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Villaseñor-Echavarri R, Melchor-Ruan J, Aranda-Audelo M, Arredondo-Saldaña G, Volkow-Fernandez P, Manzano-Robleda MDC, Padilla-Rosciano AE, Vilar-Compte D. Surgical site infection following pancreaticoduodenectomy in a referral cancer center in Mexico. Hepatobiliary Pancreat Dis Int 2024; 23:502-508. [PMID: 37076378 DOI: 10.1016/j.hbpd.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 04/06/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy is the standard treatment for resectable periampullary cancer. Surgical site infections (SSI) are common complications with increased morbidity. The study aimed to describe the prevalence, risk factors, microbiology, and outcomes of SSI among patients undergoing pancreaticoduodenectomy. METHODS We conducted a retrospective study in a referral cancer center between January 2015 and June 2021. We analyzed baseline patient characteristics and SSI occurrence. Culture results and susceptibility patterns were described. Multivariate logistic regression was used to determine risk factors, proportional hazards model to evaluate mortality, and Kaplan-Meier analysis to assess long-term survival. RESULTS A total of 219 patients were enrolled in the study; 101 (46%) developed SSI. Independent factors for SSI were diabetes mellitus, preoperative albumin level, biliary drainage, biliary prostheses, and clinically relevant postoperative pancreatic fistula. The main pathogens were Enterobacteria and Enterococci. Multidrug-resistance rate in SSI was high but not associated with increased mortality. Infected patients had higher odds of sepsis, longer hospital stay and intensive care unit stay, and readmission rate. Neither 30-day mortality nor long-term survival was significantly different between infected and non-infected patients. CONCLUSIONS SSI prevalence among patients undergoing pancreaticoduodenectomy was high and largely caused by resistant microorganisms. Most risk factors were related to preoperative instrumentation of the biliary tree. SSI was associated with greater risk of unfavorable outcomes; however, survival was unaffected.
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Affiliation(s)
- Rodrigo Villaseñor-Echavarri
- Department of Infectious Diseases, Instituto Nacional de Cancerología, Av. San Fernando 22, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico; School of Medicine, Universidad Panamericana, Augusto Rodin No. 498, Insurgentes Mixcoac, Benito Juárez, Mexico City, Mexico
| | - Javier Melchor-Ruan
- Department of Digestive Tube and Hepatopancreatobiliary Tumors, Instituto Nacional de Cancerología, Av. San Fernando 22, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico
| | - Mercedes Aranda-Audelo
- Department of Infectious Diseases, Instituto Nacional de Cancerología, Av. San Fernando 22, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico; Department of Infectious Diseases, Hospital Manuel Gea González, Calz. de Tlalpan 4800, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico
| | - Gabriela Arredondo-Saldaña
- Department of Digestive Tube and Hepatopancreatobiliary Tumors, Instituto Nacional de Cancerología, Av. San Fernando 22, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico
| | - Patricia Volkow-Fernandez
- Department of Infectious Diseases, Instituto Nacional de Cancerología, Av. San Fernando 22, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico
| | - Maria Del Carmen Manzano-Robleda
- Gastrointestinal and Endoscopy Department, Instituto Nacional de Cancerología, Av. San Fernando 22, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico
| | - Alejandro E Padilla-Rosciano
- Department of Digestive Tube and Hepatopancreatobiliary Tumors, Instituto Nacional de Cancerología, Av. San Fernando 22, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico
| | - Diana Vilar-Compte
- Department of Infectious Diseases, Instituto Nacional de Cancerología, Av. San Fernando 22, Belisario Domínguez Secc 16, Tlalpan, Mexico City, Mexico.
