Surgical management of neoplasms of the ampulla of Vater: local resection or pancreatoduodenectomy and prognostic factors for survival

Surgical outcomes and prognostic factors for ampulla of Vater cancer

BACKGROUND AND AIMS

The prognosis for patients with ampulla of Vater cancer is better than other periampullary cancers. The aim of the present study is to determine the clinicopathologic factors predictive of survival and recurrence in patients with ampulla of Vater cancer.

MATERIAL AND METHODS

From 1991 to 2008, we identified and reviewed 78 patients with ampulla of Vater cancer retrospectively. Clinicopathologic factors possibly influencing survival and recurrence were statistically analyzed.

RESULTS

Pancreaticoduodenectomy was performed in 68 patients and 2 patients underwent transduodenal ampullectomy. Hospital mortality was 2.6%. The 5-year survival rates following resection were 59.9%. Univariate analysis for overall survival revealed that total bilirubin greater than 5 mg/dl, ulcerative tumors, differentiation, and pancreatic invasion were significant prognostic factors. Recurrence occurred in 31 patients. Univariate analysis for disease-free survival revealed that total bilirubin greater than 5mg/dl, preoperative biliary drainage, tumor differentiation, and stage were statistically significant. Multivariate analysis revealed that tumor differentiation was an independent prognostic factor for recurrence. The presence of lymph node metastasis did not affect overall survival significantly in this study. However, two or more metastatic lymph nodes significantly affect disease-free survival.

CONCLUSIONS

Pancreaticoduodenectomy is a safe surgical procedure with acceptable long-term survival for ampulla of Vater cancer. Pancreaticoduodenectomy with lymph node dissection might control lymph node spread and enhance survival outcome.

Adenocarcinoma of the minor duodenal papilla treated with pancreas-sparing segmental duodenectomy: case report and review of the literature

Carcinoma of the minor duodenal papilla is extremely rare. We present the case of a 69-year-old man diagnosed with a tumor of the second portion of the duodenum by upper gastrointestinal endoscopy, which revealed a 1.5-cm elevated tumor with slight ulceration at the minor duodenal papilla. Biopsy revealed adenocarcinoma, and a computed tomography scan showed an enhanced tumor in the duodenum, with no abnormality in the pancreatic head. A pancreas-sparing segmental duodenectomy was performed, and the duodenum reconstructed with an end-to-end anastomosis. Microscopically, the tumor was a well-differentiated adenocarcinoma, with no infiltration at the cut end of the accessory pancreatic duct. The postoperative course was uneventful and the patient discharged on postoperative day 11. We reviewed previously reported cases of carcinoma of the minor duodenal papilla. Early and exact preoperative diagnosis of duodenal neoplasms makes it possible to select a less invasive treatment, which also maintains curability.

Comparative study of the radical and standard lymphadenectomy in the surgical treatment of adenocarcinoma of the ampula of Vater

OBJECTIVE

To evaluate the morbidity and mortality in patients undergoing surgical pancreatoduodenectomy (PD) in standard and radical lymphadenectomy for adenocarcinoma of papilla, analyzing the prognostic factors related to overall and disease-free survival.

METHODS

Were analyzed retrospectively from 1999 to 2007, in the Department of Abdominal and Pelvic Surgery (INCa-RJ), 50 cases of PD for adenocarcinoma of the duodenal papilla divided into two groups according to lymphadenectomy (group A: standard lymphadenectomy and group B: radical lymphadenectomy).

RESULTS

The median age was similar in both groups, as well as the distribution between the sex. In the comparison between the lymphadenectomies, only the number of lymph nodes resected (group A: 12.3 and group B: 26.5) and operative time (group A: 421 and group B: 474) were significantly different. There were no statistically significant differences in the two groups with respect to morbidity and mortality rate and length of hospitalization. The disease-free survival (group A: 35 months and group B: 51 months) and overall survival (group A: 38 months and group B: 53 months) was higher in the group of radical lymphadenectomy, but were not statistically significant.

