Carcinoma of the ampulla of Vater

Tumor budding as a strong prognostic indicator in invasive ampullary adenocarcinomas

Prognostication of invasive ampullary adenocarcinomas (AACs) and their stratification into appropriate management categories have been highly challenging owing to a lack of well-established predictive parameters. In colorectal cancers, recent studies have shown that tumor budding confers a worse prognosis and correlates significantly with nodal metastasis and recurrence; however, this has not been evaluated in AAC.To investigate the prevalence, significance, and clinical correlations of tumor budding in AAC, 244 surgically resected, stringently defined, invasive AAC were analyzed for tumor budding---defined as the presence of more than or equal to 5 isolated single cancer cells or clusters composed of fewer than 5 cancer cells per field measuring 0.785 mm using a 20× objective lens in the stroma of the invasive front. The extent of the budding was then further classified as "high" if there were greater than or equal to 3 budding foci and as "low" if there were <3 budding foci or no budding focus.One hundred ninety-four AACs (80%) were found to be high-budding and 50 (20%) were low-budding. When the clinicopathologic features and survival of the 2 groups were compared, the AACs with high-budding had larger invasion size (19 mm vs. 13 mm; P<0.001), an unrecognizable/absent preinvasive component (57% vs. 82%; P<0.005), infiltrative growth (51% vs. 2%; P<0.001), nonintestinal-type histology (72% vs. 46%; P<0.001), worse differentiation (58% vs. 10%; P<0.001), more lymphatic (74% vs. 10%; P<0.001), and perineural invasion (28% vs. 2%; P<0.001); more lymph node metastasis (44% vs. 17%; P<0.001), higher T-stage (T3 and T4) (42% vs. 10%; P<0.001), and more aggressive behavior (mean survival: 50 mo vs. 32 mo; 3-year and 5-year survival rates: 93% vs. 41% and 68% vs. 24%, respectively; P<0.001). Furthermore, using a multivariable Cox regression model, tumor budding was found to be an independent predictor of survival (P=0.01), which impacts prognosis (hazard ratio: 2.6) even more than T-stage and lymph node metastasis (hazard ratio: 1.9 and 1.8, respectively).In conclusion, tumor budding is frequently encountered in AAC. High-budding is a strong independent predictor of overall survival, with a prognostic correlation stronger than the 2 established parameters: T-stage and lymph node metastasis. Therefore, budding should be incorporated into surgical pathology reports for AAC.

Clinical Significance of Lymph Node Micrometastasis in Ampullary Carcinoma

BACKGROUND

This study aimed to clarify the clinical significance of lymph node micrometastasis in ampullary carcinoma.

MATERIALS AND METHODS

Pancreaticoduodenectomy with regional lymphadenectomy was performed for 50 consecutive patients with ampullary carcinoma. A total of 1,283 regional lymph nodes (median, 25 per patient) were examined histologically for metastases. Overt metastasis was defined as metastasis detected during routine histologic examination with hematoxylin and eosin. Micrometastasis was defined as metastasis first detected by immunohistochemistry with an antibody against cytokeratins 7 and 8. The median follow-up period was 119 months after resection.

RESULTS

Overt metastasis was positive in 90 lymph nodes from 27 patients. Micrometastasis was positive in 33 lymph nodes from 12 patients, all of whom also had overt nodal metastases. Patients with nodal micrometastasis had a larger number of lymph nodes with overt metastasis (median, 3.5) than those without (median, 0; P<0.001). Overt metastasis to distant nodes (superior mesenteric nodes, para-aortic nodes) was more frequent (P=0.001 and P=0.038, respectively) in patients with nodal micrometastasis. Nodal micrometastasis was found to be a strong independent prognostic factor on univariate (P<0.0001) and multivariate (relative risk, 5.085; P=0.007) analyses. From among the 27 patients with overt nodal metastasis, the outcome after resection was significantly worse in the patients with nodal micrometastasis (median survival time of 11 months) than in those without (median survival time of 63 months; P=0.0009).

