Impact of histopathological type on the prognosis of ampullary carcinoma: A systematic review and meta-analysis

Comparison of Ampullary and Pancreatic Adenocarcinomas: Smaller Invasion, Common Adenomatous Components, Resectability, and Histology are Factors for Improved Survival for Patients with Ampullary Adenocarcinoma

BACKGROUND

The information on the clinicopathologic/outcome differences between ampullary adenocarcinoma (AC) and pancreatic adenocarcinoma (PC) has been conflicting to the extent that it still is questioned whether ACs need to be recognized separately from PCs.

METHODS

The characteristics of 413 ACs were compared with those of 547 PCs.

RESULTS

The ACs had a better prognosis than the PCs (5-year survival, 57 % vs 23 %; p < 0.001). Even the pancreatobiliary (PB)-type ACs had a better prognosis (5-year survival, 46 % vs 23 %; p < 0.001). Several differences also were identified as contributing factors: (1) the preinvasive adenomatous component often constituted a significant proportion of the mass in ACs (>50 % of the tumor in 16 % vs 1.5 %; p < 0.001); (2) the mean size of the carcinoma was smaller in ACs (2.5 vs 3.2 cm; p < 0.001): when matched for invasion size, the survival advantage of AC was minimized, and when matched for invasion size larger than 2 cm, the survival advantage of AC lost its statistical significance; (3) lymph node (LN) metastases were less common in ACs (49 % vs 71 %; p < 0.001); (4) the definitive R1 rate was lower in ACs (4 % vs 23.5 %; p < 0.001); and (5) non-PB and non-tubular adenocarcinoma types were more common in ACs (17 % vs 3 %; p < 0.001).

CONCLUSIONS

Comparatively, ACs have better clinical survival than PCs. Potential contributing factors are the relative abundance of the preinvasive component, smaller invasion, lower LN metastasis rate, higher resectability, and common occurrence of less aggressive histologic phenotypes (intestinal, medullary, mucinous). However, this survival advantage is sustained even in PB-type ACs, highlighting the importance of accurately determining the site of origin.

Auerbach's plexus invasion as a key pathological factor for predicting outcomes in ampullary carcinoma

BACKGROUND

Ampullary carcinoma (AC) has a poor prognosis in patients with pancreatic and perineural invasion beyond the duodenal muscularis propria. However, no studies were focused on evaluating Auerbach's plexus (AP) invasion in AC, and its clinical pathological significance remains unclear. In this study, we examined the clinical significance of AP invasion in patients with AC.

METHODS

Clinicopathological examinations for AP invasion were performed in 80 patients with AC (median age: 70 years, male-to-female ratio: 43:37) who underwent endoscopic and surgical resection at Kurume University Hospital between 2005 and 2022. Statistical analysis was performed using the Kaplan-Meier method (log-rank test) and Cox proportional hazards models.

RESULTS

The median AC tumor size was 20 mm, and the most common histological type was well-differentiated adenocarcinoma (59/80, 74%). Tumor invasion beyond the duodenal muscularis propria occurred in 38 patients (48%), of whom 21 (55%) had AP invasion. Univariate analysis identified several prognostic factors, including histological type, tumor depth, stage, AP invasion, and lymph node metastasis. Multivariate analysis confirmed AP invasion (hazard ratio = 2.716, 95% confidence: 1.130-6.529, p = 0.026) as an independent prognostic factor. Additionally, patients with AP invasion had a significantly worse prognosis than those without AP invasion (p < 0.001).

CONCLUSIONS

AP invasion is a critical prognostic factor in patients with AC. Closer monitoring and more aggressive treatment strategies may be warranted for patients with AP invasion to improve their prognosis.

The Role of Adjuvant Therapy in Duodenal Adenocarcinoma and Intestinal Subtype Ampullary Carcinoma After Curative Resection

OBJECTIVE

To define the role of adjuvant therapy in duodenal adenocarcinoma (DAC) and intestinal subtype ampullary carcinoma (iAC).

BACKGROUND

DAC and iAC share a similar histologic differentiation but the benefit of adjuvant therapy remains unclear.

METHODS

Patients undergoing curative intent surgical resection for DAC and iAC between 2010 and 2021 at 5 high-volume centers were included. Patient baseline, perioperative, and long-term oncological outcomes were evaluated. Statistical testing was performed with SPSS 25 (IBM).