CONCLUSION

In this study there were no cases of metastatic lymph nodes to other groups without nodal involvement of the pancreatic-duodenal lymph node chains (13, 17), suggesting a pattern of lymph node spread. Despite the radical lymphadenectomy present rates of disease-free survival and overall survival largest such data were not statistically significant. Further studies should be conducted to evaluate the real role of radical lymphadenectomy in adenocarcinoma of the duodenal papilla.

Adjuvant radio-chemotherapy for extrahepatic biliary tract cancers

BACKGROUND

Extrahepatic biliary duct cancers (EBDC) are uncommon malignancies characterized by a poor prognosis with high rate of loco-regional recurrence. The purpose of the present study is to assess the feasibility and the potential impact of adjuvant radiotherapy (RT) in a series of patients treated in one institution.

METHODS

Twenty three patients with non-metastatic bile duct cancer treated surgically with curative intent (4 gallbladder, 7 ampullary and 12 cholangiocarcinoma) received 3D conformal external beam RT to a median total dose of 50.4 Gy. Concurrent chemotherapy based on 5-FU was delivered to 21 patients (91%). Surgical margins were negative in 11 patients (48%), narrow in 2 (9%), and microscopically involved in 8 (35%). Eleven patients (55%) had metastatic nodal involvement. The average follow-up time for all patients was 30 months (ranging from 3-98).

RESULTS

Acute gastrointestinal grade 2 toxicity (RTOG scale) was recorded in 2 patients (9%). Nausea or vomiting grade 1 and 2 was observed in 8 (35%) and 2 patients (9%) respectively. Only one patient developed a major late radiation-induced toxicity. The main pattern of recurrence was both loco-regional and distant (liver, peritoneum and/or lung). No difference was observed in loco-regional control according to the tumor location. The 5-year actuarial loco-regional control rate was 48.3% (67% and 30% for patients operated on with negative and positive/narrow/unknown margins respectively, p=0.04). The 5-year actuarial overall survival was of 35.9% for the entire group (61.4% in case of negative margins and 16.7% in case of positive/narrow/unknown margins, p=0.07).

CONCLUSIONS

Postoperative RT with 50-60 Gy is feasible with acceptable acute and late toxicities. The potential benefit observed in our series may support the use of adjuvant RT in patients with locally advanced disease. Prospective randomized trials are warranted to confirm definitively the role of RT in this tumor location.

Therapeutic delay and survival after surgery for cancer of the pancreatic head with or without preoperative biliary drainage

OBJECTIVE

To evaluate the relation between delay in surgery because of preoperative biliary drainage (PBD) and survival in patients scheduled for surgery for pancreatic head cancer.

BACKGROUND

Patients with obstructive jaundice due to pancreatic head cancer can undergo PBD. The associated delay of surgery can lead to more advanced cancer stages at surgical exploration, affecting resection rate and survival.

METHODS

We conducted a multicenter, randomized controlled clinical trial to compare PBD with early surgery (ES) for pancreatic head cancer for complications. We obtained Kaplan-Meier estimates of overall survival for patients with pathology-proven malignancy and compared survival functions of ES and PBD groups using log-rank test statistics. Multivariable Cox regression analyses were performed to evaluate the prognostic role of time to surgery for overall survival.

RESULTS

Mean times from randomization to surgery were 1.2 (0.9-1.5) and 5.1 (4.8-5.5) weeks in the ES and PBD groups, respectively (P < 0.001). In the ES group, 60 (67%) of 89 patients underwent resection, versus 53 (58%) of 91 patients in the PBD group (P = 0.20). Median survival after randomization was 12.2 (9.1-15.4) months in the ES group versus 12.7 (8.9-16.6) months in the PBD group (P = 0.91). A longer time to surgery was significantly associated with slightly lower mortality rate after surgery (hazard ratio = 0.90, 95% CI, 0.83-0.97), when taking into account resection, bilirubin, complications, pancreatic adenocarcinoma, tumor-positive lymph nodes, and microscopically residual disease.

CONCLUSIONS

In patients with pancreatic head cancer, the delay in surgery associated with PBD does not impair or benefit survival rate.

