al-Sarireh
- Department of Surgery, Morriston Hospital, Swansea, UK
| | - G K Fusai
- Department of Surgery, Royal Free London NHS Foundation Trust, London, UK
| | - K J Roberts
- Faculty of Medicine, University of Birmingham, Birmingham, UK
| | - M Fontana
- Department of Surgery, University Hospital of Verona, Verona, Italy
| | - S A White
- Department of Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Z Soonawalla
- Department of Hepatobiliary and Pancreatic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - N B Jamieson
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK.,West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - U Boggi
- Department of Surgery, Pisa University Hospital, Pisa, Italy
| | - A Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - A Shablak
- Departments of Medical Oncology, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
| | - J W Wilmink
- Department of Medical Oncology, Cancer Centre Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | | | - R Salvia
- Department of Surgery, University Hospital of Verona, Verona, Italy
| | - C Bassi
- Department of Surgery, University Hospital of Verona, Verona, Italy
| | - M G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - M Abu Hilal
- Departments of Surgery, Southampton, UK.,Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
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Prognostic factors and benefits of adjuvant therapy for ampullary cancer following pancreatoduodenectomy: A systematic review and meta-analysis. Asian J Surg 2020; 43:1133-1141. [PMID: 32249101 DOI: 10.1016/j.asjsur.2020.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/28/2020] [Accepted: 03/13/2020] [Indexed: 12/16/2022] Open
Abstract
Ampullary cancer is a relatively rare gastrointestinal malignancy. The purpose of this study was to evaluate prognostic factors for survival and assess the benefits of adjuvant therapy following pancreaticoduodenectomy for this entity. Medline and EMBASE databases were searched to identify eligible studies from January 2000 to August 2019. Review Manager 5.3 statistical software was used for meta-analysis. 71 studies met the inclusion criteria and were included in the analysis for a total of 8280 patients. The median (range) 5-year overall survival and disease-free survival rates were 58% (32-82%) and 51% (28-73%) respectively. In meta-analysis, age >65 years at diagnosis, tumor size >20 mm, poor differentiation, pancreaticobiliary histotype, pT3-4 stage disease, presence of metastatic lymph node, number of metastatic nodes, perineural invasion, lymphovascular invasion, vascular invasion, pancreatic invasion, and positive surgical margins were independently associated with worse overall survival, whereas adjuvant therapy was associated with improved overall survival. In summary, in patients with ampullary cancer undergoing pancreaticoduodenectomy, tumor factors are the main predictors of worse survival and adjuvant treatment confers a survival benefit.
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Zhao W, Wang B, Zhao A, Tian Q, Zhang L, Wang L, Zhao X, Yang J, Dong D. The role of radiotherapy in patients with resected ampullary carcinoma: findings based on the SEER database. HPB (Oxford) 2019; 21:1535-1540. [PMID: 31056288 DOI: 10.1016/j.hpb.2019.03.369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 03/20/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of adjuvant radiotherapy for resected ampullary carcinoma (AC) remains controversial. The aim of this study was to assess the effect of adjuvant radiotherapy on survival in patients who underwent resection for AC. METHODS The Surveillance, Epidemiology and End Results (SEER) database was used to identify patients diagnosed with AC from 2004 to 2012. Kaplan-Meier survival curve and multivariable Cox proportional hazards analyses were conducted to determine the effect of adjuvant radiotherapy on overall survival (OS) and disease-specific survival (DSS). Propensity score matching (PSM) method was used to balance the differences of clinicopathological characteristics between groups. RESULTS A total of 1227 patients were included. Patients who received adjuvant radiotherapy were younger, had more advanced T stage and N stage tumors and were more likely to receive chemotherapy (p < 0.001). Adjuvant radiotherapy failed to improve either OS (p = 0.119) or DSS (p = 0.188) in PSM cohorts. In subgroup analysis, no subgroup benefited from adjuvant radiotherapy and in patients older than 70 years, radiotherapy was associated with a worse OS and DSS. CONCLUSION Patients with resected AC do not benefit from adjuvant radiotherapy.
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Affiliation(s)
- Wen Zhao
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, People's Republic of China
| | - Biyuan Wang
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, People's Republic of China
| | - Andi Zhao
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, People's Republic of China
| | - Qi Tian
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, People's Republic of China
| | - Lingxiao Zhang
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, People's Republic of China
| | - Le Wang
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, People's Republic of China
| | - Xiaoai Zhao
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, People's Republic of China
| | - Jin Yang
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, People's Republic of China.
| | - Danfeng Dong
- Department of Medical Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, People's Republic of China.
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Kochar T, Dhingra P, Shah H. When Adenocarcinoma Went Hand in Hand with Neuroendocrine Tumor: A Rare Case of Adenocarcinoma Synchronous with Neuroendocrine Tumor in Ampulla of Vater. Cureus 2019; 11:e5168. [PMID: 31528518 PMCID: PMC6743665 DOI: 10.7759/cureus.5168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Neuroendocrine tumors (NETs) of gastrointestinal tract are rare entities. Their presence as synchronous lesions with adenocarcinoma has rarely been described in the literature. Cases of synchronous lesions of adenocarcinoma with neuroendocrine component have been described in the colon in the past. However, synchronous presence in the ampulla of Vater is quite uncommon. In the duodenum, NETs constitute 5.7 to 7.9% of the neuroendocrine neoplasms of the gastroenteropancreatic tract. We present a case of 65-year-old male who presented with abdominal symptoms and weight loss, was found to have adenocarcinoma of the ampulla of Vater on biopsy via endoscopic retrograde cholangiopancreatography (ERCP), for which he underwent Whipple’s surgery and was found to have neuroendocrine component along with adenocarcinoma postoperatively on histology.
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Affiliation(s)
- Tanureet Kochar
- Internal Medicine, Charleston Area Medical Center / West Virginia University, Charleston, USA
| | | | - Hamza Shah
- Gastroenterology, Charleston Area Medical Center, Charleston, USA
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Stiles ZE, Behrman SW, Deneve JL, Glazer ES, Dong L, Wan JY, Martin MG, Dickson PV. Ampullary adenocarcinoma: Defining predictors of survival and the impact of adjuvant therapy following surgical resection for stage I disease. J Surg Oncol 2018. [DOI: 10.1002/jso.25021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Zachary E. Stiles
- Department of Surgery; Division of Surgical Oncology; University of Tennessee Health Science Center; Memphis Tennessee
| | - Stephen W. Behrman
- Department of Surgery; Division of Surgical Oncology; University of Tennessee Health Science Center; Memphis Tennessee
| | - Jeremiah L. Deneve
- Department of Surgery; Division of Surgical Oncology; University of Tennessee Health Science Center; Memphis Tennessee
- West Cancer Center; Memphis Tennessee
| | - Evan S. Glazer
- Department of Surgery; Division of Surgical Oncology; University of Tennessee Health Science Center; Memphis Tennessee
- West Cancer Center; Memphis Tennessee
| | - Lei Dong
- Department of Surgery; Division of Surgical Oncology; University of Tennessee Health Science Center; Memphis Tennessee
| | - Jim Y. Wan
- Department of Preventive Medicine; Division of Biostatistics; University of Tennessee Health Science Center; Memphis Tennessee
| | - Michael G. Martin
- West Cancer Center; Memphis Tennessee
- Department of Medicine; Division of Hematology/Oncology; University of Tennessee Health Science Center; Memphis Tennessee
| | - Paxton V. Dickson
- Department of Surgery; Division of Surgical Oncology; University of Tennessee Health Science Center; Memphis Tennessee
- West Cancer Center; Memphis Tennessee
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Pancreaticoduodenectomy for periampullary tumours: a review article based on Surveillance, End Results and Epidemiology (SEER) database. Clin Transl Oncol 2018; 20:1153-1160. [PMID: 29335829 DOI: 10.1007/s12094-018-1832-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 01/04/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION This study set to examine relative survival of patients with periampullary cancers undergoing pancreaticoduodenectomy (PD). METHODS Using the Surveillance, End Results and Epidemiology (SEER) database, this study identified 9877 patients with non-metastatic pancreatic adenocarcinoma who underwent PD between 2004 and 2013. RESULTS Ampullary carcinomas have the best survival among periampullary malignancies. Lymph node ratio is a significant prognostic factor, even when stratified by tumour types. Patients receiving adjuvant radiotherapy following PD have superior survival than patients without radiotherapy (median 25 vs 20 months, p < 0.001), particularly ductal adenocarcinoma (HR: 0.74, CI95% 0.69-0.78; p < 0.001), cholangiocarcinoma (HR: 0.75, CI95% 0.59-0.97; p = 0.027), and ampullary carcinoma (HR: 0.79, CI95% 0.64-0.98; p = 0.029) with greatest survival benefit at 1-year postresection. CONCLUSION Future studies aiming to further define genetic signatures of individual periampullary cancers would allow a personalised therapeutic approach in improving survival.
