The future of adjuvant therapy in ampullary cancer: should we offer it to our patients?

Clinical and molecular characteristics of periampullary carcinoma based on pathological subtypes

Background

Periampullary carcinoma (PAC) is a relatively rare but highly aggressive malignancy, posing challenges to the determination of the optimal therapeutic approach. The objective of this study was to clarify the potential of histopathological typing in guiding chemotherapy selection for patients with advanced PAC and to characterize the distinct molecular features, underlying functional changes, and regulatory mechanisms associated with the different subtypes.

Methods

We conducted a retrospective analysis of clinical data from patients with advanced PAC admitted to the Oncology Department of Xijing Hospital between January 2015 and May 2022. These patients received first-line chemotherapy with either FOLFOX (folinic acid, fluorouracil, and oxaliplatin) or gemcitabine-based regimens. Certain patients were divided into the pathological typing group and the control group. The pathological typing group received subtype-specific chemotherapy regimens, while the control group received chemotherapy regimens based on the primary tumor site. We compared the median progression-free survival (PFS) and overall survival (OS) between the two groups. Using publicly available databases (GSE60980), we conducted differential gene screening, enrichment analysis, and immune cell infiltration assessment. A protein-protein interaction (PPI) network was constructed based on the differentially expressed genes, resulting in the identification of 60 node genes. Subsequently, a core gene selection using the least absolute shrinkage and selection operator (LASSO) regression machine learning algorithm was performed to identify the key genes specific to PAC-PB subtype.

Results

The pathological typing group consisted of 46 patients, with 26 classified as the PB subtype and 20 as the IN subtype, while the control group comprised 40 patients. Compared to those in the control group, patients in the pathological typing group demonstrated significant improvements in overall response rate (20.5% vs. 12.9%; P=0.04), median PFS (8.1 vs. 5.4 months; P=0.04), and median OS (34 vs. 25.9 months; P=0.02). Multivariate Cox regression analysis revealed that pathological typing independently influenced PFS [hazard ratio (HR) =0.20, 95% confidence interval (CI): 0.10-0.44; P=0.009] and OS (HR =0.21, 95% CI: 0.17-0.71; P=0.02). Using a publicly available PAC cohort (GSE60980), we selected 154 differentially expressed genes, which were significantly enriched in signaling pathways related to the cell cycle, fibroblasts, and epithelial-mesenchymal transition. Analysis of immune cell infiltration indicated a significant increase in the abundance of fibroblast cells and a significant decrease in that of B cells and γδ T cells in the PAC-PB subtype. Furthermore, we identified core genes specific to the PAC-PB subtype and used them to construct a PAC-PB diagnostic model.

Conclusions

Pathologic typing-guided individualized chemotherapy resulted in prolonged survival for patients with advanced PAC. The PB and IN subtypes of PAC exhibit distinct molecular regulatory mechanisms and immune infiltration microenvironments. These findings underscore the importance of considering subtype-specific factors in the development of a PAC-PB diagnostic model.

Remission from the 5-Fu-Based Chemotherapy to Gemcitabine-Based Chemotherapy-Based on the Pathological Classification of Periampullary Carcinoma: A Case Report and Literature Review

Background

Periampullary carcinoma, which includes ampullary carcinoma, pancreatic head cancer, distal common bile duct cancer, and duodenal papillary cancer, is a relatively rare malignancy with uncertain therapeutic options. Although several studies have investigated the efficacy of multiple adjuvant chemotherapy regimens for periampullary carcinoma treatment, the optimal regimen remains to be determined. The inherent heterogeneity of the mucosal origin divides periampullary carcinoma into intestinal and pancreaticobiliary types. Therefore, the selection of chemotherapy regimens based on pathological type may have potential therapeutic significance.

Case Presentation

A 72-year-old woman with moderately differentiated periampullary adenocarcinoma experienced disease progression after receiving FOLFOX regimen. Subsequently, the sample was subtyped first by H&E evaluation and then by the evaluation of an IHC panel composed of CK20, CDX2, MUC1, MUC2, and MUC5AC. The pathologists concluded that the patient’s sample was of the pancreaticobiliary (PB) subtype. The subsequent change to gemcitabine plus S-1 adjuvant therapy achieved remission of liver metastases based on the pathological classification of the cancer.

Conclusion

Based on the pathological classification, adjuvant chemotherapy with gemcitabine may be beneficial for patients with PB subtype periampullary carcinoma. 5-Fu-based adjuvant chemotherapy may be beneficial for patients with intestinal subtype periampullary carcinoma.

Adjuvant therapy for periampullary carcinoma and the significance of histopathological typing: A systematic review

•

The efficacy of adjuvant therapy for periampullary carcinoma is controversial.

•

There is a trend of classification periampullary carcinoma into PB-type and IN-type, and the prognosis of different subtypes may be significantly different.

•

The PB-type patients who accepted gemcitabine based chemotherapy and IN-type patients who accepted 5-FU based chemotherapy, maybe improved the prognosis.

•

Chemoradiotherapy appears to be more effective in patients with advanced stages.

•

There are few related studies on targeted therapy and immunotherapy, and further research is needed.

Objective

This review investigates the role of adjuvant therapy (AT) and the importance of histopathological typing in periampullary carcinoma (PAC) treatment.

Background

PAC is a relatively rare gastrointestinal malignancy. The regimen and effect of AT in PAC are still controversial. However, there is a treatment based on histopathological types (pancreaticobiliary-type, PB-type or intestinal-type, IN-type), but there are no clear guidelines indicating that typing can be used to guide the selection of AT drugs.

Methods

A literature search of PubMed and Web of Science databases was conducted for studies published from January 2001 to August 2021 on the use of AT in PAC.

Results

A total of 75 studies were included in this review. According to existing studies, AT for PAC is mostly based on 5-FU or gemcitabine, but the effect is unknown. However, when PAC is classified into different histopathological types, AT with gemcitabine is beneficial for patients with the PB-type of PAC, while 5-FU-based AT is beneficial for patients with the IN-type of PAC. In addition, the benefits of AT are more pronounced in patients with a high-risk disease, such as patients with stage II/III, T3/T4 tumors, or positive lymph node involvement. There are few studies on targeted therapy and immunotherapy for PAC.

Conclusions

This review suggests that AT has potential survival benefits, especially when based on the histopathologic type that helps the choice of drugs during AT in PAC patients.