Prognostic Factors and the Role of Adjuvant Treatment in Periampullary Carcinoma: a Single-Centre Experience of 95 Patients

Comparison of Ampullary and Pancreatic Adenocarcinomas: Smaller Invasion, Common Adenomatous Components, Resectability, and Histology are Factors for Improved Survival for Patients with Ampullary Adenocarcinoma

BACKGROUND

The information on the clinicopathologic/outcome differences between ampullary adenocarcinoma (AC) and pancreatic adenocarcinoma (PC) has been conflicting to the extent that it still is questioned whether ACs need to be recognized separately from PCs.

METHODS

The characteristics of 413 ACs were compared with those of 547 PCs.

RESULTS

The ACs had a better prognosis than the PCs (5-year survival, 57 % vs 23 %; p < 0.001). Even the pancreatobiliary (PB)-type ACs had a better prognosis (5-year survival, 46 % vs 23 %; p < 0.001). Several differences also were identified as contributing factors: (1) the preinvasive adenomatous component often constituted a significant proportion of the mass in ACs (>50 % of the tumor in 16 % vs 1.5 %; p < 0.001); (2) the mean size of the carcinoma was smaller in ACs (2.5 vs 3.2 cm; p < 0.001): when matched for invasion size, the survival advantage of AC was minimized, and when matched for invasion size larger than 2 cm, the survival advantage of AC lost its statistical significance; (3) lymph node (LN) metastases were less common in ACs (49 % vs 71 %; p < 0.001); (4) the definitive R1 rate was lower in ACs (4 % vs 23.5 %; p < 0.001); and (5) non-PB and non-tubular adenocarcinoma types were more common in ACs (17 % vs 3 %; p < 0.001).

CONCLUSIONS

Comparatively, ACs have better clinical survival than PCs. Potential contributing factors are the relative abundance of the preinvasive component, smaller invasion, lower LN metastasis rate, higher resectability, and common occurrence of less aggressive histologic phenotypes (intestinal, medullary, mucinous). However, this survival advantage is sustained even in PB-type ACs, highlighting the importance of accurately determining the site of origin.

Optimized early recurrence score for distal cholangiocarcinoma: A new attempt by adding imaging indicators

PURPOSE

To improve the preoperative prediction efficacy for patients with risk for early recurrence (ER) of distal cholangiocarcinoma (DCC).

METHODS

56 patients pathologically diagnosed as DCC were included. Their clinical data and preoperative upper abdominal enhanced MSCT images were retrospectively reviewed to look for risk factors associated with ER. ER scores were calculated by Distal Cholangiocarcinoma Early Recurrence (DICER) score and optimized ER score (OERS). Chi-square test or Mann-Whitney U test was used to compare the differences between ER group and Non-ER group, DICER score and OERS, and TNM stage and OERS. Binary logistic regression analyses were performed to identify risk factors of ER.

RESULTS

Of 56 DCC patients, 15 (26.8 %) experienced ER who were classified as ER group. Patients in ER group had significantly higher percentage of soft tissue around superior mesenteric artery (STASMA), positive lymph node, microvascular invasion and TNM stage III than those in Non-ER group, among which STASMA and positive lymph node were found to be independent risk factors for ER of DCC (All P values < 0.050). DICER score was optimized by adding STASMA and positive lymph node score to form OERS. OERS predicted more accurately than DICER score in low- and high-risk patients for ER of DCC (30.0 % vs. 0 %, 50.0 % vs. 75.0 %, P < 0.001).

CONCLUSIONS

By adding preoperative imaging indicators, OERS could improve the predictive efficacy for ER of DCC.

Discordance Between Conventional and Detailed Lymph Node Analysis in Resected, Node-negative Pancreatic or Ampullary Adenocarcinomas and Association With Adverse Survival Outcomes: A Single-institution Analysis

OBJECTIVE

To assess the frequency of occult metastases (OM) in patients with resected pancreatic ductal adenocarcinoma (PDAC) or ampullary adenocarcinoma (AA) discovered on detailed pathologic examination on lymph nodes (LNs) previously considered negative by conventional analysis and to examine the association between OM and overall survival (OS).