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Chandrasegaram MD, Gill AJ, Samra J, Price T, Chen J, Fawcett J, Merrett ND. Ampullary cancer of intestinal origin and duodenal cancer - A logical clinical and therapeutic subgroup in periampullary cancer. World J Gastrointest Oncol 2017; 9:407-415. [PMID: 29085567 PMCID: PMC5648984 DOI: 10.4251/wjgo.v9.i10.407] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 06/26/2017] [Accepted: 08/16/2017] [Indexed: 02/05/2023] Open
Abstract
Periampullary cancers include pancreatic, ampullary, biliary and duodenal cancers. At presentation, the majority of periampullary tumours have grown to involve the pancreas, bile duct, ampulla and duodenum. This can result in difficulty in defining the primary site of origin in all but the smallest tumors due to anatomical proximity and architectural distortion. This has led to variation in the reported proportions of resected periampullary cancers. Pancreatic cancer is the most common cancer resected with a pancreaticoduodenectomy followed by ampullary (16%-50%), bile duct (5%-39%), and duodenal cancer (3%-17%). Patients with resected duodenal and ampullary cancers have a better reported median survival (29-47 mo and 22-54 mo) compared to pancreatic cancer (13-19 mo). The poorer survival with pancreatic cancer relates to differences in tumour characteristics such as a higher incidence of nodal, neural and vascular invasion. While small ampullary cancers can present early with biliary obstruction, pancreatic cancers need to reach a certain size before biliary obstruction ensues. This larger size at presentation contributes to a higher incidence of resection margin involvement in pancreatic cancer. Ampullary cancers can be subdivided into intestinal or pancreatobiliary subtype cancers with histomolecular staining. This avoids relying on histomorphology alone, as even some poorly differentiated cancers preserve the histomolecular profile of their mucosa of origin. Histomolecular profiling is superior to anatomic location in prognosticating survival. Ampullary cancers of intestinal subtype and duodenal cancers are similar in their intestinal origin and form a logical clinical and therapeutic subgroup of periampullary cancers. They respond to 5-FU based chemotherapeutic regimens such as capecitabine-oxaliplatin. Unlike pancreatic cancers, KRAS mutation occurs in only approximately a third of ampullary and duodenal cancers. Future clinical trials should group ampullary cancers of intestinal origin and duodenal cancers together given their similarities and their response to fluoropyrimidine therapy in combination with oxaliplatin. The addition of anti-epidermal growth factor receptor therapy in this group warrants study.
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Affiliation(s)
- Manju D Chandrasegaram
- the Prince Charles Hospital, Brisbane, Queensland 4032, Australia
- School of Medicine, University of Queensland, Queensland 4006, Australia
| | - Anthony J Gill
- Sydney Medical School, University of Sydney, New South Wales 2006, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales 2065, Australia
| | - Jas Samra
- Sydney Medical School, University of Sydney, New South Wales 2006, Australia
- Department of Surgery, Royal North Shore Hospital, Sydney, New South Wales 2065, Australia
| | - Tim Price
- Queen Elizabeth Hospital, Adelaide, South Australia 5011, Australia
- University of Adelaide, South Australia 5005, Australia
| | - John Chen
- Flinders Medical Centre, Adelaide, South Australia 5042, Australia
- Royal Adelaide Hospital, Adelaide, South Australia 5000, Australia
| | - Jonathan Fawcett
- School of Medicine, University of Queensland, Queensland 4006, Australia
- Princess Alexandra Hospital, Brisbane, Queensland 4102, Australia
| | - Neil D Merrett
- Department of Upper GI Surgery, Bankstown Hospital, Sydney, New South Wales 2200, Australia
- Discipline of Surgery, Western Sydney University, Sydney, New South Wales 2560, Australia
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Acharya A, Markar SR, Sodergren MH, Malietzis G, Darzi A, Athanasiou T, Khan AZ. Meta-analysis of adjuvant therapy following curative surgery for periampullary adenocarcinoma. Br J Surg 2017; 104:814-822. [PMID: 28518410 DOI: 10.1002/bjs.10563] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/24/2016] [Accepted: 03/16/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Periampullary cancers are uncommon malignancies, often amenable to surgery. Several studies have suggested a role for adjuvant chemotherapy and chemoradiotherapy in improving survival of patients with periampullary cancers, with variable results. The aim of this meta-analysis was to determine the survival benefit of adjuvant therapy for periampullary cancers. METHODS A systematic review was undertaken of literature published between 1 January 2000 and 31 December 2015 to elicit and analyse the pooled overall survival associated with the use of either adjuvant chemotherapy or chemoradiotherapy versus observation in the treatment of surgically resected periampullary cancer. Included articles were also screened for information regarding stage, prognostic factors and toxicity-related events. RESULTS A total of 704 titles were screened, of which 93 full-text articles were retrieved. Fourteen full-text articles were included in the study, six of which were RCTs. A total of 1671 patients (904 in the control group and 767 who received adjuvant therapy) were included. The median 5-year overall survival rate was 37·5 per cent in the control group, compared with 40·0 per cent in the adjuvant group (hazard ratio 1·08, 95 per cent c.i. 0·91 to 1·28; P = 0·067). In 32·2 per cent of patients who had adjuvant therapy, one or more WHO grade 3 or 4 toxicity-related events were noted. Advanced T category was associated worse survival (regression coefficient -0·14, P = 0·040), whereas nodal status and grade of differentiation were not. CONCLUSION This systematic review found no associated survival benefit for adjuvant chemotherapy or chemoradiotherapy in the treatment of periampullary cancer.
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Affiliation(s)
- A Acharya
- Division of Surgery, Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - S R Markar
- Division of Surgery, Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - M H Sodergren
- Division of Surgery, Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - G Malietzis
- Division of Surgery, Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - A Darzi
- Division of Surgery, Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - T Athanasiou
- Division of Surgery, Department of Surgery and Cancer, St Mary's Hospital, Imperial College, London, UK
| | - A Z Khan
- Department of Hepatopancreatobiliary Surgery, Royal Marsden Hospital, London, UK
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Junrungsee S, Kittivarakul E, Ko-iam W, Lapisatepun W, Sandhu T, Chotirosniramit A. Prognostic Factors and Survival of Patients with Carcinoma of the Ampulla of Vater after Pancreaticoduodenectomy. Asian Pac J Cancer Prev 2017; 18:225-229. [PMID: 28240523 PMCID: PMC5563104 DOI: 10.22034/apjcp.2017.18.1.225] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background: Although carcinoma of the ampulla of Vater (CAV) is a rare tumor, accounting for just 0.2% of
gastrointestinal cancers, the survival of CAV patients is unfavorable. The five-year rates have ranged from 36.8-75.2% in
previous reports but there is a lack of data relating to Thai people. Also prognostic factors are controversial. Objectives:
This study aimed to determine survival outcomes and to identify prognostic factors for a positive outcome for CAV
patients after surgery. Methods: In this retrospective cohort study, data were collected from CAV patients who underwent
surgery in Chiang Mai University Hospital from 2005 to 2012 for time to event analysis, the log rank test and univariate
and multivariate Cox’s regression analysis. Results: There were 72 CAV patients recruited, 45.8% being male. The mean
age was 65.1 ± 10.5 years and the median waiting time for surgery was 56.5 days (24.5-91.5). The 30 day mortality
rate was 5.6%., while 5-yr survival was 33.3%. The average disease free survival was 14.6 months. Prognostic factors
relating to recurrence were positive lymph nodes (50% VS 19.6% p = 0.015) and advanced stage (44.1% VS 18.4%
p = 0.023). Multivariate analysis showed that the potential prognostic factors for CAV patients included recurrence,
moderate and poor differentiation, comorbidities and a tumor size > 2.0 cm. Conclusions: The findings of the study
indicate that the overall survival of CAV patients after surgery is quite fair, with a tendency for better outcome with
early as compared to advanced lesions. The key prognostic factors were recurrence, moderate and poor differentiation,
comorbidity and tumor size > 2.0 cm.
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Affiliation(s)
- Sunhawit Junrungsee
- Division of Hepatobiliarypancreas Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai,
Thailand.
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Doepker MP, Thompson ZJ, Centeno BA, Kim RD, Wong J, Hodul PJ. Clinicopathologic and survival analysis of resected ampullary adenocarcinoma. J Surg Oncol 2016; 114:170-5. [PMID: 27158031 DOI: 10.1002/jso.24281] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 04/20/2016] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Ampullary adenocarcinoma (AAC) is a rare neoplasm. We sought to determine the clinicopathologic factors contributing to the overall survival (OS) and recurrence-free (RFS) survival. METHODS Patients (pts) with resected AAC were identified from 1996 to 2015 and reviewed for clinicopathologic factors and correlated with outcome. RESULTS We identified and evaluated 106 pts diagnosed with AAC. The median age was 70.2 years (range 41-86) and 60 (56.6%) were male. Overall, 105 pts (99.1%) had a pancreaticoduodenectomy. An R0 resection was achieved in 101 (95%) pts. Median follow-up was 19 months with a median OS of 49.3 months. Lymph node metastasis and poorly differentiated tumors adversely affected OS on multivariate analysis (MVA). Twenty patients (18.9%) developed recurrence. The median RFS was 27 months. RFS was adversely affected by lymph node count and metastasis, tumor differentiation, and histological subtype on MVA. Survival was not affected by the addition of adjuvant therapy. Retrieval of ≤12 lymph nodes and lymph node ratio ≥0.10 resulted in worse OS on Kaplan-Meier analysis. CONCLUSIONS Our data show retrieval of ≤12 nodes, involvement of nodes with AAC, moderately or poorly differentiated tumors, and pancreaticobiliary subtype adversely affected survival, while the use of adjuvant therapy demonstrated no significant benefit. J. Surg. Oncol. 2016;114:170-175. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Matthew P Doepker
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
| | | | | | - Richard D Kim
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Joyce Wong
- Department of Surgical Oncology, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Pamela J Hodul
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida
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Yun SP, Seo HI. Prognostic impact of immunohistochemical expression of CK7 and CK20 in curatively resected ampulla of Vater cancer. BMC Gastroenterol 2015; 15:165. [PMID: 26603157 PMCID: PMC4657248 DOI: 10.1186/s12876-015-0396-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 11/18/2015] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND In the consideration of ampullary adenocarcinoma, T stage, lymph node metastases, perineural invasion, tumor differentiation, pancraticobiliary type, and lymph node ratio are considered prognostic factors. The objectives of this study were to investigate surgical outcomes and the clinicopathological predictors affecting survival and recurrence, and to examine the prognostic roles of histopathological subtype and immunohistochemical markers. METHODS From April 2006 to September 2012, 37 patients who underwent curative resection of ampullar of Vater adenocarcinoma were enrolled in this study. A retrospective review was performed based on medical records. Immunohistochemical expression, histopathological type and clinicopathologic factors were analyzed. RESULTS The 5-year overall survival rates and disease-free survival rates after surgery were 77.4 and 75.7 %, respectively. Multivariate Cox regression analysis showed that advanced T stage (p = 0.019) and positive expression of Cytokeratin 7 (CK7) with negative expression of Cytokeratin 20 (CK20) (p = 0.046) were identified as significant independent factors related to survival, and poor differentiation (p = 0.031) significantly influenced disease-free survival in multivariate analysis. CONCLUSIONS Advanced T stage is a significant prognostic factor affecting survival in ampullary adenocarcinoma. Also, positive expression of CK7 with negative expression of CK20 is an independent factor related to overall survival.