Ampullary cancer

PURPOSE OF REVIEW

This manuscript reviews the recent literature on ampullary cancer, including new staging definitions, histological characteristics and treatment options.

RECENT FINDINGS

Recent publications emphasize the importance of the histological differentiation (intestinal vs. pancreatobiliary), which is one of the most important prognostic factors for ampullary cancer. These histological subtypes can be differentiated by immunohistochemistry: while positivity for mucin-2 (MUC2) and caudal homeobox gene transcription factor-2 (CDX2) excludes the pancreatobiliary subtype, positivity for MUC1 and cytokeratin-17 (CK17) excludes the intestinal subtype. Also, different mechanisms of cancer development have been described, which might be related to the type of differentiation. Due to the very low risk of lymphatic spread, local resections appear sufficient for well differentiated T1 cancer smaller than 1 cm, whereas larger, less differentiated or more invasive cancer requires a radical resection. As cancer with intestinal differentiation shares a similar biology with colon cancer, and the pancreatobiliary differentiation is close to ductal adenocarcinoma of the pancreas, adjuvant chemotherapy should probably be given according to colon cancer (intestinal) and pancreatic cancer (pancreatobiliary), respectively. However, randomized trials are lacking.

SUMMARY

The recent research suggests that the histological differentiation of periampullary cancer is more important than the anatomical location (ampulla). Future studies are required to take this emerging issue into account.

Incidence and characteristics of chronic and lymphoplasmacytic sclerosing pancreatitis in patients scheduled to undergo a pancreatoduodenectomy

BACKGROUND

The determination of the exact nature of a pancreatic head mass in a patient scheduled to undergo a pancreatoduodenectomy can be very difficult. This is important as patients who suffer from benign disease such as pancreatitis do not always require surgery. The aim of the present study was to analyse the incidence of pancreatitis and the signs and symptoms associated with these tumours mistaken for pancreatic cancer and the diagnostic procedures performed.

METHODS

A consecutive group of patients who underwent a pancreatoduodenectomy between 1992 and 2005 with histopathologically proven pancreatic adenocarcinoma (PCA) and pancreatitis were analysed.

RESULTS

The incidence of pancreatitis after pancreatoduodenectomy is 63 out of 639 patients who underwent a pancreaticoduodenectomy (9.9%). Of these patients, 24 patients (38%) had lymphoplasmacytic sclerosing pancreatitis (LPSP) and 31 patients (49%) had focal chronic pancreatitis. Eight patients (13%) had an intermediate form with characteristics of both. Pancreatic adenocarcinoma occurred in 227 patients (36%). The presence of pancreatitis without a discrete mass on endoscopic ultrasonography (EUS) seemed to have clinical relevance with a positive likelihood ratio of 5.1. Mortality after resection was nil in both groups.

CONCLUSION

The incidence of pancreatitis is 9.9% for patients scheduled to undergo a pancreatoduodenectomy. Of these patients, 38% had LPSP, 13% had a intermediate form and 49% had focal chronic pancreatitis. The determination of the exact nature of a pancreatic head mass remains difficult.

Important Prognostic Factors in Adenocarcinoma of the Ampulla of Vater

Ampullary adenocarcinoma (AmpCA) carries a better overall survival (OS) rate than other periampullary cancers. We examined clinicopathologic features in AmpCA for impact on OS. Records of patients undergoing pancreaticoduodenectomy from 2000 to 2007 for AmpCA were reviewed and histological specimens were reanalyzed. Of 302 patients undergoing pancreaticoduodenectomy for malignancy, 45 (14.9%) had AmpCA. Mean age was 61.3 ± 12.2 years, mean tumor size was 2.6 ± 1.3 cm, 57 per cent were ≥ T3 tumors, 42 per cent were N1 stage, 13 (49%) had perineural invasion (PNI), and 29 (64%) had lymphovascular invasion (LVI). Thirteen were intestinal (29%), 14 were pancreaticobiliary (31%), and 18 were mixed (40%). Median OS was 42 months (range 4-80 mos). On log rank testing, ≥ T3 (24 vs 65 mos, P < 0.01), N1 (25 vs 61 mos, P < 0.01), poor differentiation (24 vs 44 mos, P = 0.01), pancreaticobiliary subtype (23 vs 44 mos, P = 0.01), and PNI (23 vs 44 mos, P < 0.01) were significant for worse survival. By multivariate analysis, N1 disease (hazard ratio [HR] 4.50,95% confidence interval [CI] 1.16-17.40) and PNI (HR 4.62, CI 1.11-19.21) maintained associations with worse survival, whereas histological subtype did not. N1 disease and presence of PNI demonstrated independent associations with worse survival. Given high percentage of mixed histology, PNI may be more informative than the subtype in predicting outcome for patients with AmpCA.