BACKGROUND

Poor prognosis of patients with no pathologic evidence of LN metastases may be due to OM that is not detected on conventional LN analysis.

METHODS

Patients with LN-negative resected PDAC or AA (2010-2020) were identified from our institutional database. Original hematoxylin and eosin ( H and E ) slides were reanalyzed. In addition, selected LN were analyzed by H and E (3 sections/LN) and pan-cytokeratin (AE1-AE3/PCK26) immunohistochemistry.

RESULTS

A total of 598 LNs from 74 LN-negative patients were reexamined. Nineteen patients (25.7%) had OM; 9 (47.4%) were found with immunohistochemistry but not on H and E . The number of positive LNs ranged from 1 to 3. No clinicodemographic, pathologic, or treatment-related factors were associated with OM. On conventional LN analysis, 3/19 patients (15.8%) had stage IA, 9/34 (26.5%) had stage IB, and 7/19 (36.8%) had stage IIA. On detailed LN analysis, 11/19 patients (57.9%) were upstaged to IIB, whereas 8/19 (42.1%) had isolated tumor cells only (N0i+). OM was associated with shorter OS (median OS: 22.3 vs 50.5 months; hazard ratio=3.95, 95% CI: 1.58-9.86).

CONCLUSIONS

There is a 26% discordance rate between conventional and detailed LN pathologic analysis in resected PDAC and AA. The presence of OM is associated with shorter OS.

Predictive Factors Associated With Survival in Periampullary Cancers Following Pancreaticoduodenectomy: A Retrospective Analysis

Background Periampullary cancers arise from four different anatomical sites and are in close proximity. But they have different survival outcomes. There are various clinicopathological factors associated with survival after pancreaticoduodenectomy done for periampullary cancers. So, we aimed to identify the predictive factors associated with poor survival in periampullary cancers at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Methods We analyzed the medical records of patients who underwent pancreaticoduodenectomy (PD) at Tribhuvan University Teaching Hospital, Kathmandu, from April 2004 to May 2014. Demography, clinicopathological features, and survival outcomes were analyzed retrospectively. Results This study included 61 patients. The mean age of patients was 56.2 ± 14.2 years, and there was a male preponderance (M:F = 1.4). The median survival of all patients was 24 months. Non-pancreatic periampullary cancer patients had better median survival as compared to pancreatic cancer patients (24 vs. 8 months, p = 0.03). The presence of lymphovascular invasion (LVI), peripheral invasion (PNI), nodal involvement, and a higher lymph node ratio (LNR) were associated with poor median survival. However, perineural invasion was the only factor associated with poor survival in multivariate analysis. Conclusion The presence of perineural invasion is associated with poor survival outcomes in patients with periampullary cancer following pancreaticoduodenectomy. Also, carcinoma of the head of the pancreas has poor survival as compared to other periampullary cancers.

Preoperative diagnosis of perineural invasion in patients with periampullary carcinoma by MSCT imaging: preliminary observations and clinical implications

PURPOSE

The aim of this study was to investigate the value of multi-slice computed tomography (MSCT) in preoperatively diagnosing perineural invasion (PNI) of periampullary carcinoma (PAC).

METHODS

Of 81 patients pathologically diagnosed as PAC, 73 patients were included. Their clinical documents and preoperative upper abdominal enhanced MSCT images were retrospectively reviewed to analyse clinical characteristics and MSCT features. MSCT features included tumor size, classification of fat tissue around celiac trunk and superior mesenteric artery. Chi-square test, Mann-Whitney U test or Fisher's exact test were used to compare the differences between PNI group and Non-PNI group. ROC analysis was performed to evaluate diagnostic efficiency for PAC PNI.

RESULTS

There were significant differences in some clinical characteristics and MSCT features. PAC PNI patients had significantly higher CA19-9 levels, higher CEA levels, larger tumor size and higher classification of fat tissue around celiac trunk than Non-PNI patients (All P values < 0.05). In univariate analysis, tumor size had the highest AUC as 0.806, fat tissue around celiac trunk and CEA had the highest specificity as 100% (P < 0.001). In multivariate analysis, classification of fat tissue around celiac trunk incorporated with tumor size, CA19-9, CEA, age and sex, showed the highest AUC as 0.939, with specificity of 95.0% and sensitivity of 90.4% (P < 0.001).

