Controversies in the diagnosis and treatment of periampullary tumours

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.

Impact of Surgery-Induced Myeloid-derived Suppressor Cells and the NOX2/ROS Axis on Postoperative Survival in Human Pancreatic Cancer

Preclinical studies imply that surgery triggers inflammation that may entail tumor outgrowth and metastasis. The potential impact of surgery-induced inflammation in human pancreatic cancer is insufficiently explored. This study included 17 patients with periampullary cancer [pancreatic ductal adenocarcinoma (PDAC) n = 14, ampullary carcinoma n = 2, cholangiocarcinoma n = 1] undergoing major pancreatic cancer surgery with curative intent. We analyzed the potential impact of preoperative and postoperative immune phenotypes and function on postoperative survival with >30 months follow-up. The surgery entailed prompt expansion of monocytic myeloid-derived suppressor cells (M-MDSC) that generated NOX2-derived reactive oxygen species (ROS). Strong induction of immunosuppressive M-MDSC after surgery predicted poor postoperative survival and coincided with reduced functionality of circulating natural killer (NK) cells. The negative impact of surgery-induced M-MDSC on survival remained significant in separate analysis of patients with PDAC. M-MDSC-like cells isolated from patients after surgery significantly suppressed NK cell function ex vivo, which was reversed by inhibition of NOX2-derived ROS. High NOX2 subunit expression within resected tumors from patients with PDAC correlated with poor survival whereas high expression of markers of cytotoxic cells associated with longer survival. The surgery-induced myeloid inflammation was recapitulated in vivo in a murine model of NK cell-dependent metastasis. Surgical stress thus induced systemic accumulation of M-MDSC-like cells and promoted metastasis of NK cell-sensitive tumor cells. Genetic or pharmacologic suppression of NOX2 reduced surgery-induced inflammation and distant metastasis in this model. We propose that NOX2-derived ROS generated by surgery-induced M-MDSC may be targeted for improved outcome after pancreatic cancer surgery.

SIGNIFICANCE

Pancreatic cancer surgery triggered pronounced accumulation of NOX2+ myeloid-derived suppressor cells that inhibited NK cell function and negatively prognosticated postoperative patient survival. We propose the targeting of M-MDSC as a conceivable strategy to reduce postoperative immunosuppression in pancreatic cancer.

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.

Histopathological evaluation after pancreatic surgery: Comparison of the results of HPB-specific pathologists and non-specific pathologists

Objectives

The aim of this study was to compare the results of the evaluation of HPB-specific pathologists and general pathologists on the specimens of patients who underwent pancreaticoduodenectomy by the same surgical team.

Material and Methods

The pathological results of 159 patients who underwent pancreaticoduodenectomy (PD) in the periampullary region was retrospectively examined. Histopathological evaluation results of HPB-specific pathologist (S group) and other pathologists (NS group) were compared. Tumor size (mm), total lymph nodes, metastatic lymph nodes, surgical margin positive/negative (RO/R1/R2 resection) and data of patients who underwent vascular resection were evaluated.

Results

The specimens of 91 patients were examined by a HPB-specific pathologist (S group), and the specimens of 68 patients were examined by non-specific pathologists (NS group). When compared in terms of the average total number of lymph nodes and metastatic lymph nodes dissected, a statistically significant result was observed (p= 0.04, p <0.01 respectively). Additionally, surgical margin positivity (R1) was found to be statistically higher in the S group (p= 0.02).

Conclusion

In order for the success of HPB surgery to be reflected in the clinic, it is of great importance that the specimens are examined by HPBspecific pathologists.

Development and validation of web calculators to predict early recurrence and long-term survival in patients with duodenal papilla carcinoma after pancreaticoduodenectomy

BACKGROUND

Duodenal papilla carcinoma (DPC) is prone to relapse even after radical pancreaticoduodenectomy (PD) (including robotic, laparoscopic and open approach). This study aimed to develop web calculators to predict early recurrence (ER) (within two years after surgery) and long-term survival in patients with DPC after PD.

METHODS

Patients with DPC after radical PD were included. Univariate and multivariate logistic regression analyses were used to identify independent risk factors. Two web calculators were developed based on independent risk factors in the training cohort and then tested in the validation cohort.