RESULTS

A total of 136 patients with DAC and 171 with iAC were identified. Patients with DAC had more advanced tumors than those with iAC. Median overall survival (OS) in patients with DAC was 101 months versus 155 months for patients with iAC ( P = 0.098). DAC had a higher rate of local (14.1% vs 1.2%, P < 0.001) and systemic recurrence (30.4% vs 3.5%, P < 0.001). Adjuvant therapy failed to improve OS in all patients with DAC and iAC. For DAC, patients with perineural invasion, but not other negative prognostic factors, had improved OS rates with adjuvant therapy (72 vs 44 m, P = 0.044). Patients with iAC with N+ (190 vs 57 m, P = 0.003), T3-T4 (177 vs 59 m, P = 0.050), and perineural invasion (150 vs 59 m, P = 0.019) had improved OS rates with adjuvant therapy.

CONCLUSIONS

While adjuvant therapy fails to improve OS in all patients with DAC and iAC in the current study, it improved OS in patients with DAC with perineural invasion and in patients with iAC with T3-T4 tumors, positive lymph nodes, and perineural invasion.

Tumor budding is associated with poor prognosis and clinicopathologic factors in esophageal carcinoma: A meta-analysis

BACKGROUND AND OBJECTIVE

Tumor budding is associated with the prognosis of several solid cancers, but further evidence is needed to identify its relation with esophageal cancer. Our study aims to assess the relationship between tumor budding and overall survival, disease-free survival, and clinicopathologic variables in EC.

METHODS

Multiple electronic databases were searched and 20 relevant studies containing 3370 patients were identified. The fixed effects and a random-effects model were used to perform a meta-analysis.

RESULT

Tumor budding was associated with poor overall survival in EC in both univariate analyses (HR:2.63; 95 % CI 2.06-3.38; p < 0.001) and multivariate analysis (HR: 2.00; 95 % CI 1.68 to 2.39; P < 0.001). Tumor budding was also associated with poor overall survival in subtypes of EC in subgroup analyses i.e. ESCC (HR:3.26; 95 % CI 2.48 to 4.29; P < 0.001), and EAC (HR:2.00; 95 % CI 1.36 to 2.95; P < 0.001) in univariate analysis and ESCC (HR: 2.95; 95 % CI 2.18 to 3.99; P < 0.001) and EAC (HR: 1.65; 95 % CI 1.33 to 2.04; P < 0.001) in multivariate analyses. In addition, tumor budding was also associated with poor DFS (HR: 3.39; 95 % CI 2.1 to 5.48; P < 0.001). Furthermore, tumor budding was associated with poor clinicopathologic factors like advanced T-stage, lymph node metastasis, lymphatic invasion, and venous invasion.

CONCLUSION

The findings of our study suggest that tumor budding is a promising independent prognostic factor and is correlated with poor clinicopathologic variables of esophageal carcinoma. The inclusion of tumor budding in future grading systems may help in improving currently available staging systems of esophageal carcinoma.

Comparison of clinical characteristics and prognostic factors in two site-specific categories of ampullary cancer

BACKGROUND

Ampullary cancer is a relatively rare malignant tumor in the digestive system. Its incidence has increased in recent years. As for now, its biological characteristics have not been fully clarified. Recent studies have primarily focused on the histological classification and genetic changes, but there are fewer investigations into the differences among site-specific subgroups. The clinicopathological characteristics of ampullary cancer occurring in different positions have not been elucidated. Furthermore, the role of adjuvant therapy in the treatment of patients with ampullary cancer remains controversial.

AIM

To study the clinicopathological features of the two site-specific subgroups of ampullary cancer and explore the factors affecting prognosis.

METHODS

A total of 356 patients who met the inclusion and exclusion criteria were enrolled. Patients were divided into ampulla of Vater cancer (AVC) and duodenal papilla cancer (DPC) based on the gross and microscopic findings. Baseline data, admission examination results, and perioperative outcomes were collected and analyzed. The Kaplan-Meier curve was used for survival analysis. Univariate and multivariate analysis was performed to explore the independent risk factors affecting the overall survival (OS) of both groups.

