Treatment and overall survival of four types of non-metastatic periampullary cancer: nationwide population-based cohort study

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.

Comprehensive Geriatric Assessment, Treatment Decisions, and Outcomes in Older Patients Eligible for Pancreatic Surgery

INTRODUCTION

Periampullary cancer has a poor prognosis. Surgical resection is a potentially curative but high-risk treatment. Comprehensive geriatric assessment (CGA) can inform treatment decisions, but has not yet been evaluated in older patients eligible for pancreatic surgery.

METHODS

This prospective observational study included patients ≥ 70 years of age eligible for pancreatic surgery. Frailty was defined as impairment in at least two of five domains: somatic, psychological, functional, nutritional, and social. Outcomes included postoperative complications, functional decline, and mortality.

RESULTS

Of the 88 patients included, 87 had a complete CGA. Sixty-five patients (75%) were frail and 22 (25%) were non-frail. Frail patients were more likely to receive nonsurgical treatment (43.1% vs. 9.1% p = 0.004). Fifty-seven patients underwent surgery, of which 52 (59%) underwent pancreaticoduodenectomy. The incidence of postoperative delirium was three times higher in frail patients (29.7% vs. 0%, p = 0.005). The risk of mortality was three times higher in frail patients (HR: 3.36, 95% CI: 1.43-7.89, p = 0.006).

CONCLUSION

Frailty is common in older patients eligible for pancreatic surgery and is associated with treatment decision, a higher incidence of delirium and a three times higher risk of all-cause mortality. CGA can contribute to shared decision-making and optimize perioperative care in older patients.

A simple prognostic score to predict recurrence after pancreaticoduodenectomy for ampullary carcinoma: results from the French prospective FFCD-AC cohort

BACKGROUND

Ampullary carcinoma (AC) is a rare and severe gastrointestinal cancer with a disease recurrence rate of around 40% after curative-intent surgery and for which the main prognostic factors and adjuvant treatment decision remain a matter of debate.

PATIENTS AND METHODS

The FFCD-AC cohort is a French nationwide prospective cohort, which included patients with non-metastatic resected AC. The primary objective of this study was to describe prognostic factors associated with disease-free survival (DFS) and overall survival (OS) after pancreaticoduodenectomy (PD) so as to propose a user-friendly score to better estimate the risk of recurrence. The secondary objective was to study the benefit of adjuvant therapy in terms of DFS and OS.

RESULTS

Three hundred and seventy patients with resected AC were included. Median follow-up was 40.6 months. Median age was 68.5 years (32.0-87.0 years), 53.8% of patients were male and 56.1%/37.4%/6.5% had an Eastern Cooperative Oncology Group performance status 0/1/2, respectively. Pathological subtype was intestinal/pancreatobiliary/mixed-undetermined in 29.5%/40.5%/30.0% of patients, respectively. Adjuvant chemotherapy was carried out in 61% of patients. In multivariable analysis, stage III tumor [hazard ratio (HR) 2.86, (95% confidence interval {95% CI}: 1.89-4.17), P < 0.0001], high tumor grade [HR 2.51, (95% CI: 1.42-4.43), P = 0.002] and non-intestinal subtype [HR 1.58, (95% CI: 1.00-2.49), P = 0.052] were associated with shorter DFS. A score based on these three parameters divided patients into low (n = 83), intermediate (n = 133) and high risk (n = 96) with median DFS not reached (NR)/73.1/15.2 months and a median OS NR/86.1/38.2 months, respectively. After propensity score matching, adjuvant chemotherapy was associated with longer DFS [HR 0.57, (95% CI: 0.45-0.72), P < 0.0001] in the cohort.

CONCLUSION

Our integrated score based on three easy-to-collect items-lymph node invasion, tumor grade and non-intestinal subtypes-seems highly prognostic in resected AC and needs to be confirmed in an external validation dataset to help adjuvant treatment decision making.

Tackling challenges in rare diseases: The ISGACA approach on non-pancreatic cancers in the periampullary region

OBJECTIVE

Rare but aggressive cancer types like non-pancreatic periampullary cancers pose unique challenges for cancer research due to their low incidence rates and lack of consensus on optimal treatment strategies, therefore necessitating a collaborative approach. The International Study Group on non-pancreatic peri-Ampullary CAncer (ISGACA) aimed to build a collaborative initiative to pool expertise, funding opportunities, and data from over 60 medical centers, in order to improve outcomes for underrepresented patients with rare cancers.

