Staging for Ampullary Carcinoma: Is Less Actually More?

Adjuvant therapy may improve overall survival in high-risk periampullary adenocarcinomas patients - A match-pair analysis from a multi-institutional cohort study (The MIPPAP study)

BACKGROUND

The role of adjuvant therapy in resected periampullary adenocarcinomas is equivocal due to contrasting data and limited prospective trials.

METHODS

The Multicentre Indian Pancreatic & Periampullary Adenocarcinoma Project (MIPPAP), included data from 8 institutions across India. Of the 1679 pancreatic resections, 736 patients with T3/T4 and/or Node positive adenocarcinomas (considered as high risk for recurrence) were included for analysis. Three (adjuvant): one (observation) matching, using T3/T4 T staging, nodal positivity and ampullary subtype was performed by using the nearest neighbour matching method.

RESULTS

Of 736 patients eligible for inclusion, 621 patients were matched of which 458 patients received adjuvant therapy (AT) (predominantly gemcitabine-based) and 163 patients were observed (O). With a median follow-up of 42 months, there was a statistical difference in overall survival in favour of patients receiving AT as compared to those on observation [68.7 months vs. 61.1 months, Hazard ratio: 0.73 (95% CI: 0.54-0.97); p = 0.03]. Besides AT, presence of nodal involvement (median OS: 65.4 months vs not reached; p = 0.04) predicted for inferior OS.

CONCLUSIONS

The results of the match-pair analysis suggest that adjuvant therapy improves overall survival in periampullary adenocarcinomas at high risk of recurrence with a greater benefit in T3/T4, node-positive and ampullary subtypes.

Tumor Microenvironment Prognostic Risk and Its Association With MUC5AC in Ampullary Carcinoma

CONTEXT.—

The tumor-host interaction in the tumor microenvironment (TME) affects the prognosis of patients with malignant tumors. TME assessed via tumor budding (BD) and tumor-infiltrating lymphocyte (TIL) had a prognostic impact in patients with nonampullary small intestinal and colorectal carcinomas. In ampullary carcinoma (AC), MUC5AC was recently revealed as a significant prognosticator, but studies about the TME have not been conducted.

OBJECTIVE.—

To assess TME-based prognostic risk in AC.

DESIGN.—

We generated a collective TME risk index based on high-grade BD at the invasive front (BD3) and high density of stromal-TIL (>5%) in 64 surgically resected ACs. We evaluated its predictive values for overall survival (OS) and recurrence-free survival (RFS). We also investigated the relationship of TME to MUC5AC expression.

RESULTS.—

TME prognostic risk index was classified into low-risk (BDLow/TILHigh; 26 of 64; 41%), intermediate-risk (BDLow/TILLow or BDHigh/TILHigh; 23; 36%), and high-risk (BDHigh/TILLow; 15; 23%) groups. Higher TME prognostic risk was associated with higher tumor grade (P = .03), lymphovascular invasion (P = .05), and MUC5AC immunopositivity (P = .02). TME prognostic risk index displayed better predictive ability for both OS (53.9 versus 46.1 versus 42.2) and RFS (24.8 versus 16.9 versus 15.3) than BD or TIL alone. In multivariate analysis, TME prognostic risk index was an independent prognosticator for OS (P = .003) and RFS (P = .03).

CONCLUSIONS.—

TME risk index in combination with BD and TIL was a stronger predictor of prognostic risk stratification than either BD or TIL alone for both OS and RFS in patients with AC. MUC5AC may modulate the interaction between tumor cells and immunity toward enhancing invasiveness in TME.

[Ampullary neoplasms: surgical management]

BACKGROUND

Endoscopically unresectable adenomas and carcinomas of the greater duodenal papilla and ampulla of the bile duct necessitate surgical resection. The surgical techniques need to be adapted to local tumor expansion and patterns of infiltrative growth.

OBJECTIVE

Based on the current scientific data and developments this article provides an overview of indications for surgical resection, surgical strategies and dissection techniques for ampullary tumors.

