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Ghosn M, Kourie HR, El Rassy E, Haddad FG, Hanna C, El Karak F, Nasr D. Where does chemotherapy stands in the treatment of ampullary carcinoma? A review of literature. World J Gastrointest Oncol 2016; 8:745-750. [PMID: 27795814 PMCID: PMC5064052 DOI: 10.4251/wjgo.v8.i10.745] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 07/18/2016] [Accepted: 08/18/2016] [Indexed: 02/05/2023] Open
Abstract
Ampullary carcinoma (AC) is a rare gastrointestinal tumor without clear treatment recommendations. The management of this tumor is usually extrapolated from the treatment of pancreatic, biliary duct and intestinal cancers. Few papers have studied the AC as an independent entity and yet succombs to several limitations. These studies were retrospective single institutional experiences with limited sample sizes recruited over a long period of time. Unlike metastatic ACs where chemotherapy is the only recommended option, localized AC once excised may be approached by either chemotherapy alone or concomitant chemoradiation therapy. In this review, we report the overall survival and recurrence factors of more than 1000 patients from all the studies treating exclusively ACs. We also review the medical treatment of this tumor and conclude to the necessity of multi-institutional randomized controlled studies for AC exclusively.
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Abstract
Adenocarcinomas of the ampulla of Vater and duodenum are more rare than pancreatic cancer and have a better prognosis. However, studies conducted on the management of these cancers, such as adjuvant chemotherapy and radiation therapy, are limited by small sample sizes and series that are retrospective. This review evaluates ampullary and duodenal adenocarcinomas with regard to incidence, anatomy, prognostic features, patterns of failure, and the available literature studying adjuvant therapy.
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Affiliation(s)
- Salma K Jabbour
- Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ.
| | - David Mulvihill
- Department of Radiation Oncology, Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ
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Chen JWC, Bhandari M, Astill DS, Wilson TG, Kow L, Brooke-Smith M, Toouli J, Padbury RTA. Predicting patient survival after pancreaticoduodenectomy for malignancy: histopathological criteria based on perineural infiltration and lymphovascular invasion. HPB (Oxford) 2010; 12:101-8. [PMID: 20495653 PMCID: PMC2826667 DOI: 10.1111/j.1477-2574.2009.00140.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Accepted: 10/05/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND Accurate and simple prognostic criteria based on histopathology following pancreaticoduodenectomy would be helpful in assessing prognosis and considering and evaluating adjuvant therapy. This study analysed the histological parameters influencing outcome following pancreaticoduodenectomy for periampullary malignancy. METHODS A total of 110 pancreaticoduodenectomies were performed from 1998 to 2008. The median age of patients was 69 years (range 20-89 years). The median follow-up was 4.9 years. Of the procedures, 87% (96) were performed for malignancies and the remainder (n= 14) for benign aetiologies. Of the 96 malignancies, 60 were pancreatic adenocarcinoma and the rest were ampullary (14), cholangio (9), duodenal (9) carcinomas and others. Statistical analysis was performed using log-rank and Cox regression multivariate analyses. RESULTS Patients who underwent resection had 1-, 3- and 5-year survival rates of 70%, 46% and 41%, respectively. The 1-, 3- and 5-year survival rates for periampullary cancers other than pancreatic adenocarcinoma were 83%, 69% and 61%, respectively; those for pancreatic adenocarcinoma were 62%, 31% and 27%, respectively (P < 0.003). Poor tumour differentiation (P < 0.02), tumour size >3 cm (P < 0.04), margin <or=2 mm (P < 0.02), nodal involvement (P < 0.003), perineural infiltration (P < 0.0001) and lymphovascular invasion (P < 0.002) were associated with poorer prognosis. In a multivariate analysis, histologically identified perineural infiltration (P < 0.03) and lymphovascular invasion (P= 0.05) were significant factors influencing outcome. Five-year survival was 77% in patients negative for both factors and 15% in patients positive for both (P < 0.0001). In the pancreatic adenocarcinoma subgroup, patients who were negative for both factors had a 5-year survival of 71%, whereas those who were positive for both had a 5-year survival of 16% (P < 0.02). CONCLUSIONS The presence of perineural infiltration and lymphovascular invasion on histopathology is highly significant in predicting 5-year outcomes after pancreaticoduodenectomy for periampullary and pancreatic malignancies.