RESULTS

The preoperative total bilirubin level in patients with AVC was significantly higher than those with DPC (P = 0.04). The OS for patients with DPC was 58.90 ± 38.74 months, significantly longer than 44.31 ± 35.90 months for patients with AVC (P < 0.01). The independent risk factors affecting the OS of AVC included: Preoperative albumin level (P = 0.009), total bilirubin level (P = 0.017), and number of positive lymph nodes (P = 0.005). For DPC, risk factors included: Age (P = 0.004), tumor size (P = 0.023), number of positive lymph nodes (P = 0.010) and adjuvant treatment (P = 0.020). Adjuvant therapy significantly improved the OS rate of patients with DPC, but not for those with AVC.

CONCLUSION

Patients with AVC had a shorter OS compared to those with DPC. The prognosis factors and the role of adjuvant therapy of two groups were different.

Ampullary tumors: French Intergroup Clinical Practice Guidelines for diagnosis, treatments and follow-up (TNCD, SNFGE, FFCD, UNICANCER, GERCOR, SFCD, SFED, ACHBT, AFC, SFRO, RENAPE, SNFCP, AFEF, SFP, SFR)

BACKGROUND

Management of ampullary tumors (AT) is challenging because of a low level of scientific evidence. This document is a summary of the French intergroup guidelines regarding the management of AT, either adenoma (AA) or carcinoma (AC), published in July 2023, available on the website of the French Society of Gastroenterology (SNFGE) (www.tncd.org).

METHODS

A collaborative work was conducted under the auspices of French medical, endoscopic, oncological and surgical societies involved in the management of AT. Recommendations are based on recent literature review and expert opinions and graded in three categories (A, B, C), according to quality of evidence.

RESULTS

Accurate diagnosis of AT requires at least duodenoscopy and EUS. All patients should be discussed in multidisciplinary tumor board before treatment. Surveillance may only be proposed for small AA in familial adenomatous polyposis. For AA, endoscopic papillectomy is the preferred option only if R0 resection can be achieved. When not possible, surgical papillectomy should be considered. For AC beyond pT1a N0, pancreaticoduodenectomy is the procedure of choice. Adjuvant monochemotherapy (gemcitabine, 5FU) may be proposed. For aggressive tumors (pT3/T4, pN+, R1, poorly differentiated AC, pancreatobiliary differentiation) with high risk of recurrence, 6 months polychemotherapy (CAPOX/FOLFOX for the intestinal subtype and mFOLFIRINOX for the pancreatobiliary or the mixed subtype) may be a valid alternative. Clinical and radiological follow up is recommended for 5 years.

CONCLUSIONS

These guidelines help to homogenize and highlight unmet needs in the management of AA and AC. Each individual case should be discussed by a multidisciplinary team.

Prognostic significance of histologic phenotype in periampullary adenocarcinomas

Background

Periampullary adenocarcinomas typically exhibit either intestinal or pancreatobiliary (PB) differentiation, and the type of differentiation may be prognostically more important than the anatomic site of origin. This study aimed to evaluate prognostic significance of histological type of periampullary carcinomas.

Methods

Microscopic slides from 110 consecutive pancreatoduodenectomies performed between 2010 and 2020 were reviewed and classified as intestinal or PB type. Clinicopathological factors were compared between PB-(n=93) and intestinal-type (n=17) differentiation.

Results

The intestinal type included significantly more patients with well-differentiated histology (35.3% vs. 11.8%, p=0.001) and fewer patients with perineural invasion (41.2% vs. 76.4%, p=0.029), advanced T stage (> T3; 41.2% vs.74.2%, p=0.007), and systemic recurrence (71.4% vs. 92.9%, p=0.005) than PB type. The 5-year-overall survival rate of intestinal-type was significantly higher than that of PB-type (58.8% vs. 20.4%, p=0.003). When pancreatic cancer was separately analyzed, the intestinal type showed the best 5-year-overall survival rate, with no significant difference between the PB types excluding PDAC and PDAC (39.4% vs. 19.2%, p=0.148). In multivariate analysis, curative resection (hazard ratio, 0.417; 95% CI, 0.219-0.792, p=0.008) was the only significant prognostic factor.

Conclusion

Although intestinal histologic phenotype was not an independent prognostic factor on multivariate analysis, it showed pathologic features associated with better survival, while the PB type showed more aggressive tumor biology and consequently worse survival. Further studies are needed to demonstrate the prognostic significance of histologic phenotype.