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Jang DK, Kim SJ, Chung HH, Lee JM, Yoon SB, Lee JC, Shin DW, Hwang JH, Jung MK, Lee YS, Lee HS, Park JK. Outcomes of Palliative Chemotherapy for Ampulla of Vater Adenocarcinoma: A Multicenter Cohort Study. Gut Liver 2024; 18:729-736. [PMID: 38130162 PMCID: PMC11249934 DOI: 10.5009/gnl230164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 09/07/2023] [Accepted: 10/11/2023] [Indexed: 12/23/2023] Open
Abstract
Background/Aims : Palliative chemotherapy (PC) is not standardized for patients with advanced ampulla of Vater adenocarcinoma (AA). This multicenter, retrospective study evaluated first-line PC outcomes in patients with AA. Methods : Patients diagnosed with AA between January 2010 and December 2020 who underwent PC were enrolled from 10 institutions. Overall survival (OS) and progression-free survival (PFS) according to the chemotherapy regimen were analyzed. Results : Of 255 patients (mean age, 64.0±10.0 years; male, 57.6%), 14 (5.5%) had locally advanced AA and 241 (94.5%) had metastatic AA. Gemcitabine plus cisplatin (GP) was administered as first-line chemotherapy to 192 patients (75.3%), whereas capecitabine plus oxaliplatin (CAPOX) was administered to 39 patients (15.3%). The median OS of all patients was 19.8 months (95% confidence interval [CI], 17.3 to 22.3), and that of patients who received GP and CAPOX was 20.4 months (95% CI, 17.2 to 23.6) and 16.0 months (95% CI, 11.2 to 20.7), respectively. The median PFS of GP and CAPOX patients were 8.4 months (95% CI, 7.1 to 9.7) and 5.1 months (95% CI, 2.5 to 7.8), respectively. PC for AA demonstrated improved median outcomes in both OS and PFS compared to conventional bile duct cancers that included AA. Conclusions : While previous studies have shown mixed prognostic outcomes when AA was analyzed together with other biliary tract cancers, our study unveils a distinct clinical prognosis specific to AA on a large scale with systemic anticancer therapy. These findings suggest that AA is a distinct type of tumor, different from other biliary tract cancers, and AA itself could be expected to have a favorable response to PC.
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Affiliation(s)
- Dong Kee Jang
- Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - So Jeong Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Hwe Hoon Chung
- Division of Gastroenterology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Min Lee
- Department of Internal Medicine, Korea University Anam Hospital, Seoul, Korea
| | - Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong-Chan Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Dong Woo Shin
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Min Kyu Jung
- Division of Gastroenterology, Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yoon Suk Lee
- Division of Gastroenterology, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Hee Seung Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joo Kyung Park
- Division of Gastroenterology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Sakuma M, Maeda A, Takayama Y, Takahashi T, Aoyama H, Takahashi D, Hosoi T. Laparoscopic versus open pancreaticoduodenectomy for ampullary cancer: A retrospective study. Asian J Endosc Surg 2024; 17:e13350. [PMID: 38986523 DOI: 10.1111/ases.13350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/16/2024] [Accepted: 06/19/2024] [Indexed: 07/12/2024]
Abstract
INTRODUCTION Studies comparing laparoscopic pancreaticoduodenectomy (LPD) with open pancreaticoduodenectomy (OPD) for ampullary carcinoma (AC) are limited. This study aimed to compare short- and long-term outcomes between LPD and OPD for AC. METHODS This study included patients with AC who underwent pancreaticoduodenectomy (PD) with curative intention at Ogaki Municipal Hospital from April 2008 to March 2023. RESULTS Fifty-five patients underwent LPD (n = 26) or OPD (n = 29). There were no significant differences in the demographics between the two groups. The LPD group had a significantly longer operative time (268 vs. 225 min), less blood loss (125 vs. 450 mL), and shorter postoperative hospital stay (18 vs. 23 days) than the OPD group. There was no significant difference in the morbidity ratio. Fewer lymph nodes were harvested in the LPD group than OPD group (9.5 vs. 16.0), but there were no significant differences in lymph node metastasis or pathological stages. There were no significant differences in overall survival (OS) or recurrence-free survival (RFS). The 3- and 5-year OS rates in the LPD group and the OPD group were 63.0% and 54%, 64.8%, and 61.2%, respectively. The 3- and 5-year RFS rates were 57.4% and 57.4%, 58.1%, and 54.4%, respectively. CONCLUSIONS LPD for AC had short- and long-term outcomes comparable with those of OPD. LPD could be considered the standard treatments for AC because of less blood loss and a shorter hospital stay.