METHODS

The ISGACA approach predefined a stepwise approach including a research scope, establishing a dedicated steering committee, creating a recognizable brand, identifying research gaps, following a well-defined timeline, ensuring robust data collection, addressing legal and ethical considerations, securing financial resources, investing in research ethics training and statistical expertise, raising awareness, creating uniformity, and initiating prospective studies.

RESULTS

Overall, 60 medical centers joined the ISGACA consortium (41 in Europe, 15 in North-America, three in Asia, one in Australia). The database includes 4309 patients. Nine publications and several ongoing studies which in turn allowed for a successful application of research grants. Subsequently, an international consensus meeting established uniform definitions and classifications, and one prospective multicenter international clinical trial has been initiated.

CONCLUSION

By sharing knowledge, expertise, and clinical data, the ISGACA approach has not only gathered sufficient evidence to secure grants and ethical approvals for prospective studies, but also demonstrates options for standardizing patient care and improving outcomes for patients with rare cancers. The ISGACA approach offers a detailed methodology for initiating research on rare cancers and could serve as a replicable model for future research initiatives.

Long-term outcomes after resection of extra-ampullary duodenal adenocarcinomas: single-center experience

BACKGROUND

Extra-ampullary duodenal adenocarcinoma is a rare neoplasm. The data on long-term outcomes after curative resection are limited, and the role of systemic chemotherapy is not defined in these tumors. This study aimed to investigate the prognostic factors and survival of patients with resected primary duodenal cancers.

METHODS

A retrospective analysis of patients with resected primary duodenal adenocarcinoma was conducted between January 2010 and December 2023.

RESULTS

A total of 59 patients were included in the study. The median age of patients was 60 years (IQR, 33-79), and 79.7% of patients were males. The second part of the duodenum was the most common location of the tumor in 42 patients (71.2%). Pancreaticoduodenectomy was performed in 57 patients (96.6%), and segmental duodenal resection was performed on 2 patients (3.4%). The median lymph node harvest was 18 (IQR, 2-70). Adjuvant chemotherapy was administered to 39 patients (66.1%). At a median follow-up of 32.00 months (IQR, 3.29-166.74), the 5-year overall survival (OS) and disease-free survival rates were 55.0% and 49.3%, respectively. Regarding prognostic factors, lymph node ratio (LNR; hazard ratio [HR], 2.94; 95% CI, 1.01-8.53), adenocarcinoma subtype (intestinal vs nonintestinal; HR, 4.59; 95% CI, 1.59-13.23), and margin of resection (HR, 44.24; 95% CI, 4.02-486.19) were significant factors for OS.

CONCLUSION

Margin-free surgical resection offers the best chance of cure for operable duodenal adenocarcinoma. The intestinal subtype and low LNR are predictors of better survival, and the role of adjuvant chemotherapy remains debatable until prospective randomized trials are conducted.

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.

The Five Periampullary Cancers, not Just Different Siblings but Different Families: An International Multicenter Cohort Study

BACKGROUND

Cancer arising in the periampullary region can be anatomically classified in pancreatic ductal adenocarcinoma (PDAC), distal cholangiocarcinoma (dCCA), duodenal adenocarcinoma (DAC), and ampullary carcinoma. Based on histopathology, ampullary carcinoma is currently subdivided in intestinal (AmpIT), pancreatobiliary (AmpPB), and mixed subtypes. Despite close anatomical resemblance, it is unclear how ampullary subtypes relate to the remaining periampullary cancers in tumor characteristics and behavior.

METHODS

This international cohort study included patients after curative intent resection for periampullary cancer retrieved from 44 centers (from Europe, United States, Asia, Australia, and Canada) between 2010 and 2021. Preoperative CA19-9, pathology outcomes and 8-year overall survival were compared between DAC, AmpIT, AmpPB, dCCA, and PDAC.

RESULTS

Overall, 3809 patients were analyzed, including 348 DAC, 774 AmpIT, 848 AmpPB, 1,036 dCCA, and 803 PDAC. The highest 8-year overall survival was found in patients with AmpIT and DAC (49.8% and 47.9%), followed by AmpPB (34.9%, P < 0.001), dCCA (26.4%, P  =  0.020), and finally PDAC (12.9%, P < 0.001). A better survival was correlated with lower CA19-9 levels but not with tumor size, as DAC lesions showed the largest size.