CONCLUSION

PAC PNI could be diagnosed preoperatively by evaluating abdominal enhanced MSCT images with high accuracy, combined with serum tumor marker could be more helpful.

Classification of Pancreatic Ductal Adenocarcinoma Using MALDI Mass Spectrometry Imaging Combined with Neural Networks

Despite numerous diagnostic and therapeutic advances, pancreatic ductal adenocarcinoma (PDAC) has a high mortality rate, and is the fourth leading cause of cancer death in developing countries. Besides its increasing prevalence, pancreatic malignancies are characterized by poor prognosis. Omics technologies have potential relevance for PDAC assessment but are time-intensive and relatively cost-intensive and limited by tissue heterogeneity. Matrix-assisted laser desorption/ionization mass spectrometry imaging (MALDI-MSI) can obtain spatially distinct peptide-signatures and enables tumor classification within a feasible time with relatively low cost. While MALDI-MSI data sets are inherently large, machine learning methods have the potential to greatly decrease processing time. We present a pilot study investigating the potential of MALDI-MSI in combination with neural networks, for classification of pancreatic ductal adenocarcinoma. Neural-network models were trained to distinguish between pancreatic ductal adenocarcinoma and other pancreatic cancer types. The proposed methods are able to correctly classify the PDAC types with an accuracy of up to 86% and a sensitivity of 82%. This study demonstrates that machine learning tools are able to identify different pancreatic carcinoma from complex MALDI data, enabling fast prediction of large data sets. Our results encourage a more frequent use of MALDI-MSI and machine learning in histopathological studies in the future.

Identifying Periampullary Regions in MRI Images Using Deep Learning

Background

Development and validation of a deep learning method to automatically segment the peri-ampullary (PA) region in magnetic resonance imaging (MRI) images.

Methods

A group of patients with or without periampullary carcinoma (PAC) was included. The PA regions were manually annotated in MRI images by experts. Patients were randomly divided into one training set, one validation set, and one test set. Deep learning methods were developed to automatically segment the PA region in MRI images. The segmentation performance of the methods was compared in the validation set. The model with the highest intersection over union (IoU) was evaluated in the test set.

Results

The deep learning algorithm achieved optimal accuracies in the segmentation of the PA regions in both T1 and T2 MRI images. The value of the IoU was 0.68, 0.68, and 0.64 for T1, T2, and combination of T1 and T2 images, respectively.

Conclusions

Deep learning algorithm is promising with accuracies of concordance with manual human assessment in segmentation of the PA region in MRI images. This automated non-invasive method helps clinicians to identify and locate the PA region using preoperative MRI scanning.

Centralisation of Pancreatoduodenectomy in India: Where Do We Stand?

BACKGROUND

The volume-outcome relationship dictates that high-volume centres lead to improved patient outcomes after pancreatoduodenectomy (PD). We conducted a retrospective review to fathom the situation in India for PD and whether referral to high-volume centres would make a positive impact.

METHOD

A systematic literature search in MEDLINE was performed, and all articles published from Indian centres from 01.03.2008 to 30.11.2019 were scrutinised. Any series with less than 20 patients, case reports, abstracts, unpublished data and personal communications were excluded.

RESULTS

A total of 36 unique series including 6226 patients from 24 institutes across India were identified. Amongst the 24 institutes, 2 institutes reported less than 10 cases/year, 11 reported 10-25 cases/year and 11 reported ≥26 cases/year. Overall perioperative morbidity was 42.4%, 43.4% and 41% for centres doing <10, 10-25 and ≥26 cases/year, respectively. Operative mortality also improved with increasing number of cases/year (5.1% vs. 6.6% vs. 3.2%, respectively).

CONCLUSION

With increasing volume of cases per year, trend towards improved PD outcomes is observed. To optimise the use of healthcare facilities, it would be pragmatic to consider building an organised referral system for complex surgeries to deliver unsurpassed patient care with maximum utilisation of the available healthcare infrastructure.