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Affiliation(s)
- John W C Chen
- Hepatopancreatobiliary Unit, Department of Surgery, Flinders Medical CentreBedford Park, SA, Australia
| | - Mayank Bhandari
- Hepatopancreatobiliary Unit, Department of Surgery, Flinders Medical CentreBedford Park, SA, Australia
| | - David S Astill
- Department of Anatomical Pathology, Flinders Medical CentreBedford Park, SA, Australia
| | - Thomas G Wilson
- Hepatopancreatobiliary Unit, Department of Surgery, Flinders Medical CentreBedford Park, SA, Australia
| | - Lilian Kow
- Hepatopancreatobiliary Unit, Department of Surgery, Flinders Medical CentreBedford Park, SA, Australia
| | - Mark Brooke-Smith
- Hepatopancreatobiliary Unit, Department of Surgery, Flinders Medical CentreBedford Park, SA, Australia
| | - James Toouli
- Hepatopancreatobiliary Unit, Department of Surgery, Flinders Medical CentreBedford Park, SA, Australia
| | - Robert T A Padbury
- Hepatopancreatobiliary Unit, Department of Surgery, Flinders Medical CentreBedford Park, SA, Australia
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Hatzaras I, George N, Muscarella P, Melvin WS, Ellison EC, Bloomston M. Predictors of survival in periampullary cancers following pancreaticoduodenectomy. Ann Surg Oncol 2010; 17:991-7. [PMID: 20108122 DOI: 10.1245/s10434-009-0883-9] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cancers of the ampulla of Vater, distal common bile duct, and pancreas are known to have dismal prognosis. It is often reported that ampullary cancers are less aggressive relative to the other periampullary carcinomas. We sought to evaluate predictors of survival for periampullary cancers following pancreaticoduodenectomy to identify biologic behavior. METHODS We reviewed the records of all patients who underwent pancreaticoduodenectomy for periampullary carcinoma between 1992 and 2007 at the Ohio State University Medical Center. Demographics, treatment, and outcome/survival data were analyzed. Kaplan-Meier survival curves were created and compared by log-rank analysis. Multivariate analysis was undertaken using Cox proportional-hazards method. RESULTS 346 consecutive periampullary malignancies (249 pancreatic cancers, 79 ampullary carcinomas, 18 extrahepatic cholangiocarcinomas) treated by pancreaticoduodenectomy were identified. Pancreatic cancer histology correlated with the shortest median survival (17.1 months), followed by cholangiocarcinoma (17.9 months) and ampullary carcinoma (44.3 months) (P < 0.001). Potential predictors of decreased survival on univariate analysis included site of origin, preoperative jaundice, microscopic positive margin, nodal metastasis, lymphovascular invasion, neural invasion, and poor differentiation. Only nodal metastasis (median 16.2 versus 29.9 months, P < 0.001) and neural invasion (median 17.7 versus 47.9 months, P < 0.00001) significantly predicted outcome on multivariate analysis. CONCLUSIONS Although ampullary cancers have the best prognosis overall, when controlled for tumor stage, only presence of neural invasion and nodal metastasis predict poor survival following pancreaticoduodenectomy. Biological behavior remains the most important prognostic indicator in periampullary cancers amenable to resection, regardless of site of origin.
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Affiliation(s)
- Ioannis Hatzaras
- Department of Surgery, The Ohio State University, Columbus, OH, USA
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Li JH, Ma QY, Shen SG, Hu HT. Stimulation of dorsal root ganglion neurons activity by pancreatic cancer cell lines. Cell Biol Int 2008; 32:1530-5. [PMID: 18801449 DOI: 10.1016/j.cellbi.2008.08.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 05/14/2008] [Accepted: 08/19/2008] [Indexed: 11/16/2022]
Abstract
Stimulation of mice dorsal root ganglion neurons (DRGNs) activity by human pancreatic cancer (PanCa) cell line Mia PaCa-2 and its potential molecule mechanism has been investaged. DRGNs were cultured alone or along with the MIA PaCa-2. The effects of MIA PaCa-2 to DRGNs were determined by neurofilament (NF) immunocytochemical and Nissl staining. ELISA was used to detect the concentration of insulin-like growth factor-1 (IGF-1) in the culture supernatant. Cyton size, neurite outgrowth and neuronal activity in the experimental group were greater than in the control groups. However, the concentration of IGF-1 in the supernatants was not significantly different from those in the blank and non-cultured medium groups. In the presence of MIA PaCa-2 cell line, cyton size, neurite outgrowth and neuronal activity were enhanced, which may provide more routes for the invasion of cancer cells along nerves.