CONCLUSIONS

Despite close anatomic relations of the five periampullary cancers, this study revealed differences in preoperative blood markers, pathology, and long-term survival. More tumor characteristics are shared between DAC and AmpIT and between AmpPB and dCCA than between the two ampullary subtypes. Instead of using collective definitions for "periampullary cancers" or anatomical classification, this study emphasizes the importance of individual evaluation of each histopathological subtype with the ampullary subtypes as individual entities in future studies.

Effect of MELD-Na score on overall survival of periampullary cancer

Periampullary cancers have a short overall survival (OS), and many prognostic factors have been studied for this purpose. They usually present with biliary obstruction, which negatively affects the liver, kidney, immune system, and cardiovascular system. This study aimed to investigate the effect of MELD-Na scores on OS in patients undergoing pancreaticoduodenectomy due to periampullary cancer. Patients who underwent pancreaticoduodenectomy due to periampullary cancer between January 2010 and January 2021 were included in the study. After applying the exclusion criteria, 80 of the 124 patients were included in the study. The demographic, laboratory, and pathologic data of the patients were analyzed retrospectively. Univariate analysis showed that MELD-Na score at admission, age-adjusted Charlson Comorbidity Index, adjuvant treatment, portal vein resection, lymphovascular invasion (LVI), T-stage, and tumor location were significantly associated with OS (p < 0.1). In multivariate analysis, MELD-Na score at admission (HR: 1.051, 95% CI [1.004-1.101]; p = 0.033), adjuvant treatment (HR: 4.717, 95% CI [2.371-9.383]; p < 0.001), LVI (HR: 2.473, 95% CI [1.355-4.515]; p = 0.003), and tumor location (HR: 2.380, 95% CI [1.274-4.445]; p = 0.007) were independent risk factors for OS. MELD-Na score, adjuvant treatment, LVI, and tumor location were independent risk factors for the OS of periampullary cancer. The MELD-Na score may be used to predict OS for patients undergoing pancreaticoduodenectomy due to periampullary cancer.

Treatment patterns and survival outcomes in patients with non-metastatic early-onset pancreatic cancer

BACKGROUND

The incidence of patients with early-onset pancreatic cancer (EOPC; age ≤ 50 years at diagnosis) is on the rise, placing a heavy burden on individuals, families, and society. The role of combination therapy including surgery, radiotherapy, and chemotherapy in non-metastatic EOPC is not well-defined.

AIM

To investigate the treatment patterns and survival outcomes in patients with non-metastatic EOPC.

METHODS

A total of 277 patients with non-metastatic EOPC who were treated at our institution between 2017 and 2021 were investigated retrospectively. Overall survival (OS), disease-free survival, and progression-free survival were estimated using the Kaplan-Meier method. Univariate and multivariate analyses with the Cox proportional hazards model were used to identify prognostic factors.

RESULTS

With a median follow-up time of 34.6 months, the 1-year, 2-year, and 3-year OS rates for the entire cohort were 84.3%, 51.5%, and 27.6%, respectively. The median OS of patients with localized disease who received surgery alone and adjuvant therapy (AT) were 21.2 months and 28.8 months, respectively (P = 0.007). The median OS of patients with locally advanced disease who received radiotherapy-based combination therapy (RCT), surgery after neoadjuvant therapy (NAT), and chemotherapy were 28.5 months, 25.6 months, and 14.0 months, respectively (P = 0.002). The median OS after regional recurrence were 16.0 months, 13.4 months, and 8.9 months in the RCT, chemotherapy, and supportive therapy groups, respectively (P = 0.035). Multivariate analysis demonstrated that carbohydrate antigen 19-9 level, pathological grade, T-stage, N-stage, and resection were independent prognostic factors for non-metastatic EOPC.

CONCLUSION

AT improves postoperative survival in localized patients. Surgery after NAT and RCT are the preferred therapeutic options for patients with locally advanced EOPC.

Machine learning for differentiating between pancreatobiliary-type and intestinal-type periampullary carcinomas based on CT imaging and clinical findings

PURPOSE

To develop a diagnostic model for distinguishing pancreatobiliary-type and intestinal-type periampullary adenocarcinomas using preoperative contrast-enhanced computed tomography (CT) findings combined with clinical characteristics.