Prognostic Impact of Mucin Expression in Curatively Resected Ampulla of Vater Cancer

Introduction: Mucins play a pivotal role in epithelial carcinogenesis; however, their role remains elusive in ampulla of Vater (AoV) cancer, regardless of histological subtype. Therefore, we investigated the clinical significance of MUC1, MUC2, MUC5AC, and MUC6 expression in AoV cancer. Methods: Using samples from 68 patients with AoV cancer, we performed immunohistochemical staining for MUC1, MUC2, MUC5AC, and MUC6 using a tissue microarray. Subsequently, we analyzed their expression patterns in relation to clinicopathological parameters and patient outcomes. Results: Of the patients, 98.5% exhibited positive expression for MUC1, while MUC2, MUC5AC, and MUC6 were expressed in 44.1%, 47.1%, and 41.2% of the patients, respectively. Correlation analyses between mucin expression and clinicopathological factors revealed no significant associations, except between MUC5AC expression and N stage. Univariate analysis demonstrated significant associations between MUC5AC expression and overall survival (OS). Multivariate analysis further confirmed that MUC5AC expression was a significant predictor of OS, along with the N stage. However, MUC5AC expression was not meaningfully associated with recurrence-free survival (RFS). The patients positive for MUC5AC expression had a considerably shorter OS than those with negative expression. Conclusions: Our study provides insights into the clinical impact of mucins on AoV cancer, regardless of the histological subtype. Although MUC1 expression is universal, MUC5AC expression is a significant prognostic indicator that correlates with lymph node metastasis and poor OS. These results emphasize the possible utility of MUC5AC as a biomarker for extensive lymph node dissection and the prognostic evaluation of patients with AoV cancer.

Real-world efficacy and safety of capecitabine with oxaliplatin in patients with advanced adenocarcinoma of the ampulla of Vater

BACKGROUND

Adenocarcinoma of the ampulla of Vater (AoV) is one of the rare periampullary cancers, and due to its anatomical location, it is categorized into various histologic subtypes. Its rarity and diversity pose challenges in treatment decision-making for patients with advanced AoV carcinoma. This study investigated the efficacy and safety of the combined regimen of capecitabine and oxaliplatin (CAPOX) in a real-world clinical setting.

METHODS

This investigation encompassed patients with advanced AoV carcinoma who underwent CAPOX treatment. Histologic phenotypes were identified through a combination of histopathological analysis and protein expression markers, including MUC1, CDX2, CK20, and MUC2. The correlation between histopathological determinants and survival outcomes was explored, in addition to an evaluation of the safety profile of CAPOX therapy.

RESULTS

From January 2010 to June 2023, 42 patients received CAPOX. Of these, 14 patients (33.3%) had not received any prior palliative chemotherapy, while 28 patients (66.7%) had undergone one prior line of chemotherapy. At a median follow up of 9.0 months, the median progression-free survival (PFS) was 4.38 months (95% CI, 2.78-5.69) and the median overall survival (OS) was 9.57 months (95% CI 7.56-11.6). The objective response and disease control rates were 38.1% and 61.9%, respectively. Patients who received CAPOX as a second-line treatment had poorer PFS (HR = 2.62; 95% CI, 1.49-4.90, p = 0.003) and OS (HR = 2.82, 95% CI, 1.47-5.38, p = 0.001) compared to those who received CAPOX as a first-line chemotherapy. There were no statistically significant differences in PFS (p = 0.185) and OS (p = 0.097) between groups based on histologic subtypes. Neutropenia (14.3%) emerged as the predominant grade 3-4 toxicity. Notably, treatment cessation occurred in select instances owing to grade 3 fatigue (9.5%) and peripheral neuropathy (9.5%).

CONCLUSIONS

This study confirmed the therapeutic efficacy and safety of CAPOX in a real-world setting, consistent with prior phase II trial results. While CAPOX proved feasible for advanced AoV carcinoma regardless of histologic subtype, its reduced effectiveness in second-line settings necessitates further research to determine its optimal palliative use.

Identification of patients at high risk for recurrence in carcinoma of the ampulla of Vater: Analysis in 460 patients

Aim

Carcinoma of the ampulla of Vater (CAV) shows a favorable prognosis compared to that with the other periampullary tumors, while some cases have a poor prognosis. The aims of the present study are to clarify the clinicopathological factors associated with poor recurrence-free survival (RFS) in patients with CAV after curative resection and to validate the usefulness of adjuvant chemotherapy (AC).

Patients

The study design is a multicenter retrospective cohort study. Patients with CAV who underwent pancreaticoduodenectomy between January 2008 and December 2020 at 26 hospitals were analyzed. The 30 clinicopathological factors were evaluated. A propensity score matching (PSM) was used to compare between patients with and without AC.