CONCLUSIONS

Immunohistochemically detected lymph node micrometastasis indicates intensive lymphatic spread, and thus adversely affects the survival of patients with ampullary carcinoma.

Long-term survival and recurrence patterns in ampullary cancer

OBJECTIVE

Ampullary cancers are associated with high resectability rates and good long-term survival. However, the small number of patients in various series has hampered survival analysis.

METHODS

One hundred thirteen patients with ampullary cancer underwent pancreaticoduodenectomy between 1989 and 2000, with 48% morbidity and 8% mortality. One hundred four patients who survived the operation were analyzed to identify predictors of long-term survival.

RESULTS

The overall median survival was 30.1 (1.6-140.0) months with actuarial 1-, 3-, and 5-year survival rates of 79%, 43%, and 33%, respectively. Lymph node metastasis (P = 0.002) and vascular invasion (P = 0.008) were 2 independent factors adversely influencing survival. Perioperative blood transfusion (P = 0.001) and vascular invasion (P = 0.026) were important factors predicting recurrent disease.

CONCLUSIONS

Lymph node metastasis and vascular invasion were 2 important factors, which adversely influenced survival in patients with ampullary cancer. Perioperative blood transfusion and vascular invasion were associated with recurrent disease.

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.

Patterns and predictors of failure after curative resections of carcinoma of the ampulla of Vater

BACKGROUND

Curative resection does not always equate with long-term survival. The aim was to identify patterns and predictors of failure and independent factors of prognosis after curative resection.

METHODS

Sixty-six patients with ampullary carcinoma who underwent surgical intervention were reviewed. Fifty-nine patients underwent pancreaticoduodenectomy. Cox regression analysis, log-rank test, Fisher exact test, or chi(2) test was used.

RESULTS

No patient died as a result of surgery; major complications occurred in three, and the 5-year survival rate after curative resection (n = 55) was 52.6%. Significant survival predictors were preoperative serum carcinoembryonic antigen level; gross tumor appearance; tumor, node, and tumor node metastasis stage; and microscopic lymphatic vessel and venous invasion in the primary tumor. Multivariate analysis demonstrated that lymphatic vessel invasion, tumor, and tumor node metastasis stage were significant independent prognostic factors. No patient experienced locoregional failure alone; all 24 relapsed patients had distant failure, and six of them had both. The liver was the most frequent metastatic organ, followed by nodes, peritoneum, lung, and bone. The carcinoembryonic antigen and carbohydrate antigen levels and lymphatic vessel and venous invasion were significant predictors of distant failure, and the mean time to relapse was 13 (range, 0.7-33) months.

CONCLUSIONS

Curative resection is associated with significant survival; however, effective systemic adjuvant therapy is needed to prevent distant failure for patients with elevated carcinoembryonic antigen and carbohydrate antigen levels or positive lymphatic vessel or venous invasion. A 3-year follow-up period would be necessary to document relapses.

Pancreaticoduodenectomy for Ampullary Carcinoma

Thirty-two consecutive patients with adenocarcinoma of the ampulla of Vater who had curative resection by pancreaticoduodenectomy were analyzed to determine the accuracy of preoperative investigations and factors that influenced survival. Obstructive jaundice was present in 31 patients, and most patients had pain and weight loss. Ultrasound was more useful than CT in identifying biliary obstruction, whereas CT was more accurate in demonstrating pancreatic duct dilatation and an ampullary mass. Endoscopic retrograde cholangiopancreatography with biopsy and brush cytology was the most accurate investigation and proved or was suspicious of carcinoma in all patients. Nineteen patients had postoperative complications, three of whom died (9.4%)—two of sepsis and one from aspiration following hematemesis. Actuarial 5-year survival was 46 per cent. Stage of disease was the strongest predictor of survival. All patients with T1 lesions are alive more than 5 years after resection. Patients with lymph node metastases had a significantly shorter survival than node-negative patients (P = 0.00087). Pancreaticoduodenectomy is advocated for ampullary carcinoma in good-risk patients, with the anticipation of prolonged survival in those with early (T1) lesions and node-negative disease.