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Affiliation(s)
- Sung Pil Yun
- Department of surgery, Biomedical Research Institute, Pusan National University Hospital, 189 Gudeok-Ro, Seo-Gu, Busan, 602-739, South Korea.
| | - Hyung Il Seo
- Department of surgery, Biomedical Research Institute, Pusan National University Hospital, 189 Gudeok-Ro, Seo-Gu, Busan, 602-739, South Korea.
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Panzeri F, Crippa S, Castelli P, Aleotti F, Pucci A, Partelli S, Zamboni G, Falconi M. Management of ampullary neoplasms: A tailored approach between endoscopy and surgery. World J Gastroenterol 2015; 21:7970-7987. [PMID: 26185369 PMCID: PMC4499340 DOI: 10.3748/wjg.v21.i26.7970] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/27/2015] [Accepted: 05/04/2015] [Indexed: 02/07/2023] Open
Abstract
Ampullary neoplasms, although rare, present distinctive clinical and pathological features from other neoplastic lesions of the periampullary region. No specific guidelines about their management are available, and they are often assimilated either to biliary tract or to pancreatic carcinomas. Due to their location, they tend to become symptomatic at an earlier stage compared to pancreatic malignancies. This behaviour results in a higher resectability rate at diagnosis. From a pathological point of view they arise in a zone of transition between two different epithelia, and, according to their origin, may be divided into pancreatobiliary or intestinal type. This classification has a substantial impact on prognosis. In most cases, pancreaticoduodenectomy represents the treatment of choice when there is an overt or highly suspicious malignant behaviour. The rate of potentially curative resection is as high as 90% and in high-volume centres an acceptable rate of complications is reported. In selected situations less invasive approaches, such as ampullectomy, have been advocated, although there are some concerns mainly because of a higher recurrence rate associated with limited resections for invasive carcinomas. Importantly, these methods have the drawback of not including an appropriate lymphadenectomy, while nodal involvement has been shown to be frequently present also in apparently low-risk carcinomas. Endoscopic ampullectomy is now the procedure of choice in case of low up to high-grade dysplasia providing a proper assessment of the T status by endoscopic ultrasound. In the present paper the evidence currently available is reviewed, with the aim of offering an updated framework for diagnosis and management of this specific type of disease.
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Survival in ampullary cancer: potential role of different KRAS mutations. Surgery 2015; 157:260-8. [PMID: 25616942 DOI: 10.1016/j.surg.2014.08.092] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 08/27/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The prognosis of ampullary adenocarcinoma (AA) usually is favorable; however, a subset of AA have poor biology and outcomes similar to pancreatic cancer. Patients in this subset will have early recurrence and death usually within 2 years. To date, there are no genetic markers to identify these patients. This study identifies the high-risk subset of AA and evaluates the mutational status of KRAS in predicting poor outcome. METHODS The tumor registry of an academic center was reviewed for data on patients managed operatively with AA. KRAS genotypes were determined for these patients using a polymerase chain reaction-based assay on clinical specimens. Analysis of variance and χ(2) tests was used to categorize continuous and categorical variables. Univariate and multivariate survival analyses were performed using Kaplan-Meier and Cox methods, respectively. RESULTS A total of 146 patients were identified with AA between 1982 and 2008. After stringent pathologic review, 97 patients were confirmed with AA, of whom 75 had tissue specimens available for analysis. Genotyping revealed 67% were wild-type (KRAS(WT)), and 33% were mutant for KRAS. Patients with KRAS(G12D) (n = 9), the most common mutational genotype, had poorer median survival (62 months) compared with those with KRAS(non-G12D) mutants (median survival not reached, mean 145 months) and KRAS(WT) patients (155 months, P = .05). Patients with survival ≤30 months were labeled "high-risk." Of the 9 patients with KRAS(G12D), 56% were in this high-risk subset, compared with 18% of KRAS(WT) (P = .02) and 31% of KRAS(non-G12D) (P > .05) populations. Patients with KRAS(G12D) also were more likely to present with advanced T stage. CONCLUSION The KRAS(G12D) mutation identifies a subset of AA patients with poor prognoses and may be used to identify patients at risk of early recurrence and poorer survival who may benefit from adjuvant therapy.
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Song J, Liu H, Li Z, Yang C, Sun Y, Wang C. Long-term prognosis of surgical treatment for early ampullary cancers and implications for local ampullectomy. BMC Surg 2015; 15:32. [PMID: 25888004 PMCID: PMC4375931 DOI: 10.1186/s12893-015-0019-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 03/16/2015] [Indexed: 02/07/2023] Open
Abstract
Background Early ampullary cancers present with good prognosis. Pancreaticoduodenectomy (PD) has been standard treatment for ampullary cancers, but it remains high rate of postoperative complications. So there raises a discussion on the role of local ampullectomy for early ampullary cancers (mainly focusing on pT1). Methods 89 patients with pT1 ampullary cancer who underwent surgical treatment between 1978 and 2010 were retrospectively studied. Results Rate of postoperative complications, especially post-operative pancreatic fistula (P = 0.009), after PD was higher than after local ampullectomy, . Multivariate analysis showed that tumor size (HR 2.204; P = 0.014), lymph node metastasis (HR 4.362; P < 0.001), lymph vascular invasion (HR 4.258; P < 0.001), and perineural invasion (HR 4.467; P < 0.001), gross morphology (HR 2.536; P = 0.004) and tumor grade (HR 4.213; P = 0.001) were independent risk factors for long-term survival, as well as risk factors for failure of ampullectomy in early ampullary cancer. For patients absent of these factors, local ampullectomy would achieve a good prognosis. Conclusions Because of high rate of lymph node metastasis, PD should be preferably performed for radical resection. Local ampullectomy could be an alternative for patients in high operative risk; and would achieve a good outcome in patients whose tumors were well differentiated and showed polypoid gross morphology and size ≤1 cm.
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Affiliation(s)
- Junmin Song
- Department of General Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
| | - Hongxiang Liu
- Department of General Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhen Li
- Department of General Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chao Yang
- Department of General Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuling Sun
- Department of General Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chaojie Wang
- Department of Oncology, Henan Provincial People's Hospital, Zhengzhou, China
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Chandrasegaram MD, Chiam SC, Chen JW, Khalid A, Mittinty ML, Neo EL, Tan CP, Dolan PM, Brooke-Smith ME, Kanhere H, Worthley CS. Distribution and pathological features of pancreatic, ampullary, biliary and duodenal cancers resected with pancreaticoduodenectomy. World J Surg Oncol 2015; 13:85. [PMID: 25890023 PMCID: PMC4348158 DOI: 10.1186/s12957-015-0498-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 02/01/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Pancreatic cancer (PC) has the worst survival of all periampullary cancers. This may relate to histopathological differences between pancreatic cancers and other periampullary cancers. Our aim was to examine the distribution and histopathologic features of pancreatic, ampullary, biliary and duodenal cancers resected with a pancreaticoduodenectomy (PD) and to examine local trends of periampullary cancers resected with a PD. METHODS A retrospective review of PD between January 2000 and December 2012 at a public metropolitan database was performed. The institutional ethics committee approved this study. RESULTS There were 142 PDs during the study period, of which 70 cases were pre-2010 and 72 post-2010, corresponding to a recent increase in the number of cases. Of the 142 cases, 116 were for periampullary cancers. There were also proportionately more PD for PC (26/60, 43% pre-2010 vs 39/56, 70% post-2010, P = 0.005). There were 65/116 (56%) pancreatic, 29/116 (25%), ampullary, 17/116 (15%) biliary and 5/116 (4%) duodenal cancers. Nodal involvement occurred more frequently in PC (78%) compared to ampullary (59%), biliary (47%) and duodenal cancers (20%), P = 0.002. Perineural invasion was also more frequent in PC (74%) compared to ampullary (34%), biliary (59%) and duodenal cancers (20%), P = 0.002. Microvascular invasion was seen in 57% pancreatic, 38% ampullary, 41% biliary and 20% duodenal cancers, P = 0.222. Overall, clear margins (R0) were achieved in fewer PC 41/65 (63%) compared to ampullary 27/29 (93%; P = 0.003) and biliary cancers 16/17 (94%; P = 0.014). CONCLUSIONS This study highlights that almost half of PD was performed for cancers other than PC, mainly ampullary and biliary cancers. The volume of PD has increased in recent years with an increased proportion being for PC. PC had higher rates of nodal and perineural invasion compared to ampullary, biliary and duodenal cancers.