METHODS

This retrospective study included 140 patients with periampullary adenocarcinoma who underwent preoperative enhanced CT, including pancreaticobiliary (N = 100) and intestinal (N = 40) types. They were randomly assigned to the training or internal validation set in an 8:2 ratio. Additionally, an independent external cohort of 28 patients was enrolled. Various CT features of the periampullary region were evaluated and data from clinical and laboratory tests were collected. Five machine learning classifiers were developed to identify the histologic type of periampullary adenocarcinoma, including logistic regression, random forest, multi-layer perceptron, light gradient boosting, and eXtreme gradient boosting (XGBoost).

RESULTS

All machine learning classifiers except multi-layer perceptron used achieved good performance in distinguishing pancreatobiliary-type and intestinal-type adenocarcinomas, with the area under the curve (AUC) ranging from 0.75 to 0.98. The AUC values of the XGBoost classifier in the training set, internal validation set and external validation set are 0.98, 0.89 and 0.84 respectively. The enhancement degree of tumor, the growth pattern of tumor, and carbohydrate antigen 19-9 were the most important factors in the model.

CONCLUSION

Machine learning models combining CT with clinical features can serve as a noninvasive tool to differentiate the histological subtypes of periampullary adenocarcinoma, in particular using the XGBoost classifier.

Different Periampullary Types and Subtypes Leading to Different Perioperative Outcomes of Pancreatoduodenectomy: Reality and Not a Myth; An International Multicenter Cohort Study

This international multicenter cohort study included 30 centers. Patients with duodenal adenocarcinoma (DAC), intestinal-type (AmpIT) and pancreatobiliary-type (AmpPB) ampullary adenocarcinoma, distal cholangiocarcinoma (dCCA), and pancreatic ductal adenocarcinoma (PDAC) were included. The primary outcome was 30-day or in-hospital mortality, and secondary outcomes were major morbidity (Clavien-Dindo 3b≥), clinically relevant post-operative pancreatic fistula (CR-POPF), and length of hospital stay (LOS). Results: Overall, 3622 patients were included in the study (370 DAC, 811 AmpIT, 895 AmpPB, 1083 dCCA, and 463 PDAC). Mortality rates were comparable between DAC, AmpIT, AmpPB, and dCCA (ranging from 3.7% to 5.9%), while lower for PDAC (1.5%, p = 0.013). Major morbidity rate was the lowest in PDAC (4.4%) and the highest for DAC (19.9%, p < 0.001). The highest rates of CR-POPF were observed in DAC (27.3%), AmpIT (25.5%), and dCCA (27.6%), which were significantly higher compared to AmpPB (18.5%, p = 0.001) and PDAC (8.3%, p < 0.001). The shortest LOS was found in PDAC (11 d vs. 14-15 d, p < 0.001). Discussion: In conclusion, this study shows significant variations in perioperative mortality, post-operative complications, and hospital stay among different periampullary cancers, and between the ampullary subtypes. Further research should assess the biological characteristics and tissue reactions associated with each type of periampullary cancer, including subtypes, in order to improve patient management and personalized treatment.

Neoadjuvant Therapy for Duodenal and Ampullary Adenocarcinoma: A Systematic Review

BACKGROUND

The role of systemic therapy in the management of ampullary (AA) and duodenal adenocarcinoma (DA) remains poorly understood. This study sought to synthesize current evidence supporting the use of neoadjuvant therapy (NAT) in AA and DA.

METHODS

The study searched PubMed, Cochrane Library (Wiley), Embase (Elsevier), CINAHL (EBSCO), and ClinicalTrials.gov databases for observational or randomized studies published between 2002 and 2022 evaluating survival outcomes for patients with non-metastatic AA or DA who received systemic therapy and surgical resection. The data extracted included overall survival, progression-free survival, and pathologic response (PR) rate.

RESULTS

From the 347 abstracts identified in this study, 29 reports were reviewed in full, and 15 were included in the final review. The selected studies published from 2007 to 2022 were retrospective. Eight were single-center studies; five used the National Cancer Database (NCDB); and two were European multicenter/national studies. Overall, no studies identified survival differences between NAT and upfront surgery (with or without adjuvant therapy). Two NCDB studies reported longer survival with NAT/AT than with surgery. Five single-center studies reported a significant portion of NAT patients who achieved PR, and one study identified major PR as an independent predictor of survival. Other outcomes associated with NAT included conversion from unresectable to resectable disease, reduced lymph node positivity, and decreased local recurrence rate.

CONCLUSION

Evidence supporting the use of NAT in AA and DA is weak. No randomized studies exist, and observational data show mixed results. For patients with DA and AA, NAT appears safe, but better evidence is needed to understand the preferred multidisciplinary management of DA and AA periampullary malignancies.