Factors predictive of survival in ampullary carcinoma

OBJECTIVE

To review the recent Memorial Sloan-Kettering Cancer Center experience with adenocarcinoma of the ampulla of Vater and to identify clinicopathologic factors that have an impact on patient survival.

SUMMARY BACKGROUND DATA

The prognosis for patients with tumors of the ampulla of Vater is improved relative to other periampullary neoplasms. Identification of independent prognostic factors in ampullary tumors has been limited by small numbers of tumors and a lack of pathologic review.

METHODS

Data were collected prospectively for patients presenting with periampullary carcinomas to the Memorial Sloan-Kettering Cancer Center between October 15, 1983 and June 30, 1995. The correlation between clinicopathologic variables and survival of ampullary carcinoma was tested by the Kaplan-Meier method and log-rank test, and Cox proportional hazards regression. Survival of patients with periampullary adenocarcinomas was compared by the Kaplan-Meier method.

RESULTS

In 123 patients presenting with ampullary carcinoma, 101 tumors (82.1%) were resected. Factors significantly correlated with improved survival were resection (p < 0.01), and in resected tumors, negative nodes (p = 0.04) and margins (p = 0.02) independently predicted for improved survival. In periampullary tumors, the highest rates of resection and overall survival (median, 43.6 months) were found in ampullary carcinomas.

CONCLUSIONS

Factors predictive of improved survival in ampullary carcinoma include resection, negative margins, and negative nodes. Improved overall survival in ampullary relative to periampullary adenocarcinoma is due in part to a significantly higher rate of resection.

Importance of microperineural invasion as a prognostic factor in ampullary carcinoma

BACKGROUND

This was a study of the relation of clinicopathological factors to prognosis in 25 patients who had ampullary carcinoma resected.

METHODS

The 5-year survival rate was six of the 25 patients. The presence of microperineural invasion was sought and related to outcome.

RESULTS

Factors relating to prognosis included tumour gross appearance, diameter, pancreatic invasion and microperineural invasion. The 5-year survival rate of 14 patients with microperineural invasion was 3, significantly worse than the 7 in 11 without invasion (P = 0.002, univariate analysis). By multivariate analysis, microperineural invasion was the most important prognostic factor (P = 0.02). Type of tumour recurrence was similar to that in pancreatic carcinoma.

CONCLUSION

Pancreaticoduodenectomy, rather than local resection, is the procedure of choice in patients with ampullary carcinoma.

Importance of microperineural invasion as a prognostic factor in ampullary carcinoma

BACKGROUND

This was a study of the relation of clinicopathological factors to prognosis in 25 patients who had ampullary carcinoma resected.

METHODS

The 5-year survival rate was six of the 25 patients. The presence of microperineural invasion was sought and related to outcome.

RESULTS

Factors relating to prognosis included tumour gross appearance, diameter, pancreatic invasion and microperineural invasion. The 5-year survival rate of 14 patients with microperineural invasion was 3, significantly worse than the 7 in 11 without invasion (P = 0.002, univariate analysis). By multivariate analysis, microperineural invasion was the most important prognostic factor (P = 0.02). Type of tumour recurrence was similar to that in pancreatic carcinoma.

CONCLUSION

Pancreaticoduodenectomy, rather than local resection, is the procedure of choice in patients with ampullary carcinoma.

Number of lymph node metastases is significantly associated with survival in patients with radically resected carcinoma of the ampulla of Vater

Between 1983 and 1994, 66 patients with cancer of the ampulla of Vater were studied to identify prognostic factors and determine who might benefit from radical resection. Three patients (4.5 per cent) died after operation. Radical resection including lymphadenectomy resulted in potentially curative (R0) resection in 92 per cent. The rate of nodal positivity increased with tumour diameter. Patients with up to two positive lymph nodes had a more favourable prognosis than other patients (P < 0.001). Median survival time for all patients was 41 months; the 5-year survival rate was 35 per cent. Radical resection and lymphadenectomy should therefore be the treatment of choice for patients with tumours of the ampulla of Vater.