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Affiliation(s)
- Manju D Chandrasegaram
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia. .,Division of Surgery, School of Medicine, University of Adelaide, Adelaide, SA, 5005, Australia.
| | - Su C Chiam
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia.
| | - John W Chen
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia. .,Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia. .,Flinders University, Sturt Rd, Bedford Park, Adelaide, SA, 5042, Australia.
| | - Aisha Khalid
- Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia.
| | - Murthy L Mittinty
- School of Population Health, University of Adelaide, 178 North Terrace, Adelaide, SA, 5005, Australia.
| | - Eu L Neo
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia. .,Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia.
| | - Chuan P Tan
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia.
| | - Paul M Dolan
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia.
| | - Mark E Brooke-Smith
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia. .,Flinders Medical Centre, Flinders Drive, Bedford Park, Adelaide, SA, 5042, Australia. .,Flinders University, Sturt Rd, Bedford Park, Adelaide, SA, 5042, Australia.
| | - Harsh Kanhere
- Division of Surgery, School of Medicine, University of Adelaide, Adelaide, SA, 5005, Australia. .,HPB Surgery Unit, Queen Elizabeth Hospital, 28 Woodville Road, Adelaide, SA, 5011, Australia.
| | - Chris S Worthley
- HPB Surgery Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia.
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Ahmad SR, Adler DG. Cancer of the ampulla of vater: current evaluation and therapy. Hosp Pract (1995) 2015; 42:45-61. [PMID: 25485917 DOI: 10.3810/hp.2014.12.1158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Ampullary cancer is a relatively rare cancer of the digestive tract. In contrast to pancreatic cancer, ampullary cancer is often curable if detected at an early stage. The evaluation and management of ampullary cancer is similar to, but distinct from, that of other pancreaticobiliary tumors. This manuscript will review the current evaluation, diagnosis, and therapy of patients with ampullary cancer. The diagnosis of ampullary cancer is complicated by its similar clinical presentation to pancreatic cancer as well as its nonspecific laboratory findings. Diagnostic modalities such as ERCP, EUS, and biopsy are necessary for differentiating the 2 cancers, and noninvasive imaging techniques such as MRI and CT may be used for tumor staging. Although pancreaticoduodenectomy is considered the primary curative surgical option, consensus guidelines regarding adjuvant and neoadjuvant chemoradiation therapies are lacking.
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Affiliation(s)
- Sarah R Ahmad
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT
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Amini A, Miura JT, Jayakrishnan TT, Johnston FM, Tsai S, Christians KK, Gamblin TC, Turaga KK. Is local resection adequate for T1 stage ampullary cancer? HPB (Oxford) 2015; 17:66-71. [PMID: 25395092 PMCID: PMC4266442 DOI: 10.1111/hpb.12297] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 05/15/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Concerns for morbidity after a pancreaticoduodenectomy (PD) has led to practitioners adopting endoscopic resection or ampullectomy in the treatment of T1 ampullary cancer (AC). It was hypothesized that survival for patients undergoing local resection of AC was inferior to those undergoing a PD. METHODS All the data of patients with AC reported in the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2010 were collected. Five-year survival rates according to nodal disease and histological type were compared. RESULTS There were 1916 cases of AC; 421 (22%) had T1 disease. Among those with T1 disease, 217 (51%) received endoscopic surveillance, 21 (5%) underwent local resection/ampullectomy, 20 (5%) underwent ampullectomy with regional lymphadenectomy and 163 (39%) underwent PD. For patients with complete nodal staging (PD, n = 163), 35 (22%) had metastatic disease in the nodes. Grade was significantly associated with node positivity (P = 0.007). In multivariate models, survival was improved with either an ampullectomy with regional lymphadenectomy [hazard ratio (HR) 0.19; 95% confidence interval (CI) 0.05-0.61, P < 0.005] or a PD (HR 0.23; 95% CI 0.15-0.36, P < 0.001). CONCLUSION Patients with T1 AC have a high risk for nodal metastases especially if they are higher-grade lesions. Nodal clearance with a lymphadenectomy or a PD is essential for long-term survival in these patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Kiran K Turaga
- Correspondence, Kiran K. Turaga, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Ave, Milwaukee, WI 53226, USA. Tel.:+1 414 805 5078. Fax: +1 414 805 5771. E-mail:
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Prognostic factors for long-term survival in patients with ampullary carcinoma: the results of a 15-year observation period after pancreaticoduodenectomy. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2014; 2014:970234. [PMID: 24723741 PMCID: PMC3958923 DOI: 10.1155/2014/970234] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 01/14/2014] [Indexed: 02/07/2023]
Abstract
Introduction. Although ampullary carcinoma has the best prognosis among all periampullary carcinomas, its long-term survival remains low. Prognostic factors are only available for a period of 10 years after pancreaticoduodenectomy. The aim of this retrospective study was to identify factors that influence the long-term patient survival over a 15-year observation period. Methods. From 1992 to 2007, 143 patients with ampullary carcinoma underwent pancreatic resection. 86 patients underwent pylorus-preserving pancreaticoduodenectomy (60%) and 57 patients underwent standard Kausch-Whipple pancreaticoduodenectomy (40%). Results. The overall 1-, 5-, 10-, and 15-year survival rates were 79%, 40%, 24%, and 10%, respectively. Within a mean observation period of 30 (0–205) months, 100 (69%) patients died. Survival analysis showed that positive lymph node involvement (P = 0.001), lymphatic vessel invasion (P = 0.0001), intraoperative administration of packed red blood cells (P = 0.03), an elevated CA 19-9 (P = 0.03), jaundice (P = 0.04), and an impaired patient condition (P = 0.01) are strong negative predictors for a reduced patient survival. Conclusions. Patients with ampullary carcinoma have distinctly better long-term survival than patients with pancreatic adenocarcinoma. Long-term survival depends strongly on lymphatic nodal and vessel involvement. Moreover, a preoperative elevated CA 19-9 proved to be a significant prognostic factor. Adjuvant therapy may be essential in patients with this risk constellation.
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Adequacy of lymph node retrieval for ampullary cancer and its association with improved staging and survival. World J Surg 2014; 37:1397-404. [PMID: 23546531 DOI: 10.1007/s00268-013-1995-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The aim of the present study was to determine the optimal number of lymph nodes (LN) examined to stage pN0 tumors after surgery for ampulla of Vater carcinoma (AVC). METHODS We reviewed retrospectively 127 patients with AVC who underwent pancreaticoduodenectomy (1990-2008). Univariate and multivariate analysis was performed. RESULTS Fifty-nine patients (46.5 %) were pN0, whereas 68 patients (53.5 %) were pN1. The 5-year disease-specific survival (DSS) was worse for pN1 patients than for pN0 patients (46 vs. 77 %; P < 0.0001). In the pN0 cohort, the optimal cut-off number of LN analyzed was found to be 12. The 5-year DSS for patients with ≤ 12 LN was 50 %, compared with 89 % in those with >12 LN (P = 0.001). By multivariate analysis, a LN count >12 was the only independent predictor associated with improved survival (HR 0.16, P = 0.003) among pN0 patients. Among pN1 patients, a LN count >12 was associated with a significantly better 5-year DSS (59 vs. 22 %; P = 0.027). Patients with a lymph node ratio (LNR) >0.20 had a 5-year DSS of 24 %, compared with 58 % in those with 0 < LNR ≤ 0.20 (P = 0.038). CONCLUSIONS Removal of more than 12 LN for examination is associated with improved survival rate after surgery for AVC in both pN0 and pN1 patients.
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Zhou J, Zhang Q, Li P, Shan Y, Zhao D, Cai J. Prognostic relevance of number and ratio of metastatic lymph nodes in resected carcinoma of the ampulla of Vater. Chin J Cancer Res 2014; 25:735-42. [PMID: 24385702 DOI: 10.3978/j.issn.1000-9604.2013.12.03] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 12/04/2013] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES To explore the prognostic relevance of the number and ratio of metastatic lymph nodes in resected Carcinoma of the ampulla of Vater (CAV). METHODS The clinical data of 155 patients who underwent pancreaticoduodenectomy (PD) for cancer of the ampulla of Vater between January 1990 and December 2010 were retrospectively analyzed. Kaplan-Meier method was used in survival analysis and Log rank method in comparison. Multivariate analysis was performed using Cox proportional hazards model. RESULTS Among these 155 patients, the in-hospital mortality rate was 4.5%, lymph node positive disease was 21.3%, and the 5-year survival rate was 51.6%. Patients with a lymph node ratio (LNR) >20% were more likely to have tumor differentiation, depth of duodenal involvement, depth of pancreatic invasion, T-stage and TNM-Stage. The number of the metastatic lymph nodes is important prognostic factors of the CAV. Univariate analysis showed that the factors associated with the prognosis included tumor size (P=0.036), tumor differentiation (P=0.019), LNR (P=0.032), number of metastatic lymph nodes (P=0.024), lymph node metastasis (P=0.03), depth of pancreatic invasion (P=0.001), T-stage (P=0.002), TNM stage (P=0.001), elevated CA 19-9 (P=0.000), and jaundice (P=0.021). Multivariate analysis showed that the factors associated with the prognosis were the number of metastatic lymph nodes (P=0.032; RR: 1.283; 95% CI: 1.022-1.611), tumor size (P=0.043; RR: 1.736; 95% CI: 1.017-2.963), and elevated CA 19-9 (P=0.003; RR: 3.247; 95% CI: 1.504-7.010). CONCLUSIONS LNR is a useful factor for predicting the prognosis of the radical treatment for CAV, whereas the number of metastatic lymph nodes is the most important factor. Further research on the locations, number, and LNR will be clinically meaningful to improve survival in patients with CAV.