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Affiliation(s)
| | - Atsuyuki Maeda
- Department of Surgery, Ogaki Municipal Hospital, Gifu, Japan
| | - Yuichi Takayama
- Department of Surgery, Ogaki Municipal Hospital, Gifu, Japan
| | | | - Hiroki Aoyama
- Department of Surgery, Ogaki Municipal Hospital, Gifu, Japan
| | | | - Takahiro Hosoi
- Department of Surgery, Ogaki Municipal Hospital, Gifu, Japan
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4
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Uijterwijk BA, Lemmers DH, Ghidini M, Wilmink JW, Zaniboni A, Fusai GK, Zerbi A, Koerkamp BG, Luyer M, Ghorbani P, Salvia R, White S, Ielpo B, Goh BKP, Boggi U, Kazemier G, House MG, Mavroeidis VK, Björnsson B, Mazzola M, Serradilla M, Korkolis D, Alseidi A, Roberts KJ, Soonawalla Z, Pessaux P, Fisher WE, Koek S, Kent TS, Vladimirov M, Bolm L, Jamieson N, Dalla Valle R, Kleeff J, Mazzotta A, Suarez Muñoz MA, Cabús SS, Ball CG, Berger AC, Ferarri C, Besselink MG, Hilal MA. The road to tailored adjuvant chemotherapy for all four non-pancreatic periampullary cancers: An international multimethod cohort study. Br J Cancer 2024; 131:117-125. [PMID: 38806725 PMCID: PMC11231293 DOI: 10.1038/s41416-024-02692-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 03/25/2024] [Accepted: 04/10/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Despite differences in tumour behaviour and characteristics between duodenal adenocarcinoma (DAC), the intestinal (AmpIT) and pancreatobiliary (AmpPB) subtype of ampullary adenocarcinoma and distal cholangiocarcinoma (dCCA), the effect of adjuvant chemotherapy (ACT) on these cancers, as well as the optimal ACT regimen, has not been comprehensively assessed. This study aims to assess the influence of tailored ACT on DAC, dCCA, AmpIT, and AmpPB. PATIENTS AND METHODS Patients after pancreatoduodenectomy for non-pancreatic periampullary adenocarcinoma were identified and collected from 36 tertiary centres between 2010 - 2021. Per non-pancreatic periampullary tumour type, the effect of adjuvant chemotherapy and the main relevant regimens of adjuvant chemotherapy were compared. The primary outcome was overall survival (OS). RESULTS The study included a total of 2866 patients with DAC (n = 330), AmpIT (n = 765), AmpPB (n = 819), and dCCA (n = 952). Among them, 1329 received ACT, and 1537 did not. ACT was associated with significant improvement in OS for AmpPB (P = 0.004) and dCCA (P < 0.001). Moreover, for patients with dCCA, capecitabine mono ACT provided the greatest OS benefit compared to gemcitabine (P = 0.004) and gemcitabine - cisplatin (P = 0.001). For patients with AmpPB, no superior ACT regime was found (P > 0.226). ACT was not associated with improved OS for DAC and AmpIT (P = 0.113 and P = 0.445, respectively). DISCUSSION Patients with resected AmpPB and dCCA appear to benefit from ACT. While the optimal ACT for AmpPB remains undetermined, it appears that dCCA shows the most favourable response to capecitabine monotherapy. Tailored adjuvant treatments are essential for enhancing prognosis across all four non-pancreatic periampullary adenocarcinomas.
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Affiliation(s)
- Bas A Uijterwijk
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy.
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands.
- Cancer Center Amsterdam, Amsterdam, the Netherlands.
| | - Daniël H Lemmers
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Michele Ghidini
- Oncology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Johanna W Wilmink
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Alberto Zaniboni
- Department of Medical Oncology, Fondazione Poliambulanza, Brescia, Italy
| | | | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Misha Luyer
- Catharina Hospital Eindhoven, Department of Surgery, Eindhoven, Netherlands
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Roberto Salvia
- Department of Surgery, University Hospital of Verona, Verona, Italy
| | - Steven White
- Department of Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | - Brian K P Goh
- Singapore General Hospital, Department of Hepatopancreatobiliary and Transplant Surgery, Duke-National University of Singapore, Singapore, Singapore
| | - Ugo Boggi
- Department of Surgery, Pisa University Hospital, Pisa, Italy
| | - Geert Kazemier
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Amsterdam UMC, location VUmc, Amsterdam, the Netherlands
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Vasileios K Mavroeidis
- Department of Academic Surgery, The Royal Marsden Hospital, London, UK
- Department of Hepatobiliary and Pancreatic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Bergthor Björnsson
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Michele Mazzola
- Division of Oncologic and Mini-invasive General Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Mario Serradilla
- Department of Surgery, Miguel Servet University Hospital, Zargosa, Spain
| | - Dimitris Korkolis
- Department of Surgery, Hellenic Anticancer Hospital 'Saint Savvas', Athens, Greece
| | - Adnan Alseidi
- Department of Surgery, Virginia Mason, Seattle, WA, USA
| | - Keith J Roberts
- Faculty of medicine, University of Birmingham, Birmingham, UK
| | - Zahir Soonawalla
- Department of Hepatobiliary and Pancreatic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Patrick Pessaux
- Hepatobiliary and Pancreatic Surgical Unit, Nouvel Hôpital Civil (NHC), Strasbourg, France
| | | | - Sharnice Koek
- Fiona Stanley Hospital, Department of Surgery, Perth, WA, Australia
| | - Tara S Kent
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Miljana Vladimirov
- Department of General Surgery, Paracelsus Medical University Nürnberg, 90419, Nürnberg, Germany
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, campus Lübeck, Lübeck, Germany
| | - Nigel Jamieson
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Jorg Kleeff
- Department of Surgery, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Alessandro Mazzotta
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
| | | | | | - Chad G Ball
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Adam C Berger
- Department of Surgery, Jefferson Medical College, Philadelphia, USA
| | - Clarissa Ferarri
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy.