MATERIAL AND METHODS

A review of the literature addressing surgical management of ampullary neoplasms was performed. Current evidence and recommendations were summarized.

RESULTS AND CONCLUSION

Ampullary neoplasms can originate from intestinal or pancreatobiliary epithelial cells. Differentiating these histopathological subtypes is of crucial relevance concerning therapeutic strategy and prognosis in ampullary adenocarcinoma. All ampullary adenomas carry a risk of malignant transformation and therefore justify resection. Endoscopic papillectomy, surgical transduodenal ampullectomy and partial pancreatoduodenectomy are suitable resection techniques for ampullary adenoma. The selection of the procedure depends on intraductal tumor extension, tumor size and degree of dysplasia. Ampullary carcinoma is managed by upfront pancreatoduodenectomy comprising systematic lymph node dissection and level II dissection of the mesopancreas. Lymph node status and perineural sheath invasion are key prognostic factors concerning overall survival.

The 8th Edition American Joint Committee on Cancer Staging for Hepato-pancreato-biliary Cancer: A Review and Update

CONTEXT.—

Cancer staging provides critical information for patients and treating physicians to battle against cancer, predict prognosis, and guide treatment decisions. The American Joint Committee on Cancer (AJCC) staging system uses a tumor, node, metastasis (TNM) scoring algorithm and is the foremost classification system for adult cancers. This system is updated every 6 to 8 years to allow sufficient time for implementation of changes and for relevant examination and discussion of data validating those changes in staging.

OBJECTIVE.—

To review the updates in the 8th edition American Joint Committee on Cancer staging system on hepato-pancreato-biliary cancer.

DATA SOURCES.—

Literature review.

CONCLUSIONS.—

The 8th edition, published in 2016 and implemented on January 1, 2018, has been in use for approximately 3 years. Compared with the 7th edition, some of the changes are quite radical. This review aims to provide a summary of the changes/updates of the 8th edition with focus on hepato-pancreato-biliary cancers, and evaluate its performance through literature review.

Benefits of 18F-FDG PET/CT for the preoperative characterisation or staging of disease in the ampullary and duodenal papillary

OBJECTIVES

Diagnosing ampullary and duodenal papillary carcinomas (ADPCs) is challenging. In the present study, we investigated the application value of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in the preoperative evaluation of these tumours.

METHODS

¹⁸F-FDG PET/CT images of 58 patients with ADPC and 28 patients with benign disease were retrospectively analysed. Preoperative ¹⁸F-FDG PET/CT was compared to contrast-enhanced (CE) CT and magnetic resonance imaging (MRI) in terms of diagnostic efficacy, certainty, staging and impact on treatment decisions.

RESULTS

¹⁸F-FDG PET/CT showed a high sensitivity (93.1%) and a medium specificity (78.6%) for diagnosing ADPC. Compared to CE CT/MRI, ¹⁸F-FDG PET/CT had a higher diagnostic specificity (78.6 vs. 35.7%, p = 0.001) but a similar sensitivity (93.1 vs. 89.6%, p = 0.508). ¹⁸F-FDG PET/CT provided a much higher diagnostic certainty than CE CT/MRI (definite reports, 88.4 vs. 50.0%, χ² = 29.698, p < 0.001), especially for small tumours ≤ 1.5 cm, and found distant metastases in five patients. The ¹⁸F-FDG PET/CT findings affected the treatment plans of 11 patients and improved the confidence in the diagnoses of 28 patients.

CONCLUSIONS

The present study demonstrated that ¹⁸F-FDG PET/CT can supplement CE CT/MRI to provide a more accurate diagnosis for ADPC, and thus, plays an important role in the decision-making process before complicated pancreaticoduodenectomy procedures.

KEY POINTS

• It is a challenge for CT and MRI to diagnose ampullary carcinoma, especially at their early stage. • Our study demonstrated that the benefit of PET/CT was improving the diagnostic confidence for ampullary and duodenal papillary carcinomas. • ¹⁸F-FDG PET/CT can change the treatment decision for ampullary and duodenal papillary carcinomas.