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Affiliation(s)
- Jianguo Zhou
- Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100021, China
| | - Qian Zhang
- Department of General Surgery, Aerospace Central Hospital, Beijing 100049, China
| | - Peng Li
- Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100021, China
| | - Yi Shan
- Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100021, China
| | - Dongbing Zhao
- Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100021, China
| | - Jianqiang Cai
- Department of Abdominal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100021, China
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Askew J, Connor S. Review of the investigation and surgical management of resectable ampullary adenocarcinoma. HPB (Oxford) 2013; 15:829-38. [PMID: 23458317 PMCID: PMC4503279 DOI: 10.1111/hpb.12038] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 11/24/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ampullary adenocarcinoma is considered to have a better prognosis than either pancreatic or bile duct adenocarcinoma. Pancreaticoduodenectomy is associated with significant mortality and morbidity. Some recent publications have advocated the use of endoscopic papillectomy for the treatment of early ampullary adenocarcinoma. This article reviews investigations and surgical treatment options of ampullary tumours. METHODS A systematic review of English-language articles was carried out using an electronic search of the Ovid MEDLINE (from 1996 onwards), PubMed and Cochrane Database of Systematic Reviews databases to identify studies related to the investigation and management of ampullary tumours. RESULTS Distinguishing between ampullary adenoma and adenocarcinoma is challenging given the inaccuracy of endoscopic biopsy, for which high false negative rates of 25-50% have been reported. Endoscopic ultrasound is the most accurate method for local staging of ampullary lesions, but distinguishing between T1 and T2 adenocarcinomas is difficult. Lymph node metastasis occurs early in the disease process; it is lowest for T1 tumours, but the risk is still high at 8-45%. Case reports of successful endoscopic resection and transduodenal ampullectomy of T1 adenocarcinomas have been published, but their duration of follow-up is limited. CONCLUSIONS Optimal staging should be used to distinguish between ampullary adenoma and adenocarcinoma. Pancreaticoduodenectomy remains the treatment of choice for all ampullary adenocarcinomas.
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Affiliation(s)
- James Askew
- Department of Surgery, Christchurch HospitalChristchurch, New Zealand
| | - Saxon Connor
- Department of Surgery, Christchurch HospitalChristchurch, New Zealand
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Lee SR, Kim HO, Park YL, Shin JH. Lymph node ratio predicts local recurrence for periampullary tumours. ANZ J Surg 2013; 84:353-8. [PMID: 23521761 DOI: 10.1111/ans.12129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2013] [Indexed: 01/28/2023]
Abstract
BACKGROUND To better define the prognostic role of nodal disease, evaluation of metastatic lymph node ratio (MLR) has been performed, and this method has recently gained prominence in various gastrointestinal cancers. The present study attempts to identify prognostic factors and evaluate the independent prognostic influence of MLR in patients who have undergone curative pancreaticoduodenectomy. METHODS In our institution within the study period, 111 patients received curative pancreaticoduodenectomy for periampullary cancers. Clinicopathologic data were collected and MLR was calculated for each of the patients. Patients were then divided into four groups based on MLR value: MLR 1 = 0; MLR 2 = 0.01-0.2; MLR 3 0.21-0.4; and MLR 4 >0.4. RESULTS Increasing MLR correlates with high recurrence rate and lower overall survival (OS) with significance (P < 0.001, P < 0.001). The recurrent group showed significantly lower OS than the non-recurrent group (P < 0.001). In the multivariate analysis for recurrence, MLR was identified as the only independent prognostic factor (P < 0.001). CONCLUSIONS The simple and easily obtainable MLR is well qualified as a prognostic factor in patients who undergo curatively radical resection for periampullary cancer. Furthermore, MLR can overcome the limitations of evaluation of lymph nodes status, allowing it to be used as a potential prognostic factor.
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Affiliation(s)
- Sung Ryol Lee
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Verbeke CS, Gladhaug IP. Resection margin involvement and tumour origin in pancreatic head cancer. Br J Surg 2012; 99:1036-49. [PMID: 22517199 DOI: 10.1002/bjs.8734] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND Assessment of the origin of adenocarcinoma in pancreatoduodenectomy specimens (pancreatic, ampullary or biliary) and resection margin status is not performed in a consistent manner in different centres. The aim of this review was to identify the impact of such variations on patient outcome. METHODS A systematic literature search for articles on pancreatic, ampullary, distal bile duct and periampullary cancer was performed, with special attention to data on resection margin status, pathological examination and outcome. RESULTS The frequent reclassification of tumour origin following slide review, and the wide variation in published incidence of pancreatic (33-89 per cent), ampullary (5-42 per cent) and distal bile duct (5-38 per cent) cancers indicate that the histopathological distinction between the three cancer groups is less accurate than generally believed. Recent studies have shown that the wide range of rates of microscopic margin involvement (R1) in pancreatoduodenectomy specimens (18-85, 0-27 and 0-72 per cent respectively for pancreatic, ampullary and distal bile duct cancers) is mainly caused by differences in pathological assessment rather than surgical practice and patient selection. As a consequence of the existing inconsistency in reporting of these data items, the clinical significance of microscopic margin involvement in each of the three cancer groups remains unclear. CONCLUSION Inaccurate and inconsistent distinction between pancreatic, ampullary and distal bile duct cancer, combined with inaccuracies in resection margin assessment, results in obfuscation of key clinicopathological data. Specimen dissection technique plays a key role in the quality of the assessment of both tumour origin and margin status. Unless the pathological examination is meticulous and standardized, comparison of results between centres and observations in multicentre trials will remain of limited value.
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Affiliation(s)
- C S Verbeke
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
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Dumitrascu T, Dima S, Herlea V, Tomulescu V, Ionescu M, Popescu I. Neuroendocrine tumours of the ampulla of Vater: clinico-pathological features, surgical approach and assessment of prognosis. Langenbecks Arch Surg 2012; 397:933-43. [PMID: 22476195 PMCID: PMC3401309 DOI: 10.1007/s00423-012-0951-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 03/16/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND/AIMS Neuroendocrine tumours occur very rarely in the ampulla of Vater and their clinical behaviour is unknown. The aim of this study is to assess the clinico-pathological features, surgical approach and prognosis of these patients. METHODS Six patients with neuroendocrine tumours of the ampulla of Vater treated with curative intent surgery at a single centre were retrospectively analysed. A univariate analysis of potential prognostic factors was also performed (data provided from the present study and literature review). RESULTS Pancreaticoduodenectomy was curative in all the patients. Overall and disease-free survival rates were significantly better for G1/G2 tumours (p = 0.006 and p = 0.004, respectively). Although frequent, lymph node metastases did not influenced both overall (p = 0.760) and disease-free survival rates (p = 0.745). No significant differences of survival were observed in patients with ENETS stage I/II disease, as compared to ENETS stage III disease (p = 0.169 and p = 0.137, respectively). No differences were observed according to UICC staging system (p = 0.073 and p = 0.177, respectively). Tumours that are less than 2 cm or limited to the ampulla appear to have a better prognosis. CONCLUSION The WHO 2010 classification appear to accurately predict patient prognosis, while the ENETS or UICC staging systems have a limited value (especially in regard to lymph node metastases). Radical surgery (i.e. pancreaticoduodenectomy with lymphadenectomy) should be the standard approach in most patients with NET of the ampulla of Vater because this procedure removes all the potential tumour-bearing tissue.