Lymph node involvement in ampullary cancer: the importance of the number, ratio, and location of metastatic nodes

BACKGROUND AND OBJECTIVES

Lymph node involvement significantly affects survival of cancer patients. The aim of this study was to evaluate the importance of the number, ratio, and location of metastatic lymph nodes in ampullary cancers.

METHODS

Medical records of 111 patients who underwent curative pancreaticoduodenectomy for ampullary carcinomas were reviewed.

RESULTS

Metastatic lymph nodes were found in 52 (47%) patients and the median number of involved nodes was 3 (95% confidence interval (CI) 3-4; range 1-17). In the univariate analysis, gender, type of pancreaticoduodenectomy, depth of tumor invasion, perineural invasion, presence of metastatic nodes, their number, and ratio of metastatic nodes significantly correlated with patient survival. However, the location of metastatic nodes did not influence survival among patients with nodal involvement. Only four or more metastatic nodes (relative risk 7.35, 95% CI 3.34-16.17) and tumor invasion of peripancreatic soft tissues (relative risk 5.00, 95% CI 1.20-20.92) were the independent prognostic factors in the multivariate analysis.

CONCLUSIONS

The number of metastatic nodes significantly affected patient survival. Although the location and ratio of metastatic nodes were not independent prognostic factors, these variables should be further evaluated with large-scale population data sets.

Redefining resection margin status in pancreatic cancer

Curative resection is crucial to survival in pancreatic cancer; however, despite optimization and standardization of surgical procedures, this is not always achieved. This review highlights that the rates of microscopic margin involvement (R1) vary markedly between studies and, although resection margin status is believed to be a key prognostic factor, the rates of margin involvement and local tumour recurrence or overall survival of pancreatic cancer patients are often incongruent. Recent studies indicate that the discrepancy between margin status and clinical outcome is caused by frequent underreporting of microscopic margin involvement. Lack of standardization of pathological examination, confusing nomenclature and controversy regarding the definition of microscopic margin involvement have resulted in the wide variation of reported R1 rates that precludes meaningful comparison of data and clinicopathological correlation.

[Primary small bowel adenocarcinoma]

INTRODUCTION

Primary small bowel adenocarcinoma is an uncommon tumour, with non-specific symptoms that cause a delay in the diagnosis and consequently a worse outcome for the patient. We analyse our experience in the management of this disease.

MATERIAL AND METHOD

We performed a retrospective study of our experience with 17 patients diagnosed with primary small bowel adenocarcinoma, excluding all the cases suggesting secondary involvement of the small bowel from an adenocarcinoma in other locations.

RESULTS

We analysed 9 females (53%) and 8 males (47%) with a mean age of 61.8 years. Tumour location was duodenum (8 cases), jejunum (5) and ileum (4). Those with duodenal tumours underwent 4 pancreaticoduodenectomies, 3 gastroenterostomies and 1 diagnostic biopsy; 6 bowel resections with lymphadenectomy, 2 en-bloc resections and 1 by-pass were performed on those with jejuno-ileal tumours. There were complications in 3 patients (18%). General survival was 18 months; in duodenal and jejunal tumours it was 15 months vs. 58 in ileal ones (p = 0.048). Survival was 48 months in the absence of lymph node metastases vs. 11 in those with (p = 0.067). In those tumours infiltrating the retroperitoneum, survival was 15 months compared to 23 when not affected (p = 0.09).