Long-term Outcomes After Laparoscopic, Robotic, and Open Pancreatoduodenectomy for Distal Cholangiocarcinoma: An International Propensity Score-matched Cohort Study

OBJECTIVE

This study aimed to compare surgical and oncological outcomes after minimally invasive pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) for distal cholangiocarcinoma (dCCA).

BACKGROUND

A dCCA might be a good indication for MIPD, as it is often diagnosed as primary resectable disease. However, multicenter series on MIPD for dCCA are lacking.

METHODS

This is an international multicenter propensity score-matched cohort study including patients after MIPD or OPD for dCCA in 8 centers from 5 countries (2010-2021). Primary outcomes included overall survival (OS) and disease-free interval (DFI). Secondary outcomes included perioperative and postoperative complications and predictors for OS or DFI. Subgroup analyses included robotic pancreatoduodenectomy (RPD) and laparoscopic pancreatoduodenectomy (LPD).

RESULTS

Overall, 478 patients after pancreatoduodenectomy for dCCA were included of which 97 after MIPD (37 RPD, 60 LPD) and 381 after OPD. MIPD was associated with less blood loss (300 vs 420 mL, P =0.025), longer operation time (453 vs 340 min; P <0.001), and less surgical site infections (7.8% vs 19.3%; P =0.042) compared with OPD. The median OS (30 vs 25 mo) and DFI (29 vs 18) for MIPD did not differ significantly between MIPD and OPD. Tumor stage (Hazard ratio: 2.939, P <0.001) and administration of adjuvant chemotherapy (Hazard ratio: 0.640, P =0.033) were individual predictors for OS. RPD was associated with a higher lymph node yield (18.0 vs 13.5; P =0.008) and less major morbidity (Clavien-Dindo 3b-5; 8.1% vs 32.1%; P =0.005) compared with LPD.

DISCUSSION

Both surgical and oncological outcomes of MIPD for dCCA are acceptable as compared with OPD. Surgical outcomes seem to favor RPD as compared with LPD but more data are needed. Randomized controlled trials should be performed to confirm these findings.

The prognostic effect of the systemic immune-inflammation index on overall survival of periampullary cancer

OBJECTIVE

The systemic immune-inflammation index (SII) is used to assess survival in many cancers. SII has been examined separately in pancreatic head, ampulla, and distal choledochus cancers, and different cut-off values were found. Detecting the location of periampullary cancer before surgery may be difficult or misleading. This study aimed to investigate the use of SII in predicting overall survival (OS) with periampullary cancers regardless of tumor location.

METHODS

Between January 2010 and January 2020, 163 patients who underwent pancreaticoduodenectomy for periampullary tumors were assessed. After applying the exclusion criteria, data from 116 patients with cancer who underwent pancreaticoduodenectomy were included in the study.

RESULTS

OS was compared using Kaplan-Meier curves. The prognostic significance of baseline SII and other factors were assessed in univariate and multivariate analyses using the Cox proportional hazard regression model. Univariate analysis demonstrated that age ≥60.5 years (hazard ratio [HR]: 2.042, 95% CI: [1.355-3.078]; p = 0.001), male sex (HR: 1.863, 95% CI: [1.231-2.821]; p = 0.003), tumor in the pancreatic head vs. ampulla (HR: 2.150, 95% CI: [1.364-3.389]; p = 0.001), tumor in the pancreatic head vs. distal choledochus (HR: 1.945, 95% CI: [1.091-3.472]; p = 0.024), N (+) stage (HR: 1.868, 95% CI: [1.223-2.854]; p = 0.004), total bilirubin level >0.35 (HR: 2.131, 95% CI: [1.245-3.649]; p = 0.006), NLR >2.13 (HR: 1.911, 95% CI: [1.248-2.925]; p = 0.003), and SII >704 (HR: 1.966, 95% CI: [1.310-2.950]; p = 0.001) were significantly associated with OS. Multivariate analysis revealed that SII >704 (HR: 2.375; p < 0.001), age ≥ 60.5 years (HR: 2.728; p < 0.001), N-stage positivity (HR: 3.431; p < 0.001), and tumor in the pancreatic head vs. ampulla (HR: 2.801; p < 0.001) were independently associated with poor survival. There was no difference between tumor locations in terms of SII (p = 0.206).