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Affiliation(s)
- Traian Dumitrascu
- Department of Surgery, Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Fundeni Street no 258, 022328 Bucharest, Romania
| | - Simona Dima
- Department of Surgery, Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Fundeni Street no 258, 022328 Bucharest, Romania
| | - Vlad Herlea
- Department of Pathology, Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Fundeni Street no 258, 022328 Bucharest, Romania
| | - Victor Tomulescu
- Department of Surgery, Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Fundeni Street no 258, 022328 Bucharest, Romania
| | - Mihnea Ionescu
- Department of Surgery, Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Fundeni Street no 258, 022328 Bucharest, Romania
| | - Irinel Popescu
- Department of Surgery, Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Fundeni Street no 258, 022328 Bucharest, Romania
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Sakabe R, Murakami Y, Uemura K, Sudo T, Hashimoto Y, Kondo N, Nakashima A, Ohge H, Sueda T, Hiyama E. Prognostic Significance of Telomerase Activity and Human Telomerase Reverse Transcriptase Expression in Ampullary Carcinoma. Ann Surg Oncol 2012; 19:3072-80. [DOI: 10.1245/s10434-012-2245-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Indexed: 12/19/2022]
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Choi SB, Kim WB, Song TJ, Suh SO, Kim YC, Choi SY. Surgical outcomes and prognostic factors for ampulla of Vater cancer. Scand J Surg 2012; 100:92-8. [PMID: 21737384 DOI: 10.1177/145749691110000205] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS The prognosis for patients with ampulla of Vater cancer is better than other periampullary cancers. The aim of the present study is to determine the clinicopathologic factors predictive of survival and recurrence in patients with ampulla of Vater cancer. MATERIAL AND METHODS From 1991 to 2008, we identified and reviewed 78 patients with ampulla of Vater cancer retrospectively. Clinicopathologic factors possibly influencing survival and recurrence were statistically analyzed. RESULTS Pancreaticoduodenectomy was performed in 68 patients and 2 patients underwent transduodenal ampullectomy. Hospital mortality was 2.6%. The 5-year survival rates following resection were 59.9%. Univariate analysis for overall survival revealed that total bilirubin greater than 5 mg/dl, ulcerative tumors, differentiation, and pancreatic invasion were significant prognostic factors. Recurrence occurred in 31 patients. Univariate analysis for disease-free survival revealed that total bilirubin greater than 5mg/dl, preoperative biliary drainage, tumor differentiation, and stage were statistically significant. Multivariate analysis revealed that tumor differentiation was an independent prognostic factor for recurrence. The presence of lymph node metastasis did not affect overall survival significantly in this study. However, two or more metastatic lymph nodes significantly affect disease-free survival. CONCLUSIONS Pancreaticoduodenectomy is a safe surgical procedure with acceptable long-term survival for ampulla of Vater cancer. Pancreaticoduodenectomy with lymph node dissection might control lymph node spread and enhance survival outcome.
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Affiliation(s)
- S B Choi
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
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Narang AK, Miller RC, Hsu CC, Bhatia S, Pawlik TM, Laheru D, Hruban RH, Zhou J, Winter JM, Haddock MG, Donohue JH, Schulick RD, Wolfgang CL, Cameron JL, Herman JM. Evaluation of adjuvant chemoradiation therapy for ampullary adenocarcinoma: the Johns Hopkins Hospital-Mayo Clinic collaborative study. Radiat Oncol 2011; 6:126. [PMID: 21951377 PMCID: PMC3204241 DOI: 10.1186/1748-717x-6-126] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 09/28/2011] [Indexed: 12/12/2022] Open
Abstract
Background The role of adjuvant chemoradiation therapy for ampullary carcinoma is unknown. Previous literature suggests that certain populations with high risk factors for recurrence may benefit from adjuvant chemoradiation. We combined the experience of two institutions to better delineate which patients may benefit from adjuvant chemoradiation. Methods Patients who underwent curative surgery for ampullary carcinoma at the Johns Hopkins Hospital (n = 290; 1992-2007) and at the Mayo Clinic (n = 130; 1977-2005) were reviewed. Patients with <60 days of follow-up, metastatic disease at surgery, or insufficient pathologic data were excluded. The final combined study consisted of 186 patients (n = 104 Johns Hopkins, n = 82 Mayo). Most patients received 5-FU based chemoradiation with conformal radiation. Cox proportional hazards models were used for survival analysis. Results Median overall-survival was 39.9 months with 2- and 5-year survival rates of 62.4% and 39.1%. On univariate analysis, adverse prognostic factors for overall survival included T3/T4 stage disease (RR = 1.86, p = 0.002), node positive status (RR = 3.18, p < 0.001), and poor histological grade (RR = 1.69, p = 0.011). Patients who received adjuvant chemoradiation (n = 66) vs. surgery alone (n = 120) showed a higher rate of T3/T4 stage disease (57.6% vs. 30.8%, P < 0.001), lymph node involvement (72.7% vs. 30.0%, P < 0.001), and close or positive margins (4.6% vs. 0.0%, P = 0.019). Five year survival rates among node negative and node positive patients were 58.7% and 18.4% respectively. When compared with surgery alone, use of adjuvant chemoradiation improved survival among node positive patients (mOS 32.1 vs. 15.7 mos, 5 yr OS: 27.5% vs. 5.9%; RR = 0.47, P = 0.004). After adjusting for adverse prognostic factors on multivariate analysis, patients treated with adjuvant chemoradiation demonstrated a significant survival benefit (RR = 0.40, P < 0.001). Disease relapse occurred in 37.1% of all patients, most commonly metastatic disease in the liver or peritoneum. Conclusions Node-positive patients with resected ampullary adenocarcinoma may benefit from 5-FU based adjuvant chemoradiation. Since a significant proportion of patients develop metastatic disease, there is a need for more effective systemic treatment.
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Affiliation(s)
- Amol K Narang
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hornick JR, Johnston FM, Simon PO, Younkin M, Chamberlin M, Mitchem JB, Azar RR, Linehan DC, Strasberg SM, Edmundowicz SA, Hawkins WG. A single-institution review of 157 patients presenting with benign and malignant tumors of the ampulla of Vater: management and outcomes. Surgery 2011; 150:169-76. [PMID: 21801957 DOI: 10.1016/j.surg.2011.05.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Accepted: 05/13/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although benign ampullary tumors are removed endoscopically, due to their potential to progress to malignant disease, the favored treatment for adenocarcinoma is pancreaticoduodenectomy. We reviewed our institution's experience in order to identify which patients were at highest risk of disease progression following surgical resection, as well as evaluate whether localized T1 tumors are best treated by pancreaticoduodenectomy. METHODS We retrospectively reviewed 157 patients who presented with an ampullary mass, from 2001 to 2010, and identified 51 with benign adenoma and 106 with adenocarcinoma. RESULTS Patients with malignant tumors most often presented with larger tumors and jaundice, which alone was predictive of survival (OR = 67). Forty-five percent of patients with pathologically confirmed T1 tumors had positive lymph nodes and median survival was modest at 60 months. Lymph node involvement was predictive of recurrence and decreased survival. CONCLUSION Patients with malignant tumors often present with jaundice and larger tumors. These findings should warrant suspicion for cancer and expedited preoperative workup. Based on our finding that nearly half the patients with T1 tumors had positive lymph nodes, we recommend pancreaticoduodenectomy for any patient with biopsy proven adenocarcinoma who is a suitable candidate for surgery.
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Affiliation(s)
- John R Hornick
- Division of Hepatobiliary, Pancreatic, and Gastrointestinal Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
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Showalter TN, Zhan T, Anne PR, Chervoneva I, Mitchell EP, Yeo CJ, Rosato EL, Kennedy EP, Berger AC. The influence of prognostic factors and adjuvant chemoradiation on survival after pancreaticoduodenectomy for ampullary carcinoma. J Gastrointest Surg 2011; 15:1411-6. [PMID: 21523621 DOI: 10.1007/s11605-011-1518-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 03/24/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The prognosis after pancreaticoduodenectomy (PD) for ampullary carcinoma (AC) is superior to that of pancreatic cancer. Decisions regarding adjuvant therapy are influenced by factors such as nodal status, stage, and grade, but the influence of these individual variables on survival is unclear. METHODS A prospective tumor registry database was queried to identify patients who underwent PD for AC at Thomas Jefferson University between Jan 1997 and Apr 2009. The study was conducted with the approval of the institutional review board. Data were collected through review of hospital and departmental charts. Overall survival (OS) was analyzed using univariate and multivariate Cox proportional hazard models. The proportional hazard assumption was verified for the overall model and individual covariates. RESULTS A total of 61 patients underwent PD for AC at our institution. There were five perioperative deaths (8.2%). Mean age was 70 years (62% male). Median survival time (MST) was 50 months for all patients. Only primary tumor stage, T1/T2 versus T3/T4 (American Joint Committee on Cancer Staging, version 6), was associated with OS in univariate analyses (p = 0.003). The association of nodal status with OS was borderline-significant (p = 0.08), with the MST being 84 months for node-negative and 17 months for node-positive patients. The remaining covariates were not predictors of OS. In the multivariate analysis, only primary tumor stage (HR, 5.1; p < 0.001) and age (HR, 1.04; p = 0.06), but not nodal status or adjuvant therapy, were associated with overall survival. CONCLUSIONS Advanced primary tumor stage and age were associated with inferior OS after PD for AC. Adjuvant therapy did not impact survival. Patients with advanced tumor stage should be considered for clinical trials of adjuvant therapy after PD with novel compounds and optimized radiation therapy strategies.
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Affiliation(s)
- Timothy N Showalter
- Department of Radiation Oncology, Jefferson Medical College of Thomas Jefferson University, Kimmel Cancer Center, Philadelphia, PA, USA
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Abstract
Adenomatous lesions of the ampulla of Vater are relatively rare neoplasms that raise many questions regarding standard management. Adenocarcinoma often will be found in ampullary lesions and should be treated by pancreaticoduodenectomy (PD). Benign-appearing adenomas may be treated by PD, transduodenal ampullectomy (AMP), or endoscopic ampullectomy (EA). AMP and EA have decreased morbidity and mortality compared with PD but are limited by concerns for appropriate resection margins, high recurrence rates, and the need for surveillance endoscopy or additional procedures. Preoperative endoscopic biopsies should be obtained to identify carcinoma, but they have high false-negative rates and cannot be relied upon to rule out malignancy. Intraoperative frozen section evaluation should be requested routinely during AMP, with conversion to PD if carcinoma is demonstrated. The gold standard management of benign adenomas has not been clarified, but the goal for all treatment modalities is complete resection. Patients with familial adenomatous polyposis may be exceptions to this, and routine surveillance endoscopy and biopsy with selective resection have been advocated by some as an alternative to complete resection. Adjuvant chemoradiation has a very limited role in the treatment of ampullary carcinoma and ideally should be offered in the setting of a clinical trial. Metastatic and locally advanced, unresectable lesions may be palliated by surgical or endoscopic bypass, as well as by celiac plexus blockade.