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5
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Uijterwijk BA, Lemmers DH, Ghidini M, Wilmink H, Zaniboni A, Salvia R, Kito Fusai G, Groot Koerkamp B, Koek S, Ghorbani P, Zerbi A, Nappo G, Luyer M, Goh BKP, Roberts KJ, Boggi U, Mavroeidis VK, White S, Kazemier G, Björnsson B, Serradilla-Martín M, House MG, Alseidi A, Ielpo B, Mazzola M, Jamieson N, Wellner U, Soonawalla Z, Cabús SS, Dalla Valle R, Pessaux P, Vladimirov M, Kent TS, Tang CN, Fisher WE, Kleeff J, Mazzotta A, Suarez Muñoz MA, Berger AC, Ball CG, Korkolis D, Bannone E, Ferarri C, Besselink MG, Abu Hilal M. The Five Periampullary Cancers, not Just Different Siblings but Different Families: An International Multicenter Cohort Study. Ann Surg Oncol 2024:10.1245/s10434-024-15555-8. [PMID: 38888860 DOI: 10.1245/s10434-024-15555-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 05/21/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Cancer arising in the periampullary region can be anatomically classified in pancreatic ductal adenocarcinoma (PDAC), distal cholangiocarcinoma (dCCA), duodenal adenocarcinoma (DAC), and ampullary carcinoma. Based on histopathology, ampullary carcinoma is currently subdivided in intestinal (AmpIT), pancreatobiliary (AmpPB), and mixed subtypes. Despite close anatomical resemblance, it is unclear how ampullary subtypes relate to the remaining periampullary cancers in tumor characteristics and behavior. METHODS This international cohort study included patients after curative intent resection for periampullary cancer retrieved from 44 centers (from Europe, United States, Asia, Australia, and Canada) between 2010 and 2021. Preoperative CA19-9, pathology outcomes and 8-year overall survival were compared between DAC, AmpIT, AmpPB, dCCA, and PDAC. RESULTS Overall, 3809 patients were analyzed, including 348 DAC, 774 AmpIT, 848 AmpPB, 1,036 dCCA, and 803 PDAC. The highest 8-year overall survival was found in patients with AmpIT and DAC (49.8% and 47.9%), followed by AmpPB (34.9%, P < 0.001), dCCA (26.4%, P = 0.020), and finally PDAC (12.9%, P < 0.001). A better survival was correlated with lower CA19-9 levels but not with tumor size, as DAC lesions showed the largest size. CONCLUSIONS Despite close anatomic relations of the five periampullary cancers, this study revealed differences in preoperative blood markers, pathology, and long-term survival. More tumor characteristics are shared between DAC and AmpIT and between AmpPB and dCCA than between the two ampullary subtypes. Instead of using collective definitions for "periampullary cancers" or anatomical classification, this study emphasizes the importance of individual evaluation of each histopathological subtype with the ampullary subtypes as individual entities in future studies.
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Affiliation(s)
- Bas A Uijterwijk
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Daniël H Lemmers
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Michele Ghidini
- Department of Medical Oncology, Policlinico di Milano, Fondazione IRCCS Ca' Granda, Milano, Italy
| | - Hanneke Wilmink
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Alberto Zaniboni
- Department of Medical Oncology, Fondazione Poliambulanza, Brescia, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Sharnice Koek
- Department of Surgery, Fiona Stanley Hospital, Perth, Australia
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Gennaro Nappo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Misha Luyer
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Duke-National University of Singapore, Singapore, Singapore
| | - Keith J Roberts
- Faculty of Medicine, University of Birmingham, Birmingham, UK
| | - Ugo Boggi
- Department of Surgery, Pisa University Hospital, Pisa, Italy
| | - Vasileios K Mavroeidis
- Department of Academic Surgery, The Royal Marsden Hospital, London, UK
- Department of Hepatobiliary and Pancreatic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Steven White
- Department of Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Geert Kazemier
- Department of Surgery, Amsterdam UMC, VUmc, Amsterdam, The Netherlands
| | | | | | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Adnan Alseidi
- Department of Surgery, Virginia Mason, Seattle, WA, USA
| | | | - Michele Mazzola
- Division of Oncologic and Mini-invasive General Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Nigel Jamieson
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Ulrich Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Zahir Soonawalla
- Department of Hepatobiliary and Pancreatic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - Patrick Pessaux
- Hepatobiliary and Pancreatic Surgical Unit, Nouvel Hôpital Civil (NHC), Strasbourg, France
| | - Miljana Vladimirov
- Department of Surgery, Paracelsus Medical Private University (PMU, Nuremberg, Germany
| | - Tara S Kent
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Chung N Tang
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - William E Fisher
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Jorg Kleeff
- Department of Surgery, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Alessandro Mazzotta
- Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
| | | | - Adam C Berger
- Department of Surgery, Jefferson Medical College, Philadelphia, PA, USA
| | - Chad G Ball
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Elisa Bannone
- Department of Hepato-Biliary and Pancreatic Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Clarissa Ferarri
- Department of Hepato-Biliary and Pancreatic Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mohammed Abu Hilal
- Department of Hepato-Biliary and Pancreatic Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy.