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Affiliation(s)
- Jun-Hui Li
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an 710061, China
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Sudo T, Murakami Y, Uemura K, Hayashidani Y, Hashimoto Y, Ohge H, Shimamoto F, Sueda T. Prognostic impact of perineural invasion following pancreatoduodenectomy with lymphadenectomy for ampullary carcinoma. Dig Dis Sci 2008; 53:2281-6. [PMID: 18095164 DOI: 10.1007/s10620-007-0117-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Accepted: 11/05/2007] [Indexed: 12/12/2022]
Abstract
The aim of this study was to identify prognostic factors in patients undergoing pancreatoduodenectomy with lymphadenectomy for ampullary carcinoma. The records of 46 consecutive patients with ampullary carcinoma who underwent pancreatoduodenectomy from 1988 through 2006 were retrospectively reviewed. A 98% rate of potentially curative (R0) resection was achieved. There was no 30-day mortality. Overall 5-year survival rate was 64%. Univariate analysis revealed that T3 and T4 tumor (i.e., pancreatic parenchymal invasion) (P < 0.001), lymph node metastasis (P = 0.01), and perineural invasion (P < 0.001) were significant predictors of poor prognosis. Furthermore, perineural invasion was found to be a significant independent predictor of poor prognosis by multivariate analysis (P = 0.024). Pancreatoduodenectomy with lymphadenectomy for ampullary carcinoma is a safe surgical procedure with an acceptable cure rate. The presence of perineural invasion may be useful for predicting poor prognosis in patients with ampullary carcinoma who undergo potentially curative resection.
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Affiliation(s)
- Takeshi Sudo
- Department of Surgery, Division of Clinical Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.
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Li J, Ma Q. Hyperglycemia promotes the perineural invasion in pancreatic cancer. Med Hypotheses. 2008;71:386-389. [PMID: 18571873 DOI: 10.1016/j.mehy.2008.05.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Revised: 04/21/2008] [Accepted: 04/28/2008] [Indexed: 01/05/2023]
Abstract
The role of hyperglycemia in perineural invasion in pancreatic cancer is not clear. Pancreatic cancer is characterized by extremely high frequency of perineural invasion (can be as high as 90%, even 100%), which has been associated with poorer survival. In previous epidemiologic, the prevalence of diabetes mellitus in pancreatic cancer is 34-40% and more than half of them are new-onset, which means the course of disease of diabetes mellitus is less than 24 months before cancer diagnosis. The association between diabetes mellitus and pancreatic cancer has long been recognized as that long-standing diabetes mellitus is thought to be an etiologic factor for pancreatic cancer and new-onset diabetes mellitus may be a manifestation of the cancer. Long-standing diabetes mellitus can cause peripheral neuropathy. The main morphological features of established neuropathy include a combination of demyelinization and axonal degeneration of myelinated fibers, degeneration with regeneration of unmyelinated fibers and endoneurial microangiopathy, with nerve fiber loss in its final stage. Diabetes mellitus can also induce the high expression of cytokines such as nerve growth factor to repair the damaged nerves. We present the hypothesis that hyperglycemia promotes the perineural invasion in pancreatic cancer through two mechanisms. One is that hyperglycemia enhances the proliferation of cancer cells, which subsequently increase the expression of cytokines such as nerve growth factor. The overexpression of nerve growth factor can enhance the interaction between nerve and cancer cell and neurotropism. The other is that hyperglycemia causes demyelinization and axonal degeneration of nerves, which can form defections to make cancer cells enter nerves with deeply invasion. The above two mechanisms can promote the perineural invasion in pancreatic cancer. Controlling hyperglycemia might reduce the perineural invasion in pancreatic cancer.