RESULTS

Of the 251 patients who met the inclusion criteria, 180 and 71 patients were enrolled in the training and validation cohorts, respectively. Multivariate logistic regression analysis revealed that tumor size [Odds Ratio (OR) 1.386; 95% confidence interval (CI) 1070-1.797; P = 0.014]; number of lymph node metastasis (OR 2.535; 95% CI 1.114-5.769; P = 0.027), perineural invasion (OR 3.078; 95% CI 1.147-8.257; P = 0.026), and tumor differentiation (OR 3.552; 95% CI 1.132-11.152; P = 0.030) were independent risk factors for ER. Nomogram based on the above four factors achieved good C-statistics of 0.759 and 0.729 in predicting ER in the training and the validation cohorts, respectively. Time-dependent ROC analysis (timeROC) and decision curve analysis (DCA) revealed that the nomogram provided superior diagnostic capacity and net benefit compared with single variable.

CONCLUSIONS

This study developed and validated two web calculators that can predict ER and long-term survival in patients with DPC with high degree of stability and accuracy.

The Optimal Cutoff Value of Tumor Markers for Prognosis Prediction in Ampullary Cancer

BACKGROUND

Carbohydrate antigen 19-9 (CA 19-9) is a representative tumor marker used for the diagnosis of pancreatic and biliary tract cancers. There are few published research results that can be applied to actual clinical practice for ampullary cancer (AC) alone. This study aimed to demonstrate the relationship between the prognosis of AC and the level of CA 19-9, and to determine the optimal thresholds.

METHODS

Patients who underwent curative resection (pancreaticoduodenectomy (PD) or pylorus preserving pancreaticoduodenectomy (PPPD)) for AC at the Seoul National University Hospital between January 2000 and December 2017 were enrolled. To determine the optimal cutoff values that could clearly stratify the survival outcome, the conditional inference tree (C-tree) method was used. After obtaining the optimal cutoff values, they were compared to the upper normal clinical limit of 36 U/mL for CA 19-9. Results In total, 385 patients were enrolled in this study. The median value of the tumor marker CA 19-9 was 18.6 U/mL. Using the C-tree method, 46 U/mL was determined to be the optimal cutoff value for CA 19-9. Histological differentiation, N stage, and adjuvant chemotherapy were significant predictors. CA 19-9 36 U/mL had marginal significance as a prognostic factor. In contrast, the new cutoff value, CA 19-9 46 U/mL, was found to be a statistically significant prognostic factor (HR: 1.37, p = 0.048).

CONCLUSIONS

The new cutoff value of CA 19-9 46 U/mL may be used for evaluating the prognosis of AC. Therefore, it may be an effective indicator for determining treatment strategies such as surgical treatments and adjuvant chemotherapy.

Hepatic artery lymph node relevance in periampullary tumors: A retrospective analysis of survival outcomes

Background

The Periampullary area comprehends a heterogeneous and complex structure with different histological tissues. Surgical standards include the peripancreatic regional lymphadenectomy, and during pancreatoduodenectomy (PD) the hepatic artery lymph node HALN(8a) is dissected. We aimed to describe the prognostic significance of the HALN(8a) lymph node metastasis in terms of disease-free survival (DFS) and overall survival (OS) in a specific cohort of patients in limited economic and social conditions.

Methods

A retrospective study was conducted based on a prospective database from the HPB department of patients who underwent pancreaticoduodenectomy (PD) due to periampullary tumors during 2014-2021. Overall survival (OS) and disease-free survival (DFS) were estimated to be associated with positive HALN(8a) using Kaplan-Meier analysis. Log Rank test and Cox proportional hazards regression analysis was used.

Results

111 patients were included, 55,4% female. The most frequent pathology was ductal adenocarcinoma (60.3%). The positive rate of the HALN(8a) node was 21.62%. The Median OS time was 25.5 months, and the median DFS time was 13,8 months. Positive HLAN(8a) node, the cutoff of lymph node ratio resection (LNRR), and vascular invasion showed a strong association with OS. (CoxRegression p = 0.03 HR 0.5, p 0.003 HR = 1.8, p = 0.02 HR 0.4 CI 95%). In terms of DFS, lymph node ratio cutoff, tumoral size, and vascular invasion showed a statistically significant association with the outcome (p = 0.008, HR = 1.5; p = 0.04 HR = 2.1; p = 0.02 HR = 0.4 CI 95%).

Conclusion

In this series of PD, OS was reduced in patients with HALN(8a) compromise in patients with pancreatic cancer, however without statistical significance in DFS. In multivariate analysis, lymph node status remains an independent predictor of OS and DFS. Further studies are needed.

Preoperative Misdiagnosis in Patients Undergoing Pancreatoduodenectomy

Distal bile duct cholangiocarcinoma, ampullary adenocarcinoma, duodenal carcinoma, and ductal adenocarcinoma (PDAC) of the head of the pancreas usually have similar clinical presentation since they arise in the same circumscribed anatomical area, within 2 cm of the major duodenal papilla [...].