CONCLUSIONS

Curative treatment consists of small bowel resection. Retroperitoneal infiltration was a non-resectability criterion in our series. Ileal location is associated with a better outcome. Advanced stages, lymph node metastases, non-resected cases and retroperitoneal infiltration tended to be associated with a poor prognosis in our group.

Assessment of survival advantage in ampullary carcinoma in relation to tumour biology and morphology

INTRODUCTION

Carcinoma of the ampulla of Vater is said to carry a significantly better prognosis than pancreatic ductal adenocarcinomas arising in the pancreatic head. However, it is uncertain as to whether this is due to the fact that they have differing oncological characteristics or simply an earlier presentation as a result of the exophytic morphology of ampullary lesions causing obstruction of the bile ducts.

METHODS

All patients undergoing pancreaticoduodenectomy between January 1998 and December 2004 were identified from a prospectively maintained database. Patients with a pathologically confirmed ampullary (AMP) tumour were compared to those with a carcinoma of the head of the pancreas (HOP). Tumour characteristics including size, stage and degree of differentiation were analysed as were survival data.

RESULTS

71 AMP and 144 HOP tumours were resected during the period studied and had full histology reports available for assessment. The median diameter of the AMP tumours was significantly less than those of the HOP (2 cm vs. 3 cm; p = 0.04). The T stage distribution differed significantly between the AMP and HOP tumours in favour of the former (Stages I--10 vs. 0 (p = 0.03); II--29 vs. 13 (p = 0.04); III--25 vs. 121 (p = 0.01); IV--7 vs. 10). The number of resection specimens with positive lymph nodes was lower in the AMP group (31 vs. 121; p = 0.03) as was the prevalence of vascular invasion (33 vs. 114; p = 0.006) and neural invasion (23 vs. 134; p = 0.009). There was no difference in the degree of differentiation of the AMP and HOP tumours. The 5-year survival rates were significantly better in the AMP group at 60% vs. 20% (p = 0.008). Subdivision of AMP carcinoma into polypoid (60%) and ulcerating (40%) lesions revealed a non-significant survival advantage in favour of polypoid tumours at (64% vs. 60%; p = 0.07) at 5 years.

CONCLUSIONS

The outcome of resection for AMP is significantly better than for pancreatic ductal adenocarcinomas arising in the periampullary region. Although the anatomical position of AMP tumours may contribute to this survival advantage, the HOP tumours exhibit more adverse histological features suggesting that they are different diseases and hence the difference in survival.

Pancreas-preserving total duodenectomy versus standard pancreatoduodenectomy for patients with familial adenomatous polyposis and polyps in the duodenum

BACKGROUND

Pancreas-preserving total duodenectomy (PPTD) was introduced as a replacement for pancreatoduodenectomy (PD) for familial adenomatous polyposis (FAP). This study analysed the results of PPTD in the Netherlands and reviewed the relevant literature.

METHODS

All 26 patients who underwent PPTD for FAP in four centres in the Netherlands between January 2000 and January 2007 were compared with a group of 77 patients who had PD for ampulla of Vater adenocarcinoma at one centre during the same interval.

RESULTS

Morbidity rates were similar after PPTD for FAP (16 patients, 62 per cent) and PD for ampulla of Vater adenocarcinoma (44 patients, 57 per cent) (P = 0.694). One patient (4 per cent) died after PPTD and two (3 per cent) after PD. A review of the literature, including patients from the present study, found that 71 patients had PPTD, with postoperative morbidity in 36 (51 per cent) and one death (1 per cent). In publications containing a total of 94 patients who underwent PD for FAP, 43 (46 per cent) developed complications and three (3 per cent) died.

CONCLUSION

PPTD has similar short-term results to PD in terms of morbidity and mortality.

Technical aspects of performing transduodenal ampullectomy

Transduodenal ampullectomy is a procedure that can be used to remove either benign or malignant tumors arising from the ampulla of Vater. Specific indications for performing this procedure remain controversial. In this report, we describe the technical details necessary for successfully completing an ampullectomy.

Prognostic impact of perineural invasion following pancreatoduodenectomy with lymphadenectomy for ampullary carcinoma

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.