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Iacono C, Verlato G, Zamboni G, Scarpa A, Montresor E, Capelli P, Bortolasi L, Serio G. Adenocarcinoma of the ampulla of Vater: T-stage, chromosome 17p allelic loss, and extended pancreaticoduodenectomy are relevant prognostic factors. J Gastrointest Surg 2007; 11:578-88. [PMID: 17468917 DOI: 10.1007/s11605-007-0136-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the prognostic significance of different clinico-pathological and molecular factors, and to compare survival after standard and extended pancreaticoduodenectomy (PD) in ampulla of Vater adenocarcinoma (AVAC). There are discordant data on factors affecting prognosis, and hence therapeutic choices, in AVAC. PATIENTS AND METHODS Clinical-pathological factors were evaluated in 59 patients, subjected to PD for AVAC; in 42 subjects information on chromosome 17p and 18q allelic losses (LOH) and microsatellite instability (MSI) was also available. The association between survival and type of PD was investigated in the 25 patients operated between 1990 and 2001 (16 standard and nine extended). RESULTS The overall 5- and 10-year tumor-related survival rates were 46% and 33%, respectively. Sixteen patients had T-stages 1-2, 14 T-stage 3, and 29 T-stage 4 cancers. Chromosome 17p and 18q LOH were detected in 23 (55%) and 15 cases (36%), respectively, and in 12 cases (29%) coexisted. Five cases were MSI-positive (12%). At univariate analysis, poor survival was associated with cancer ulceration (P = 0.051), poor differentiation (P = 0.008), T-stage 4 (P < 0.001), nodal metastases (P = 0.004), chromosome 17p (P < 0.001) and 18q LOH (P = 0.002), and absence of MSI (P = 0.009). At multivariate analysis, only T-stage (P = 0.002) and 17p LOH (P = 0.001) were independent predictors of survival. All patients with MSI-positive cancers were long-survivors (>12 yrs), whereas only 30% of MSI-negative cancer patients survived at 5 years. Extended pancreaticoduodenectomy was associated with a 3-year disease-related survival higher than standard resection (83% vs 31%; P = 0.018). CONCLUSION MSI and chromosome 17p status allow to better define prognosis within ampullary cancers at the same stage. Surgery alone resulted curative in MSI-positive cancer patients, whereas it was inadequate in patients showing allelic losses, who might benefit from adjuvant therapy. In this observational study, extended PD was associated with increased survival compared to standard procedures.
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Affiliation(s)
- Calogero Iacono
- Department of Surgery and Gastroenterology, University of Verona Medical School, Verona, Italy.
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Dai H, Li R, Wheeler T, Ozen M, Ittmann M, Anderson M, Wang Y, Rowley D, Younes M, Ayala GE. Enhanced survival in perineural invasion of pancreatic cancer: an in vitro approach. Hum Pathol 2007; 38:299-307. [PMID: 17097719 DOI: 10.1016/j.humpath.2006.08.002] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Revised: 08/01/2006] [Accepted: 08/02/2006] [Indexed: 11/20/2022]
Abstract
Pancreatic cancer (PanCa) is characterized by perineural invasion (PNI), early lymph node and liver metastasis, and poor prognosis. PNI is one of the important causes of local recurrence. Little is known about the mechanism of PNI in PanCa. We presented a novel model system that may shed light on the mystery of PNI in PanCa. In this study, mouse dorsal root ganglia (DRGs) and human PanCa cell line (MIA PaCa-2) were cocultured in Matrigel matrix (BD Biosciences, San Jose, CA) to build this PNI model. MIA PaCa-2 cell line alone (control 1) or DRG alone (control 2) was cultured with Matrigel matrix as controls. Neurite outgrowth, cell colony growth, neurite-colony contact, and retrograde extension were observed under inverted microscopy and then were photographed and quantitated with the Optimas imaging system (Optimas Corp., Bothell, MA). At day 14, both the experimental and control 2 samples were harvested and subjected to total RNA isolation and fixed in paraffin-embedded blocks. Slides cut from paraffin blocks were studied with Ki-67 immunostaining and TUNEL assay. Gene profiling was performed using complementary DNA microarray. Overexpressed target genes were verified by quantitative reverse transcriptase polymerase chain reaction. The results showed that reciprocity was observed between neurites and MIA PaCa colonies with 24 hours of coculture. Neurite outgrowth was stimulated in the presence of pancreatic carcinoma cells, which showed 2-fold more area than did control 2. After 72 hours, MIA PaCa colonies cocultured with DRG exhibited 58% more colony area than did control 1. The Ki-67 index of the DRG/MIA PaCa cells (mean, 5.02%) was significantly higher than that in control 1 (mean, 1.18%) (P < .05); in contrast, the apoptotic index in the DRG/MIA PaCa cells was significantly lower (mean, 0.45%) than that in the control 1 (mean, 1.85%) (P < .001). Prosurvival genes MALT1 and TRAF were increased 2-fold in DRG/MIA PaCa compared with controls. We demonstrated that neural-epithelial interaction is a mutually beneficial process for the growth of nerves and PanCa cells. It is possible that oncogenes and growth factors might act synergistically in promoting proliferation and/or inhibiting apoptosis, a survival strategy crucial to the development of PNI in PanCa.
