The Prognostic Relevance of the Number and Location of Positive Lymph Nodes for Ampulla of Vater Carcinoma

New nomogram for predicting lymph node positivity in pancreatic head cancer

Background

Pancreatic cancer is one of the most malignant cancers worldwide, and it mostly occurs in the head of the pancreas. Existing laparoscopic pancreaticoduodenectomy (LPD) surgical techniques have has undergone a learning curve, a wide variety of approaches for the treatment of pancreatic cancer have been proposed, and the operation has matured. At present, pancreatic head cancer has been gradually changing from "surgeons' evaluation of anatomical resection" to "biologically inappropriate resection". In this study, the risk of lymph node metastasis in pancreatic head cancer was predicted using common preoperative clinical indicators.

Methods

The preoperative clinical data of 191 patients with pancreatic head cancer who received LPD in the First Affiliated Hospital of Jilin University from May 2016 to December 2021 were obtained. A univariate regression analysis study was conducted, and the indicators with a significance level of P<0.05 were included in the univariate logistic regression analysis into multivariate. Lastly, a nomogram was built based on age, tumor size, leucocyte,albumin(ALB), and lymphocytes/monocytes(LMR). The model with the highest resolution was selected by obtaining the area under a curve. The clinical net benefit of the prediction model was examined using decision curve analyses.Risk stratification was performed by combining preoperative CT scan with existing models.

Results

Multivariate logistic regression analysis found age, tumor size, WBC, ALB, and LMR as five independent factors. A nomogram model was constructed based on the above indicators. The model was calibrated by validating the calibration curve within 1000 bootstrap resamples. The ROC curve achieved an AUC of 0.745(confidence interval of 95%: 0.673-0.816), thus indicating that the model had excellent discriminative skills. DCA suggested that the predictive model achieved a high net benefit in the nearly entire threshold probability range.

Conclusions

This study has been the first to investigate a nomogram for preoperative prediction of lymphatic metastasis in pancreatic head cancer. The result suggests that age, ALB, tumor size, WBC, and LMR are independent risk factors for lymph node metastasis in pancreatic head cancer. This study may provide a novel perspective for the selection of appropriate continuous treatment regimens, the increase of the survival rate of patients with pancreatic head cancer, and the selection of appropriate neoadjuvant therapy 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.