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Affiliation(s)
- George W Dittrick
- Department of Surgery, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246, USA.
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Kato Y, Murakami Y, Uemura K, Sudo T, Hashimoto Y, Hiyama E, Sueda T. Impact of intratumoral thymidylate synthase expression on prognosis after surgical resection for ampullary carcinoma. J Surg Oncol 2011; 103:663-8. [DOI: 10.1002/jso.21879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 01/06/2011] [Indexed: 12/14/2022]
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Kohler I, Jacob D, Budzies J, Lehmann A, Weichert W, Schulz S, Neuhaus P, Röcken C. Phenotypic and genotypic characterization of carcinomas of the papilla of Vater has prognostic and putative therapeutic implications. Am J Clin Pathol 2011; 135:202-11. [PMID: 21228360 DOI: 10.1309/ajcpctcuqsyi89yt] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
We further characterize the heterogeneous carcinomas of the papilla of Vater (CPVs) in relation to various clinicopathologic patient characteristics and patient survival. Of the 71 reevaluated CPVs, 32 were intestinal, 26 were pancreatobiliary, 6 were mixed, 4 were mucinous, and 3 were poorly differentiated carcinomas. The prevalence of cytokeratin 20 and cytokeratin 7 correlated with the intestinal (25/32 [78%] vs 13/32 [41%]) and pancreatobiliary (6/26 [23%] vs 24/26 [92%]) phenotypes. CDX2 was found in mucinous (3/4 [75%]), intestinal (7/32 [22%]), and some mixed (1/6 [1%]) CPVs. A KRAS mutation was detected in all poorly differentiated CPVs and in about 20% of each of the other types. In multivariate analyses, tumor type, local tumor spread, and lymph node metastases were independent prognostic factors of patient survival. We provide further evidence of the prognostic relevance of the phenotypic and genotypic diversity of CPVs. Besides the poorly differentiated CPV, the most common KRAS wild type makes them a putative target for an anti-epidermal growth factor receptor therapy.
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Affiliation(s)
- Ilona Kohler
- Department of Pathology, Charité University Hospital, Berlin, Germany
| | - Dietmar Jacob
- Department of Surgery, Charité University Hospital, Berlin, Germany
| | - Jan Budzies
- Department of Pathology, Charité University Hospital, Berlin, Germany
| | - Annika Lehmann
- Department of Pathology, Charité University Hospital, Berlin, Germany
| | - Wilko Weichert
- Department of Pathology, Charité University Hospital, Berlin, Germany
| | - Stefan Schulz
- Institute of Pharmacology and Toxicology, Friedrich-Schiller-University, Jena, Germany
| | - Peter Neuhaus
- Department of Surgery, Charité University Hospital, Berlin, Germany
| | - Christoph Röcken
- Department of Pathology, Charité University Hospital, Berlin, Germany
- Department of Pathology, Christian-Albrechts-University, Kiel, Germany
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Manta R, Conigliaro R, Castellani D, Messerotti A, Bertani H, Sabatino G, Vetruccio E, Losi L, Villanacci V, Bassotti G. Linear endoscopic ultrasonography vs magnetic resonance imaging in ampullary tumors. World J Gastroenterol 2010; 16:5592-7. [PMID: 21105192 PMCID: PMC2992677 DOI: 10.3748/wjg.v16.i44.5592] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess linear endoscopic ultrasound (L-EUS) and magnetic resonance imaging (MRI) in biliary tract dilation and suspect small ampullary tumor.
METHODS: L-EUS and MRI data were compared in 24 patients with small ampullary tumors; all with subsequent histological confirmation. Data were collected prospectively and the accuracy of detection, histological characterization and N staging were assessed retrospectively using the results of surgical or endoscopic treatment as a benchmark.
RESULTS: A suspicion of ampullary tumor was present in 75% of MRI and all L-EUS examinations, with 80% agreement between EUS and histological findings at endoscopy. However, L-EUS and histological TN staging at surgery showed moderate agreement (κ = 0.54).
CONCLUSION: L-EUS could be a useful adjunct as a diagnostic tool in the evaluation of patients with suspected ampullary tumors.
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Clinicopathologic analysis of ampullary neoplasms in 450 patients: implications for surgical strategy and long-term prognosis. J Gastrointest Surg 2010. [PMID: 19911239 DOI: 10.1007/s11605-00901080-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND Whether ampullary neoplasms are best surgically managed by pancreaticoduodenectomy versus local ampullectomy is controversial. We sought to examine the outcome of patients undergoing pancreaticoduodenectomy versus ampullectomy, as well as to identify factors predictive of lymph node metastasis in patients with ampullary neoplasms. METHODS Between 1970 and 2007, 450 patients who underwent surgical resection of ampullary adenoma or adenocarcinoma were identified from a prospective, single-institution database. Data on clinicopathologic factors, morbidity, mortality, and survival were analyzed. RESULTS The initial surgical procedure was pancreaticoduodenectomy in 96.7% patients and ampullectomy in 3.3%. Final diagnosis was invasive adenocarcinoma (77.1%) or adenoma (22.9%). Median tumor size was similar for adenomas associated with an adenocarcinoma (2.5 cm) versus adenomas without invasive cancer (2.9 cm; P=0.71). Morbidity was comparable with pancreaticoduodenectomy (52.2%) versus ampullectomy (33.3%; P=0.15), as was 30-day mortality (pancreaticoduodenectomy, 2.1% versus ampullectomy, 0%; P=0.6). Metastatic disease to regional lymph nodes was present in 54.5% patients with adenocarcinoma. Factors associated with presence of lymph node metastasis included tumor size > or = 1 cm (OR 2.1), poor histologicgrade (OR 4.8), perineural invasion (OR 3.0), microscopic vessel invasion (OR 6.6), and depth of invasion > pT1 (OR 4.3; all P<0.05). Specifically, risk of lymph node metastasis increased with T stage (T1, 28.0%; T2, 50.9%; T3, 71.7%; T4, 77.3%; P<0.001). CONCLUSION When surgery is indicated, radical resection is required for early invasive adenocarcinoma of the ampulla of Vater, as lymph node metastases are present in nearly 30% of patients with T1 disease. Pancreaticoduodenectomy should be the preferred approach for most ampullary neoplasms that require surgical resection.
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Winter JM, Cameron JL, Olino K, Herman JM, de Jong MC, Hruban RH, Wolfgang CL, Eckhauser F, Edil BH, Choti MA, Schulick RD, Pawlik TM. Clinicopathologic analysis of ampullary neoplasms in 450 patients: implications for surgical strategy and long-term prognosis. J Gastrointest Surg 2010; 14:379-87. [PMID: 19911239 DOI: 10.1007/s11605-009-1080-7] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Accepted: 10/26/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Whether ampullary neoplasms are best surgically managed by pancreaticoduodenectomy versus local ampullectomy is controversial. We sought to examine the outcome of patients undergoing pancreaticoduodenectomy versus ampullectomy, as well as to identify factors predictive of lymph node metastasis in patients with ampullary neoplasms. METHODS Between 1970 and 2007, 450 patients who underwent surgical resection of ampullary adenoma or adenocarcinoma were identified from a prospective, single-institution database. Data on clinicopathologic factors, morbidity, mortality, and survival were analyzed. RESULTS The initial surgical procedure was pancreaticoduodenectomy in 96.7% patients and ampullectomy in 3.3%. Final diagnosis was invasive adenocarcinoma (77.1%) or adenoma (22.9%). Median tumor size was similar for adenomas associated with an adenocarcinoma (2.5 cm) versus adenomas without invasive cancer (2.9 cm; P=0.71). Morbidity was comparable with pancreaticoduodenectomy (52.2%) versus ampullectomy (33.3%; P=0.15), as was 30-day mortality (pancreaticoduodenectomy, 2.1% versus ampullectomy, 0%; P=0.6). Metastatic disease to regional lymph nodes was present in 54.5% patients with adenocarcinoma. Factors associated with presence of lymph node metastasis included tumor size > or = 1 cm (OR 2.1), poor histologicgrade (OR 4.8), perineural invasion (OR 3.0), microscopic vessel invasion (OR 6.6), and depth of invasion > pT1 (OR 4.3; all P<0.05). Specifically, risk of lymph node metastasis increased with T stage (T1, 28.0%; T2, 50.9%; T3, 71.7%; T4, 77.3%; P<0.001). CONCLUSION When surgery is indicated, radical resection is required for early invasive adenocarcinoma of the ampulla of Vater, as lymph node metastases are present in nearly 30% of patients with T1 disease. Pancreaticoduodenectomy should be the preferred approach for most ampullary neoplasms that require surgical resection.