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Affiliation(s)
- Hong Dai
- Department of Pathology, Baylor College of Medicine, Houston, TX 77030, USA
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Chiche L, Alkofer B, Parienti JJ, Rouleau V, Salamé E, Samama G, Segol P. Usefulness of follow-up after pancreatoduodenectomy for carcinoma of the ampulla of Vater. HPB (Oxford) 2007; 9:140-5. [PMID: 18333130 PMCID: PMC2020781 DOI: 10.1080/13651820601103829] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The prognosis for carcinoma of the ampulla of Vater (CAV) is better than for pancreatic cancer. The 5-year survival median rate after resection of CAV is 45%, but late recurrences remain possible. Several survival factors have been identified (lymph nodes, perineural invasion), but few data are available on the type of recurrences, their impact and their management. PATIENTS AND METHODS A total of 41 patients treated by pancreatoduodenectomy (PD) for CAV from 1980 to 2003 were studied retrospectively. Patient selection, long-term survival recurrence rate and recurrence treatment were reviewed. Univariate and multivariate proportional hazards analysis were conducted on this series. RESULTS The mean follow-up was 48 months. Five-year survival was 62.8%. Eleven patients had recurrences (6-67 months). Recurrence was associated with time to all-causes death (hazard ratio [HR] 4.3, p=0.003). Factors predictive of recurrence were perineural invasion (HR 5.3, p=0.02), lymph node invasion (HR 5.3, p=0.02) and differentiation (HR 0.2, p=0.05). Three patients underwent surgical R0 treatment of their recurrences. Two who presented with solitary liver metastasis are alive and disease-free. CONCLUSIONS Recurrence represents a serious threat in the prognosis of CAV after surgery. Some of these recurrences, in particular liver metastases, are accessible for a curative treatment. This finding supports the usefulness of a close and long-term follow-up after surgery to improve survival of patients with CAV, especially in the group of patients with a good prognosis.