Adenoma of the major duodenal papilla with intraductal extension into the lower common bile duct

Although benign and malignant tumors of the major duodenal papilla can be detected endoscopically, definitive diagnosis of such lesions by histologic examination of biopsy specimens is sometimes difficult, especially in cases with intraductal extension into the bile duct or pancreatic duct. We herein report a case of adenoma of the major duodenal papilla showing an intraductal extension into the lower common bile duct that necessitated pylorus-preserving pancreaticoduodenectomy.

Tumors of the ampulla of vater: histopathologic classification and predictors of survival

BACKGROUND

The histology and clinical behavior of ampullary tumors vary substantially. We speculated that this might reflect the presence of two kinds of ampullary adenocarcinoma: pancreaticobiliary and intestinal.

STUDY DESIGN

We analyzed patient demographics, presentation, survival (mean followup 44 months), and tumor histology for 157 consecutive ampullary tumors resected from 1989 to 2006. Histologic features were reviewed by a pathologist blinded to clinical outcomes. Survival was compared using Kaplan-Meier/Cox proportional hazards analysis.

RESULTS

There were 33 benign (32 adenomas and 1 paraganglioma) and 124 malignant (118 adenocarcinomas and 6 neuroendocrine) tumors. One hundred fifteen (73%) patients underwent a Whipple procedure, 32 (20%) a local resection, and 10 (7%) a palliative operation. For adenocarcinomas, survival in univariate models was affected by jaundice, histologic grade, lymphovascular, or perineural invasion, T stage, nodal metastasis, and pancreaticobiliary subtype (p < 0.05). Size of tumor did not predict survival, nor did cribriform/papillary features, dirty necrosis, apical mucin, or nuclear atypia. In multivariate models, lymphovascular invasion, perineural invasion, stage, and pancreaticobiliary subtype predicted survival (p < 0.05). Patients with pancreaticobiliary ampullary adenocarcinomas presented with jaundice more often than those with the intestinal kind (p = 0.01) and had worse survival.

CONCLUSIONS

In addition to other factors, tumor type (intestinal versus pancreaticobiliary) had a major effect on survival in patients with ampullary adenocarcinoma. The current concept of ampullary adenocarcinoma as a unique entity, distinct from duodenal and pancreatic adenocarcinoma, might be wrong. Intestinal ampullary adenocarcinomas behaved like their duodenal counterparts, but pancreaticobiliary ones were more aggressive and behaved like pancreatic adenocarcinomas.

An audit of outcomes of a series of periampullary carcinomas

BACKGROUND

Non-pancreatic periampullary carcinoma such as ampullary carcinoma (AmpCA), distal cholangiocellular carcinoma (CholCA) and duodenal carcinoma (DuoCA) have a better prognosis than pancreatic head adenocarcinoma (PanCA). This study describes the outcome and parameters, which predict survival of non-pancreatic periampullary carcinoma after resection.

METHODS AND PATIENTS

Data from 148 consecutive patients with non-pancreatic periampullary carcinomas were recorded prospectively between 1993 and 2005 and analyzed using univariate and multivariate models.

RESULTS

One hundred thirty-three of 148 (90%) patients were resected for histologically proven non-pancreatic periampullary carcinomas. R0 resection was achieved for 92% of AmpCA, for 88% of CholCA and for all the DuoCA. The lowest recurrence rate was seen in DuoCA with 18%, followed by AmpCA with 21% and CholCA with 46%. The mean survival time was 60.9 months for AmpCA patients, 42.9 months for CholCA and 45.4 months for DuoCA patients. Five-year survival was 50.5%, 29.9% and 24.5% for AmpCA, CholCA and DuoCA, respectively. Multivariate analysis identified low bilirubin levels (<100 micromol/l), R0 resections and absence of surgical complications to be strong independent predictors of survival (p<0.05). In AmpCA low tumor stages are also an independent predictor of long-term survival (p<0.01). For T1/T2 AmpCA the 5-year survival rate was 61%, whereas none of the patients with a T3/T4 tumor survived 5 years.