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Affiliation(s)
- Jordan M Winter
- Department of Surgery, Johns Hopkins Medical Institutions, Halsted 610, 600 N Wolfe Street, Baltimore, MD 21287, USA
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Sommerville CAM, Limongelli P, Pai M, Ahmad R, Stamp G, Habib NA, Williamson RCN, Jiao LR. Survival analysis after pancreatic resection for ampullary and pancreatic head carcinoma: an analysis of clinicopathological factors. J Surg Oncol 2010; 100:651-6. [PMID: 19722229 DOI: 10.1002/jso.21390] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Surgery remains the only curative option for the treatment of pancreatic and ampullary carcinomas. To examine the survival differences between ampullary and pancreatic head carcinomas after pancreaticoduodenectomy. METHODS A retrospective review of patients with ampullary or pancreatic head adenocarcinoma undergoing curative resection during a 6-year period prior to 2000. RESULTS A total of 104 patients underwent pancreaticoduodenectomy for pancreatic head and ampullary carcinomas (n = 65 and n = 39, respectively). Histologically, pancreatic cancer was worse, with more lymph node involvement and more positive resection margins and vascular and perineural invasions than found in ampullary carcinoma. The median disease-free and overall survival rates were significantly better for ampullary cancer when compared with pancreatic cancer (17 vs. 9 months [P = 0.001] and 35 vs. 24 months [P = 0.006], respectively). The actuarial 5-year disease-free and overall survival rates were 4.4% and 10.5%, respectively, for pancreatic carcinoma and 27.9% and 31.8%, respectively, for ampullary carcinoma. Multivariate analysis showed that microscopic resection margin involvement (P = 0.02) and involvement of over three nodes (P < 0.001) were significant factors affecting the overall survival for pancreatic and ampullary carcinomas, respectively. CONCLUSIONS In this study, patients with ampullary carcinoma have a better prognosis and survival than those with pancreatic carcinoma.
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Affiliation(s)
- C A M Sommerville
- Division of Surgery and Cancer, HPB Unit, Hammersmith Hospital, Imperial College, London, England
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Adjuvant gemcitabine plus S-1 chemotherapy improves survival after aggressive surgical resection for advanced biliary carcinoma. Ann Surg 2010; 250:950-6. [PMID: 19953713 DOI: 10.1097/sla.0b013e3181b0fc8b] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy of adjuvant gemcitabine plus S-1 chemotherapy after aggressive surgical resection for advanced biliary carcinoma. SUMMARY BACKGROUND DATA No effective adjuvant therapy for advanced biliary carcinoma has been reported although its prognosis is extremely poor. METHODS Medical records were reviewed for 103 patients with International Union Against Cancer (UICC) stage II biliary carcinoma who underwent aggressive surgical resection. About 50 patients received 10 cycles of adjuvant gemcitabine plus S-1 chemotherapy and 53 patients did not. Clinicopathological factors and patient survival were compared between the 2 groups using univariate and multivariate analysis. A cycle of chemotherapy consisted of intravenous gemcitabine 700 mg/m(2) on day 1 and oral S-1 50 mg/m(2) for 7 consecutive days, followed by a 1-week break from chemotherapy. RESULTS Patient demographics, tumor characteristics, and surgical procedures did not differ between the 2 groups. Aggressive surgical procedures including major hepatectomy or pancreatoduodenectomy were performed for 94 of 103 patients. In the chemotherapy group, 37 patients (74%) were given the full number of 10 cycles. The use of postoperative adjuvant chemotherapy (P < 0.001) and surgical margin status (P = 0.003) were independently associated with long-term survival by multivariate analysis. Five-year survival rates of patients who did or did not receive postoperative adjuvant chemotherapy were 57% and 24%, respectively (P < 0.001). Toxicity during chemotherapy was mild. CONCLUSIONS Adjuvant gemcitabine plus S-1 chemotherapy may be one of several factors contributing to improved outcomes after aggressive surgical resection of advanced biliary carcinoma in recent years.
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Sierzega M, Nowak K, Kulig J, Matyja A, Nowak W, Popiela T. Lymph node involvement in ampullary cancer: the importance of the number, ratio, and location of metastatic nodes. J Surg Oncol 2009; 100:19-24. [PMID: 19384907 DOI: 10.1002/jso.21283] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Lymph node involvement significantly affects survival of cancer patients. The aim of this study was to evaluate the importance of the number, ratio, and location of metastatic lymph nodes in ampullary cancers. METHODS Medical records of 111 patients who underwent curative pancreaticoduodenectomy for ampullary carcinomas were reviewed. RESULTS Metastatic lymph nodes were found in 52 (47%) patients and the median number of involved nodes was 3 (95% confidence interval (CI) 3-4; range 1-17). In the univariate analysis, gender, type of pancreaticoduodenectomy, depth of tumor invasion, perineural invasion, presence of metastatic nodes, their number, and ratio of metastatic nodes significantly correlated with patient survival. However, the location of metastatic nodes did not influence survival among patients with nodal involvement. Only four or more metastatic nodes (relative risk 7.35, 95% CI 3.34-16.17) and tumor invasion of peripancreatic soft tissues (relative risk 5.00, 95% CI 1.20-20.92) were the independent prognostic factors in the multivariate analysis. CONCLUSIONS The number of metastatic nodes significantly affected patient survival. Although the location and ratio of metastatic nodes were not independent prognostic factors, these variables should be further evaluated with large-scale population data sets.
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Affiliation(s)
- Marek Sierzega
- 1st Department of Surgery, Jagiellonian University Medical College, Krakow, Poland.
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Zhou J, Hsu CC, Winter JM, Pawlik TM, Laheru D, Hughes MA, Donehower R, Wolfgang C, Akbar U, Schulick R, Cameron J, Herman JM. Adjuvant chemoradiation versus surgery alone for adenocarcinoma of the ampulla of Vater. Radiother Oncol 2009; 92:244-8. [PMID: 19541379 DOI: 10.1016/j.radonc.2009.05.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Revised: 04/30/2009] [Accepted: 05/10/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND PURPOSE To examine the role of adjuvant chemoradiation (CRT) in patients with resected ampullary adenocarcinoma. MATERIALS AND METHODS The records of patients who underwent curative surgery for ampullary adenocarcinoma at a single institution between 1992 and 2007 were reviewed. Final analysis included 111 patients, 45% of which also received adjuvant CRT. RESULTS Median overall survival (OS) was 36.2 months for all patients. Adverse prognostic factors for OS included T stage (T3/4 vs. T1/T2, p=0.046), node status (positive vs. negative, p<0.001), and histological grade (grade 3 vs. 1/2, p=0.09). Patients receiving CRT were more likely to have advanced T-stage (p=0.001), node positivity (p<0.001), and poor histologic grade (p=0.015). Patients who received CRT were also significantly younger (p=0.001). On univariate analysis, adjuvant CRT failed to result in a significant difference in survival when compared to surgery alone (median OS: 33.4 vs. 36.2 months, p=0.969). Patients with node-positive resections who underwent CRT had a non-significant improvement in survival (median OS: 21.6 vs. 13.0 months, p=0.092). Thirty-three percent of patients developed distant metastasis. Common sites of distant metastasis included liver (23%) and peritoneum (7%). CONCLUSIONS Adjuvant chemoradiation following curative resection for ampullary adenocarcinoma did not lead to a statistically significant benefit in overall survival. A significant proportion of patients still developed distant metastatic disease suggesting a need for more effective systemic adjuvant therapy.
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Affiliation(s)
- Jessica Zhou
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins Hospital, 401 N. Broadway, Baltimore, MD 21231, USA
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Voutsadakis IA, Doumas S, Tsapakidis K, Papagianni M, Papandreou CN. Bone and brain metastases from ampullary adenocarcinoma. World J Gastroenterol 2009; 15:2665-8. [PMID: 19496199 PMCID: PMC2691500 DOI: 10.3748/wjg.15.2665] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Ampullary carcinoma is the second most common cancer of the peri-ampullary area after pancreatic carcinoma and metastasizes mostly intra-abdominally and to the liver. Extra-abdominal metastases are less frequent. In this report we describe the case of a patient with resected adenocarcinoma of the ampulla of Vater who developed skeletal metastases in the lower extremity and brain metastases. We briefly discuss aspects of this comparatively rare gastrointestinal malignancy.
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Murakami Y, Uemura K, Hayasidani Y, Sudo T, Hashimoto Y, Ohge H, Sueda T. Indication for postoperative adjuvant therapy in biliary carcinoma based on analysis of recurrence and survival after surgical resection. Dig Dis Sci 2009; 54:1360-4. [PMID: 18975086 DOI: 10.1007/s10620-008-0492-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Accepted: 08/22/2008] [Indexed: 02/08/2023]
Abstract
Postoperative adjuvant therapy is mandatory for biliary carcinoma because of its unfavorable prognosis. The aim of this study was to evaluate the indication for postoperative adjuvant therapy in biliary carcinoma. The charts of 139 consecutive patients with biliary carcinoma (37 ampullary carcinomas, 36 distal carcinomas, 38 carcinomas of the gallbladder, and 28 hilar cholangiocarcinomas) who underwent surgical resection were retrospectively reviewed. Recurrence rates and survival rates after surgery were analyzed. Of the 139 carcinomas, the recurrence rates of International Union Against Cancer (UICC) stages IA, IB, IIA, IIB, and III cancers were 9%, 20%, 60%, 83%, and 100%, respectively. The recurrence rates of UICC stages II and III cancers were significantly higher than that of UICC stage I cancer (82% vs 13%, P < 0.001). The 5-year survival rates for patients with UICC stages IA, IB, IIA, IIB, and III cancers were 85%, 75%, 36%, 20%, and 0%, respectively. The 5-year survival rates for UICC stages II and III cancers were significantly lower than that for UICC stage I cancer (21% vs 82%, P < 0.001). Postoperative adjuvant therapy should be given to patients with UICC stages II and III biliary carcinomas because of their high rate of recurrence and the poor prognosis.
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Affiliation(s)
- Yoshiaki Murakami
- Department of Surgery, Division of Clinical Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, Minami-ku, Hiroshima, Japan.
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