Influence of non-jaundice stage at diagnosis on clinicopathological features and long-term survival of patients with periampullary carcinomas

The effect of non-jaundice stage at diagnosis on clinicopathological features and prognosis of patients with periampullary carcinomas (PACs) remains uncertain.The 504 patients who were pathologically diagnosed with PACs between 2012 and 2017 were retrospective analyzed. Kaplan-Meier method was used to estimate survival and log-rank tests were used for comparisons between groups.Patients were divided into the non-jaundice group and the jaundice group according to serum total bilirubin (3 mg/dL) at diagnosis. By comparison with the jaundice group, more patients of the non-jaundice group manifested abdominal pain with longer duration. The degree of deterioration of complete blood count, liver function and CA19-9 in the non-jaundice group was significantly lower (P < .001). The non-jaundice group had larger tumor size (P = .001), more duodenal carcinoma and pancreatic carcinoma (P < .001), lower resection rate (P = .001) and less pancreatic and perineural invasion (P = .017, P = .002). The I stage was significantly more common in the non-jaundice group (P < .001). The cumulative 5-year survival of the non-jaundice group was significantly higher (P = .032). Multivariate analysis for all patients demonstrated that CEA level, cell differentiation, chemotherapy, and recurrence were independent prognostic factors.Patients with PACs in a non-jaundice stage at diagnosis showed more favorable clinicopathological features and long-term survival than such patients with jaundice.

Combination of CEUS and MRI for the diagnosis of periampullary space-occupying lesions: a retrospective analysis

Background

The value of magnetic resonance imaging (MRI), contrast-enhanced ultrasound (CEUS), and the combination of CEUS and MRI (CCWM) for the diagnosis of periampullary space-occupying lesions (PSOL) was investigated.

Methods

A total of 102 patients diagnosed with PSOLs by surgery or biopsy were recruited retrospectively. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MRI, CEUS, and CCWM were analyzed.

Results

MRI, CEUS, and CCWM allowed for the accurate detection of 91.17, 92.15, and 99.01% of PSOLs, respectively. The specificity, PPV, and accuracy of CCWM were significantly different from MRI and CEUS (p < 0.05). However, there the sensitivity and NPV were not significantly different among the three diagnostic technologies. In addition, the specificity, PPV, and accuracy were not significantly different between MRI and CEUS (all p > 0.05).

Conclusions

CCWM is valuable for differentiating benign and malignant PSOL, which provides important guiding significances for the clinic.

Ampullary and pancreatic adenocarcinoma-a comparative study

Background

Pancreatic ductal adenocarcinoma (PDAC) and ampullary adenocarcinoma (AAC) are 2 gastrointestinal cancers that share overlapping symptoms. Although some studies have proposed the hypothesis of differences in pathogenesis and prognosis in these 2 cancers; they remain treated similarly. The classification of AAC into three subtypes [pancreatobiliary (PB), intestinal (IT) and mixed (M)] is especially crucial for the 3 axes of patients management (diagnosis, prognosis and therapy). Some studies suggest that PB subtype pathogenesis is comparable to PDAC. The objective of this study was to conduct a comparative analysis between PDAC and AAC; notably PB subtype; via mutational status analysis of 3 oncogenes (KRAS, NRAS and BRAF) hoping to consolidate AAC biology understanding.

Methods

Nine hot spot mutation sites of KRAS, NRAS and BRAF were analysed using pyrosequencing in 39 PDAC and 21 AAC from Tunisian patients. Comparative study was performed using SPSS software.

Results

Mutations in oncogenes were detected in almost 43% of AAC, especially in PB (47%) and 95% of PDAC. KRAS was the most mutated oncogene. There were statistical significant differences between PDAC and AAC in tumor differentiation (P<0.001), perineural invasion (P<0.001), vascular emboli (P=0.001), T stage (P=0.007), N stage (P=0.001) and mutational status (P<0.001). When comparing PDAC and PB subtype, there were also significant differences in tumor size (P=0.001), tumor differentiation (P<0.001), perineural invasion (P<0.001), vascular emboli (P=0.001), T stage (P=0.033), N stage (P<0.001) and mutational status (P<0.001).

Conclusions

AAC even PB subtype is different from PDAC. We think that these different tumor types require highly individualized therapy guided by their histomolecular characteristics and that we should stop diagnosing and treating them as a unique entity.