Prognostic Significance of Nodal Ratio in Patients Undergoing Adjuvant Chemoradiotherapy After Curative Resection for Ampullary Cancer

The clinical significance of the lymph node ratio as a recurrence indicator in ampullary cancer after curative pancreaticoduodenectomy

BACKGROUND

The clinical significance of the lymph node ratio (LNR), the number of metastatic lymph nodes per dissected lymph node, has not been sufficiently clarified in ampullary cancer.

METHODS

Among patients diagnosed histopathologically with ampullary cancer between 1980 and 2018, the study included 106 who underwent pathological radical resection by pancreaticoduodenectomy. The relationships between the LNR and metastatic lymph node sites and prognosis were examined.

RESULTS

Multivariate analysis revealed that sex and lymph node metastasis were independent prognostic factors. In the 46 patients (43%) with metastatic lymph nodes, the LNR in the recurrence group was significantly higher than that in the non-recurrence group (0.15 ± 0.11 vs. 0.089 ± 0.071, p = 0.025). The receiver operating characteristic curve demonstrated that the LNR cut-off value, 0.07 (area under the curve = 0.70, sensitivity 81%, specificity 56%), was a significant indicator for recurrence (22% vs. 61%, p = 0.016) and prognosis (5-year survival: 48% vs. 83%, p = 0.028). Among the metastatic lymph node sites in the 46 positive cases, lymph node metastases developed from the peripancreatic head region (80%, 37/46) to the superior mesenteric artery (33%, 15/46) and para-aortic (11%, 5/46) regions.

CONCLUSION

Lymph node metastasis is an independent prognostic factor, and the LNR is a significant indicator for recurrence and prognosis in patients with ampullary cancer.

Impact of circumferential resection margin on survival in ampullary cancer: retrospective analysis

BACKGROUND

Ampullary carcinoma is a clinically variable entity. This study aimed to evaluate prognostic factors for the outcome of resected ampullary carcinoma patients with particular intent to analyse the influence of surgical radicality.

METHODS

Patients undergoing resection between 2002 and 2017 were analysed. Clinicopathological parameters, perioperative outcome and survival were examined. Risk factor analysis for postresection survival was performed. Resection margin status was evaluated according to the revised classification for pancreatic adenocarcinoma.

RESULTS

A total of 234 patients were identified, 97.9 per cent (n = 229) underwent formal resection, while 2.1 per cent (n = 5) underwent ampullary resection. Histological subtypes were 46.6 per cent (n = 109) pancreatobiliary, 34.2 per cent (n = 80) intestinal, 11.5 per cent (n = 27) mixed, and 7.7 per cent (n = 18) undetermined. In the pancreatobiliary group, tumours were more advanced with more vascular resections, pT4 stage, G3 differentiation and pN+ status. Five-year overall survival was significantly different for pancreatobiliary compared to intestinal (51.7 per cent versus 72.8 per cent, P = 0.0087). In univariable analysis, age, pT4 stage, pN+, pancreatobiliary subtype and positive resection margin were significantly associated with worse overall survival. Long-term outcome was significantly better after true R0 resection (circumferential resection margin-, tumour clearance >1 mm) compared with circumferential resection margin+ (<1 mm) and R1 resections (5-year overall survival: 69.6 per cent, median overall survival 191 months versus 42.4 per cent and 53 months; P = 0.0017).

CONCLUSION

Postresection survival of ampullary carcinoma patients is determined by histological subtype and surgical radicality. Intestinal differentiation is associated with less advanced tumour stages and better differentiation, which is reflected in a significantly better overall survival compared to pancreatobiliary differentiation. Despite this, true R0-resection is a prognostic key determinant in both entities, achieving 5-year survival in two-thirds of patients.

Comparing the predictive performance of different lymph node staging systems for postoperative overall survival in patients with ampullary carcinoma

Aim

This study was to analyze and compare the predictive performance of the 7th and the 8th edition American Joint Committee on Cancer (AJCC) N staging system, lymph nodes ratio (LNR) and log odds of positive lymph node (LODDS) for the survival of patients with ampullary carcinomas (ACs).

Method

This retrospective cohort study included patients with primary ACs after surgery from the Surveillance, Epidemiology, and End Results (SEER) 2004-2015. Univariate and multivariate Cox proportional hazard models were used. The study population was divided into a training set and a testing set in a ratio of 7-3. The C-index and area under the curve (AUC) were used to compare the predictive performance of the four staging on overall survival (OS) in the training set and the testing set.

Results

A total of 7,480 patients with primary ACs (1,178 survived and 1,128 dead) were in this study. The average follow-up time was 41.1 months. N1 stage and N2 stage of the 8th edition AJCC N staging system, LNR staging (0-0.3), LNR (>0.3), LODDS (-2.4 to -0.8) and LODDS (>-0.8) were associated with OS in AC patients after adjusting for age, race, pT stage, tumor size, grade, radiation, and insurance. The C-index of the 7th AJCC N staging was significantly lower than the C-index of the 8th AJCC N staging in the training set [0.608 vs. 0.629, P < 0.001] and testing set [0.635 vs. 0.658, P < 0.001]. The C-index of the LODDS staging was significantly higher than the C-index of the 8th AJCC N staging in the training set [0.641 vs. 0.629, P = 0.034] and testing set [0.671 vs. 0.658, P = 0.034]. LODDS staging may be a potential predictor of OS at 6 months [AUC = 0.687], 12 months (AUC = 0.692), and 48 months (AUC = 0.709), and LNR staging (AUC = 0.655) may be a potential predictor of OS at 24 months in AC patients. The predictive ability of LNR staging and LODDS staging were also found in different subgroups.

Conclusion

The LNR and LODDS staging systems' predictive performance for OS of AC patients were superior to the 8th edition AJCC N staging system, especially in patients ages ≥65 or with higher tumor grade (grade II and III). The LNR staging and the LODDS staging were potential predictors for 24-month OS, and 6, 12, 24 and 48-month OS, respectively.

Development and Validation of a New Lymph Node Ratio-Based Staging System for Ampullary Carcinoma After Curative Pancreaticoduodenectomy

Background

Lymph node metastasis (LNM) is closely associated with the prognosis of ampullary carcinoma (AC). The purpose of this study is to explore the relationship between lymph node ratio (LNR) and the prognosis of patients with AC after curative pancreaticoduodenectomy and to establish a new LNR-based staging system.

Methods

AC patients in the Cancer Hospital, Chinese Academy of Medical Sciences, between 1998 and 2020 were retrospectively reviewed as the training cohort; and AC patients in the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2018 were obtained as the validation cohort. Within the training group, Kaplan–Meier survival analyses and Cox proportional hazards regression were conducted to assess the prognostic value of LNR and establish a new LNR-based staging system. Then, the new staging system was compared with the 8th American Joint Committee on Cancer (AJCC) TNM staging system in both the training and validation cohorts.

Results

A total of 264 patients in the training cohort and 199 patients in the validation cohort were enrolled. Significant overall survival (OS) difference was observed between LNR-low stage and LNR-high stage in both training (p = 0.001) and validation cohorts (p < 0.001). Then a new LNR-based staging system was developed. Under the new system, the number of patients in the training cohort and validation cohort of stage I, stage II, and stage III was 30 (11%) vs. 18 (9%), 190 (72%) vs. 96 (48%), and 44 (17%) vs. 85 (43%), respectively. The new staging system classified patients with respect to survival better than did the 8th AJCC TNM staging system.

Conclusions

The new LNR-based staging system had better discriminability for predicting survival in AC patients after curative pancreaticoduodenectomy. More data are needed for further validation.