CONCLUSION

Only T1/T2 ampullary carcinomas have a good prognosis, whereas T3/T4 ampullary tumors show aggressiveness similar to that of pancreatic head adenocarcinomas. Absence of surgical complications determines long-term outcome. Therefore, the combination of a complication-free and radical resection is essential for long-term survival.

Prognostic significance of extracapsular lymph node involvement in patients with adenocarcinoma of the ampulla of Vater

Background

Lymphatic dissemination is an important predictor of survival in patients with adenocarcinoma of the ampulla of Vater. The incidence and clinical consequences of extracapsular lymph node involvement (LNI) in patients who undergo resection are unknown.

Methods

In a consecutive series of 160 patients with adenocarcinoma of the ampulla of Vater, 75 (46·9 per cent) had positive lymph nodes (N1). The relation of extracapsular LNI with tumour stage and number of positive nodes was evaluated and its prognostic significance analysed.

Results

Extracapsular LNI was identified in 44 (59 per cent) of the 75 patients. Median overall survival was 30 and 18 months in patients with intracapsular and extracapsular LNI respectively (P = 0·015). The 5-year overall survival rate was 20 and 9 per cent respectively, compared with 59 per cent in patients without LNI (N0). Extracapsular LNI and tumour differentiation were independent prognostic factors for survival. In patients with N1 disease, extracapsular LNI was the only significant prognostic factor for recurrent disease after radical resection (R0).

Conclusion

The presence of extracapsular LNI identifies a subgroup of patients who have a significantly worse prognosis. Adjuvant therapy is advised following resection in these patients.

Resection margins and R1 rates in pancreatic cancer--are we there yet?

The prognosis of pancreatic cancer is poor, even for those patients who undergo surgical resection. The rate of local recurrence is high, despite the fact that in most series complete ('R0') resection is reported to be achieved in the majority of patients. The discrepancy between pathological assessment and clinical outcome indicates that microscopic margin involvement (R1) is frequently underreported, and potential causes for this are discussed in this review. Special emphasis is given to the variation that exists between currently used dissection techniques and their impact on the assessment of the resection margins in pancreatoduodenectomy specimens.

Number of positive lymph nodes independently affects long-term survival after resection in patients with ampullary carcinoma

AIM

The nodal status is an established prognostic factor in ampullary carcinoma. The aim of this study was to compare the prognostic power of the anatomic location of positive nodes with that of the number of positive nodes.

METHODS

Of 73 consecutive patients treated for ampullary carcinoma, 62 underwent pancreaticoduodenectomy with regional lymphadenectomy. A survival analysis of these 62 patients by nodal status was conducted retrospectively. A total of 1942 lymph nodes taken from the patients were examined histologically for metastasis. The location of positive regional nodes was classified into 4 categories, according to the Japanese staging system. The number of positive regional nodes was recorded for each patient. The median follow-up period was 124 months.

RESULTS

Nodal disease was found in 31 patients, of whom 23 had 1-3 positive regional nodes and 8 had >or=4 positive regional nodes. Univariate analysis revealed that both the location (p<0.0001) and the number (p<0.0001) of positive nodes were significant prognostic factors. Multivariate analysis revealed that the number of positive nodes was an independent prognostic factor (p=0.007), while the location failed to remain as an independent variable. The median survival time was 59 months with a 5-year survival rate of 48% in patients with 1-3 positive nodes, whereas all patients with >or=4 positive nodes died of the disease within 29 months of resection (p=0.0001).

CONCLUSION

The number, not the location, of positive regional lymph nodes independently affects long-term survival after resection in patients with ampullary carcinoma.

Usefulness of follow-up after pancreatoduodenectomy for carcinoma of the ampulla of Vater

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.