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Affiliation(s)
- Laurence Chiche
- Hepatobiliary Surgery and Transplantation, CHU CaenCAENFrance
| | - Barbara Alkofer
- Hepatobiliary Surgery and Transplantation, CHU CaenCAENFrance
| | | | | | - Ephrem Salamé
- Hepatobiliary Surgery and Transplantation, CHU CaenCAENFrance
| | - Guy Samama
- General and Laparoscopic Surgery, CHU CaenCAENFrance
| | - Philippe Segol
- Hepatobiliary Surgery and Transplantation, CHU CaenCAENFrance
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Kim RD, Kundhal PS, McGilvray ID, Cattral MS, Taylor B, Langer B, Grant DR, Zogopoulos G, Shah SA, Greig PD, Gallinger S. Predictors of failure after pancreaticoduodenectomy for ampullary carcinoma. J Am Coll Surg 2005; 202:112-9. [PMID: 16377504 DOI: 10.1016/j.jamcollsurg.2005.08.002] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2005] [Revised: 08/01/2005] [Accepted: 08/01/2005] [Indexed: 01/05/2023]
Abstract
BACKGROUND Complete resection offers the only potential cure for ampullary carcinoma. We analyzed factors that contribute to treatment failure and survival in patients who underwent pancreaticoduodenectomy for ampullary carcinoma. STUDY DESIGN We retrospectively reviewed all patients who underwent pancreaticoduodenectomy between August 1994 and August 2003 for ampullary carcinoma. Demographic, clinical, and pathologic data were collected. Chi-square analysis was used for categorical data and the t-test was used for continuous variables. Kaplan-Meier analyses were compared using the log-rank test to examine patient survival. RESULTS Forty-three patients (24 men) aged 63.7 +/- 11.4 years (standard deviation) were followed for a mean of 23.9 months (median 660 days, range 18 to 2,249 days). Jaundice (n = 33) and weight loss (n = 13) were the most common presenting symptoms. Stage (p < 0.01) and degree of differentiation (p < 0.029) were significant predictors of failure by univariate analysis. But only stage (p < 0.04) was a significant predictor by multivariate analysis. Further analysis revealed that nodal status (p < 0.001), but not tumor grade, was a significant predictor of treatment failure. Neither demographic nor clinical variables were significant predictors. Five-year overall and disease-free survival rates were 67.4% and 51.4%, respectively. Both metastases and disease recurrence had significant impact on patient survival. CONCLUSIONS Tumor stage is associated with treatment failure after pancreaticoduodenectomy for ampullary carcinoma and may identify candidates for adjuvant therapy. Because an aggressive surgical approach can be adopted safely with the best chance for cure, we recommend that pancreaticoduodenectomy be offered to all patients with ampullary tumors when malignancy or dysplasia is in question.
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Affiliation(s)
- Robin D Kim
- Department of Surgery, Toronto General Hospital, University Health Network, Ontario, Canada
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13
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van Geenen RC, van Gulik TM, Offerhaus GJ, de Wit LT, Busch OR, Obertop H, Gouma DJ. Survival after pancreaticoduodenectomy for periampullary adenocarcinoma: an update. Eur J Surg Oncol 2001; 27:549-57. [PMID: 11520088 DOI: 10.1053/ejso.2001.1162] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIM Survival after pancreaticoduodenectomy for periampullary tumours is limited. Over the last decade peri-operative management has improved and morbidity and mortality decreased. The aim of the study was to analyse recent survival data after pancreaticoduodenectomy and to determine factors that influence survival. METHODS From October 1992 to September 1998, 204 patients with a ductal adenocarcinoma in the pancreatic head (108), distal bile duct (32), and ampulla (64) who underwent standard pancreaticoduodenectomy, were analysed with regard to histology and tumour status. Survival was calculated by using the Kaplan-Meier method. Risk factors were identified in a univariate and multivariate analysis. RESULTS Median survival after resection for carcinoma of the pancreatic head, distal bile duct, and ampulla were 16, 25 and 24 months, respectively (P=0.008). In the univariate analysis vein resection, blood transfusion of more than four packed red cells, the presence of tumour positive resection margins, lymph-node metastases and poor tumour differentiation significantly decreased survival. In the multivariate analysis positive resection margins, lymph-node metastases, and poor tumour differentiation independently influenced survival. CONCLUSIONS Resection margins, lymph-node status and tumour differentiation are independent prognostic factors. Survival after standard pancreaticoduodenectomy for periampullary tumours has not improved.
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Affiliation(s)
- R C van Geenen
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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14
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Abstract
Our review supports the clinical impression that periampullary cancers vary in outcome after resection. Overall survival after pancreaticoduodenectomy is greatest for patients with ampullary and duodenal cancers, intermediate for patients with bile duct cancer, and least for patients with pancreatic cancer. Moreover, survival for each tumor stage is greater for nonpancreatic periampullary cancers than for pancreatic cancers. Invasion of the pancreas by nonpancreatic periampullary cancers is a major factor adversely affecting survival. Recent data suggest that inherent differences in tumor biology rather than embryologic, anatomic, or histologic factors probably account for these differences in survival. Finally, although pancreaticoduodenectomy remains the procedure of choice for resectable periampullary cancers, further increases in survival will likely evolve through more effective neoadjuvant or adjuvant therapies rather than modifications in the surgical approach.