CONCLUSIONS

SII is an independent prognostic risk factor and may be a marker for predicting OS in patients with periampullary cancer. There was no statistical difference between the tumor locations in terms of SII. A single cut-off value of SII may be used for periampullary cancer survival without the need for a pathology specimen.

Evaluation of Systemic Treatments of Small Intestinal Adenocarcinomas: A Systematic Review and Meta-analysis

Importance

Although small intestinal adenocarcinomas (SIAs) are rare, they have a poor prognosis, and the optimal treatment strategies are largely unknown. Because of the lack of high-quality evidence, guidelines for colorectal cancer are often followed in the treatment of SIAs.

Objective

To review the current evidence regarding survival benefit of systemic therapies, including chemotherapy, targeted agents, and immunotherapy, for patients with SIAs.

Data Sources

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses, MEDLINE and Embase were searched for articles published from January 1, 2005, until June 1, 2022.

Study Selection

Retrospective cohort studies and prospective phase 2 or 3 trials describing survival after systemic therapies for patients with SIAs were eligible for inclusion. Assessment of study eligibility was blinded and performed by 3 reviewers.

Data Extraction and Synthesis

The reviewers independently extracted data. Random effects, inverse variance, pairwise meta-analyses were performed.

Main Outcomes and Measures

Primary outcomes were overall survival (OS) and progression-free survival (PFS) of patients with SIAs after systemic therapies. Measures of interest included hazard ratios for survival and median survival times.

Results

Overall, 57 retrospective cohort and phase 2 studies of 35 176 patients were included. Adjuvant chemotherapy, generally fluoropyrimidine-based, was associated with increased OS in stage I to III SIAs (hazard ratio [HR], 0.60; 95% CI, 0.53-0.68), especially in stage III tumors (HR, 0.55; 95% CI, 0.48-0.64), irrespective of tumor localization. Palliative chemotherapy was also associated with an OS benefit (HR, 0.48; 95% CI, 0.40-0.58). Fluoropyrimidine-oxaliplatin combinations were superior to other regimens (OS: HR, 0.54; 95% CI, 0.30-0.99; PFS: HR, 0.46; 95% CI, 0.30-0.71). Furthermore, bevacizumab added to chemotherapy compared with chemotherapy alone was associated with significantly prolonged PFS (HR, 0.62; 95% CI, 0.43-0.89). Immunotherapy showed a 50% overall response rate in previously treated defective mismatch repair tumors.

Conclusions and Relevance

In this systematic review and meta-analysis, adjuvant and palliative chemotherapy were both associated with improved survival of patients with SIAs, especially fluoropyrimidine-based regimens and fluoropyrimidine-oxaliplatin combinations. Adding bevacizumab to chemotherapy appears to prolong PFS and deserves further investigation. Immunotherapy seems beneficial and should be considered for patients with defective mismatch repair tumors. International collaborations should be undertaken to confirm and improve efficacy of systemic therapies for patients with SIAs.

Machine learning models for predicting survival in patients with ampullary adenocarcinoma

OBJECTIVE

The aim of this study was to predict the long-term survival probability of patients with ampullary adenocarcinoma (AAC), which would provide a theoretical basis for the long-term care of these patients.

METHODS

Data on patients with AAC during 2004-2015 were obtained from the Surveillance, Epidemiology, and End Results database, which were split at a 7:3 ratio into two independent cohorts: training and testing cohorts. Differences in survival between the two groups were tested using the Kaplan-Meier estimator and log-rank test methods. We constructed six survival analysis methods: the American Joint Committee on Cancer TNM stage, Cox Proportional Hazards regression, CoxTime, DeepSurv, XGBoost Survival Embeddings, and Random Survival Forest. The performances of these models were evaluated using the C-index, receiver operating characteristic (ROC), and calibration curves.

RESULTS

This study included 2,935 patients with AAC. Univariate Cox regression analyses of the training cohort indicated that race, marital status at diagnosis, scope of regional lymph node surgery, tumor grade, summary stage, American Joint Committee on Cancer stage, TNM stage T, and TNM stage N were important factors affecting survival (P ​< ​0.05). The results of the C-index indicated that DeepSurv performed the best among the six models, with the highest C-index of 0.731. The areas under the ROC curves of the DeepSurv model at the 1-year, 3-year, 5-year, and 10-year time points were 0.823, 0.786, 0.803, and 0.813, respectively. The calibration curve indicated that DeepSurv performed well, with good calibration.

CONCLUSIONS

Machine learning models such as DeepSurv have a stronger performance in the survival analysis of patients with AAC.