Results

Finally, 460 patients were analyzed. Median duration of follow-up was 47.2 months. Twenty-one prognostic factors associated with poor RFS were identified by univariate analysis. In multivariate analysis, aged ≥71, tumor diameter ≥12 mm, pT2 or higher stage (pT≥2), portal vein invasion (PV+), venous invasion(V+), and node positive disease (pN+) were independent prognostic factors for poor RFS. Out of 80 patients who received AC, 63 patients were assigned to analysis for PSM. The results showed no beneficial effect of AC on RFS. The preoperative factors potentially predicting pT≥2, V+, and/or N+ were at least one of following; (1) CA19-9 > 37 IU/mL, (2) ulcerative or mixed type appearance, (3) except for well-differentiated tumor, or (4) except for intestinal subtype of histology.

Conclusions

Aged ≥71, tumor diameter ≥12 mm, pT≥2, PV+, V+, and pN+ were independent prognostic factors for poor RFS in patients with CAV. An additional therapeutic strategy may be desirable in CAV patients at high risk for recurrence.

Prognostic significance of trophoblastic cell surface antigen 2 expression and pathologic parameters in patients with ampullary adenocarcinoma

Trophoblastic cell surface antigen 2 (TROP2) has been reported to be up-regulated in several types of carcinomas and is associated with aggressive behavior and poor survival. However, TROP2 expression and its clinical significance in ampullary adenocarcinoma (AA) have not been investigated. We examined TROP2 expression by immunohistochemistry in 112 patients with AAs. The associations of TROP2 expression with clinicopathologic characteristics were evaluated by χ2 analyses or Fisher's exact tests. The associations of TROP2 expression and pathologic parameters with survival were evaluated by the Kaplan-Meier method and univariate and multivariate Cox regression analyses. Eighty-six AAs (76.8%) were positive for TROP2, which showed a membranous and cytoplasmic staining. TROP2 expression was associated with higher frequency (P = .04) and higher number (P = .03) of lymph node metastasis, higher pN stage (P = .03), less frequent adenoma (P = .04), and higher frequency of recurrence/metastasis (P = .004). TROP2 expression was associated with shorter disease-free survival (P = .02) and overall survival (P = .03). TROP2 expression was an independent prognostic factor for disease-free survival (P = .04). We demonstrated that TROP2 was expressed in 76.8% of AAs. TROP2 expression was associated with higher frequency and high number of lymph node metastasis and higher pN stage. More importantly, TROP2 expression was associated with higher frequency of recurrence/metastasis, shorter disease-free and overall survival and was an independent prognostic factor for disease-free survival. Our results suggest that TROP2 may be used both as a prognostic marker and as a therapeutic target for patients with AAs.

Adjuvant Chemotherapy and Effect on Long-Term Survival in Ampullary Adenocarcinoma: A Multicenter Cohort Study

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).

Impact of cancer-associated fibroblasts on survival of patients with ampullary carcinoma

Background

Cancer-associated fibroblasts (CAFs) reportedly enhance the progression of gastrointestinal surgery; however, the role of CAFs in ampullary carcinomas remains poorly examined. This study aimed to investigate the effect of CAFs on the survival of patients with ampullary carcinoma.

Materials and methods

A retrospective analysis of 67 patients who underwent pancreatoduodenectomy between January 2000 and December 2021 was performed. CAFs were defined as spindle-shaped cells that expressed α-smooth muscle actin (α-SMA) and fibroblast activation protein (FAP). The impact of CAFs on survival, including recurrence-free (RFS) and disease-specific survival (DSS), as well as prognostic factors associated with survival, was analyzed.

Results

The high-α-SMA group had significantly worse 5-year RFS (47.6% vs. 82.2%, p = 0.003) and 5-year DSS (67.5% vs. 93.3%, p = 0.01) than the low-α-SMA group. RFS (p = 0.04) and DSS (p = 0.02) in the high-FAP group were significantly worse than those in the low-FAP group. Multivariable analyses found that high α-SMA expression was an independent predictor of RFS [hazard ratio (HR): 3.68; 95% confidence intervals (CI): 1.21–12.4; p = 0.02] and DSS (HR: 8.54; 95% CI: 1.21–170; p = 0.03).

Conclusions

CAFs, particularly α-SMA, can be useful predictors of survival in patients undergoing radical resection for ampullary carcinomas.