Impact of lymph node metastasis on survival in patients with pathological T1 carcinoma of the ampulla of Vater

To determine the prognostic factors for patients with pathological T1 (pT1) carcinoma of the ampulla of Vater, 36 consecutive patients with carcinoma of the ampulla of Vater who underwent surgery were retrospectively analyzed in terms of clinicopathological features. The overall 5-year Kaplan-Meier survival in all patients was 50.2%, and the median survival of all patients was 64.0 months. Factors favorably influencing a long-term outcome were the absence of lymph node metastasis (P < 0.0001), the absence of ulcer formation of the tumor (P = 0.0062), and the absence of tumor invasion into the duodenum (P = 0.0025) and the pancreas (P = 0.0098). In a multivariate analysis, lymph node metastasis was the only predictor of survival (P = 0.0023). In the pT1 stage patients, 20% of the patients had lymph node metastasis, and their survival was statistically poor compared to the pT1 patients without lymph node metastasis (P = 0.017). As for survival after the operation, there was no significant difference between pancreatoduodenectomy and pylorus-preserving pancreatoduodenectomy.

Clinical significance of immunohistochemically detectable lymph node metastasis in adenocarcinoma of the ampulla of Vater

BACKGROUND

The aim of this study was to assess the impact of immunohistochemically identified lymph node metastasis on survival in patients with carcinoma of the ampulla of Vater.

METHODS

Three hundred and twenty-six regional lymph nodes dissected from pancreatoduodenectomy specimens from 25 patients with ampulla of Vater carcinoma were immunostained with anticytokeratin antibody (CAM 5.2). The clinicopathological significance of immunohistochemically detectable lymph node metastasis was evaluated and compared with that of other potential prognostic factors.

RESULTS

The frequency of lymph node involvement in relation to the total number of dissected lymph nodes increased from 5.5 per cent (18 of 326) using haematoxylin and eosin staining to 9.5 per cent (31 of 326) using cytokeratin immunostaining (P < 0.001). Lymph node involvement was revealed by haematoxylin and eosin staining in eight of 25 patients and by cytokeratin immunostaining in 11 of 25 patients (P = 0.006). Absence of immunohistochemically detectable lymph node metastasis was identified as an independent predictor of improved postoperative survival.

CONCLUSION

Immunostaining of dissected lymph nodes adds additional information to data obtained by conventional haematoxylin and eosin staining when determining the prognosis of patients with carcinoma of the ampulla of Vater.

Local resection of ampullary tumors

There is no consensus on the appropriateness of local resection for ampullary tumors, because malignant recurrence of what were thought to be benign tumors has been reported. This study examined the role of local resection in the management of ampullary tumors. Thirty patients (mean age 66 years) had transduodenal local resections performed at UCSF-Moffitt Hospital or the San Francisco VA Medical Center (February, 1992 to March, 2004). Mean follow-up time was 5.8 years. Preoperative biopsies (obtained in all patients) showed 18 adenomas, four adenomas with dysplasia, five adenomas with atypia, one adenoma with dysplasia and focal adenocarcinoma, and two tumors seen on endoscopy, whose biopsies showed only duodenal mucosa. In comparison with the final pathology findings, the results of frozen section examinations for malignancy in 20 patients, during the operation, were false-negative in three cases. The final pathologic diagnosis was 23 villous adenomas, six adenocarcinomas, and one paraganglioma. On preoperative biopsies, all patients who had high-grade dysplasia and one of five patients with atypia turned out to have invasive adenocarcinoma when the entire specimen was examined postoperatively. Two (33%) adenocarcinomas recurred at a mean of 4 years; both had negative margins at the initial resection. Among the 23 adenomas, three (13%) recurred (all as adenomas) at a mean of 3.2 years; in only one of these cases was the margin positive at the time of resection. Tumor size did not influence recurrence rate. Ampullary tumors with high-grade dysplasia on preoperative biopsy should be treated by pancreaticoduodenectomy because they usually harbor malignancy. Recurrence is too common and unpredictable after local resection of malignant lesions for this to be considered an acceptable alternative to pancreaticoduodenectomy. Ampullary adenomas can be resected locally with good results, but the recurrence rate was 13%, so endoscopic surveillance is indicated postoperatively. Frozen sections were obtained during the operation, but they were less reliable than expected. No adenomas recurred as carcinomas, suggesting that local resection is appropriate for these tumors in the absence of dysplasia or atypia on preoperative biopsies.

Predictors of failure after pancreaticoduodenectomy for ampullary carcinoma

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.