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Affiliation(s)
- J M Sarmiento
- Department of Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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15
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Lee JH, Whittington R, Williams NN, Berry MF, Vaughn DJ, Haller DG, Rosato EF. Outcome of pancreaticoduodenectomy and impact of adjuvant therapy for ampullary carcinomas. Int J Radiat Oncol Biol Phys 2000; 47:945-53. [PMID: 10863064 DOI: 10.1016/s0360-3016(00)00537-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE To determine the clinical outcomes and potential impact of adjuvant chemoradiation in patients undergoing surgical resection of ampullary carcinoma. PATIENTS AND METHODS Between 1988 and 1997, 39 patients underwent pancreaticoduodenectomy for ampullary adenocarcinomas. Clinical and pathologic factors, adjuvant therapy records, and disease status were obtained from chart review. Thirteen (33%) patients received adjuvant chemoradiation. Radiation therapy was delivered to the surgical bed and regional nodes to a median dose of 4,860 cGy with concurrent bolus or continuous infusion of 5-fluorouracil. Outcomes measures included locoregional control, disease-free survival, and overall survival. Univariate analysis was used to assess the impact of various patient- and tumor-related factors and the use of adjuvant therapy. Twenty (51%) patients with tumor invasion into the pancreas (T3) or node-positive disease were classified in a "high-risk" subgroup. RESULTS After a median follow-up of 45 months for survivors, overall 3-year survival was 55%. Survival was significantly worse for patients with positive nodes (23% vs. 73%, p < 0.001) and high-risk status (30% vs. 80%, p = 0.002). Disease-free survival was 54% at 3 years. There were 3 postoperative deaths, and these patients (all high risk) are excluded from further analysis on adjuvant therapy. In univariate analysis, the use of adjuvant chemoradiation had no clear impact on local-regional control or overall survival. However, by controlling for risk status in multivariate analysis, the use of adjuvant therapy reached statistical significance for overall survival (p = 0. 03). Among the high-risk patients, 7 (77%) of 9 patients receiving adjuvant therapy remained disease-free during follow-up compared with only 1 (14%) of 7 patients not receiving adjuvant therapy (p = 0.012). CONCLUSION Despite the relatively favorable prognosis of ampullary carcinomas compared with other pancreaticobiliary tumors, patients with nodal metastases or T3 disease are at high risk for disease relapse. The use of adjuvant chemoradiation may improve long-term disease control in these patients.
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Affiliation(s)
- J H Lee
- Departments of Radiation Oncology, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Abstract
BACKGROUND Ampulla of Vater tumours are rare but usually resectable. There is debate as to the better surgical approach between the standard radical procedure, which provides adequate resection margins, and local resection, which may carry a lower mortality. This study reports the 16-year experience of a specialist unit with these tumours, and compares our results with that of recently published series. METHOD A retrospective review of patients admitted with an ampullary tumour to the Hepatobiliary and Pancreatic Surgery Unit, Royal Adelaide Hospital, Adelaide, Australia, between January 1981 and April 1997. RESULTS Twenty-five patients (13 men, 12 women) of median age 65 years were admitted with an ampullary tumour to the unit during this period. The most common presentation was obstructive jaundice. Multiple endoscopic biopsy was found to be very reliable in distinguishing between benign and malignant tumours. Five patients, all male, had benign neoplasms: three adenomas, one carcinoid and one gangliocytic paraganglioma. Transduodenal local excision was performed in four patients. One patient had a Whipple procedure resulting in the only in-hospital death at 3 months. Twenty patients had adenocarcinoma, of which 13 patients had a pancreaticoduodenectomy, two local excisions, two palliative bypasses, two were unfit for surgery and one declined surgery. The resectability rate was 88%, with no operative mortalities. The 5-year actuarial survival of patients who underwent radical resection was 49%. CONCLUSIONS Proximal pancreaticoduodenectomy, preferably a pylorus-preserving procedure, is safe and effective in the treatment of ampullary carcinoma, with low operative mortality and good long-term survival. Local resection is only recommended for small benign tumours and for patients who may be unfit for radical surgery.
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Affiliation(s)
- S K Toh
- Hepatobiliary and Pancreatic Surgical Unit, Royal Adelaide Hospital, South Australia, Australia
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