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6
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Sun CY, Zhang XJ, Li Z, Fei H, Li ZF, Zhao DB. Preoperative prognostic nutritional index predicts long-term outcomes of patients with ampullary adenocarcinoma after curative pancreatoduodenectomy. World J Gastrointest Surg 2024; 16:1291-1300. [PMID: 38817277 PMCID: PMC11135320 DOI: 10.4240/wjgs.v16.i5.1291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 04/10/2024] [Accepted: 04/24/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND The prognostic nutritional index (PNI), a marker of immune-nutrition balance, has predictive value for the survival and prognosis of patients with various cancers. AIM To explore the clinical significance of the preoperative PNI on the prognosis of ampullary adenocarcinoma (AC) patients who underwent curative pancreaticoduodenectomy. METHODS The data concerning 233 patients diagnosed with ACs were extracted and analyzed at our institution from January 1998 to December 2020. All patients were categorized into low and high PNI groups based on the cutoff value determined by receiver operating characteristic curve analysis. We compared disease-free survival (DFS) and overall survival (OS) between these groups and assessed prognostic factors through univariate and multivariate analyses. RESULTS The optimal cutoff value for the PNI was established at 45.3. Patients with a PNI ≥ 45.3 were categorized into the PNI-high group, while those with a PNI < 45.3 were assigned to the PNI-low group. Patients within the PNI-low group tended to be of advanced age and exhibited higher levels of aspartate transaminase and total bilirubin and a lower creatinine level than were those in the PNI-high group. The 5-year OS rates for patients with a PNI ≥ 45.3 and a PNI < 45.3 were 61.8% and 43.4%, respectively, while the 5-year DFS rates were 53.5% and 38.3%, respectively. Patients in the PNI- low group had shorter OS (P = 0.006) and DFS (P = 0.012). In addition, multivariate analysis revealed that the PNI, pathological T stage and pathological N stage were found to be independent prognostic factors for both OS and DFS. CONCLUSION The PNI is a straightforward and valuable marker for predicting long-term survival after pancreatoduodenectomy. The PNI should be incorporated into the standard assessment of patients with AC.
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Affiliation(s)
- Chong-Yuan Sun
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xiao-Jie Zhang
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Zheng Li
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - He Fei
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Ze-Feng Li
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Dong-Bing Zhao
- Department of Pancreatic and Gastric Surgical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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7
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Lee S, Park SJ, Shin K, Hong TH, Kim IH, Lee MA. Real-world efficacy and safety of capecitabine with oxaliplatin in patients with advanced adenocarcinoma of the ampulla of Vater. BMC Cancer 2024; 24:634. [PMID: 38783256 PMCID: PMC11119299 DOI: 10.1186/s12885-024-12398-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Adenocarcinoma of the ampulla of Vater (AoV) is one of the rare periampullary cancers, and due to its anatomical location, it is categorized into various histologic subtypes. Its rarity and diversity pose challenges in treatment decision-making for patients with advanced AoV carcinoma. This study investigated the efficacy and safety of the combined regimen of capecitabine and oxaliplatin (CAPOX) in a real-world clinical setting. METHODS This investigation encompassed patients with advanced AoV carcinoma who underwent CAPOX treatment. Histologic phenotypes were identified through a combination of histopathological analysis and protein expression markers, including MUC1, CDX2, CK20, and MUC2. The correlation between histopathological determinants and survival outcomes was explored, in addition to an evaluation of the safety profile of CAPOX therapy. RESULTS From January 2010 to June 2023, 42 patients received CAPOX. Of these, 14 patients (33.3%) had not received any prior palliative chemotherapy, while 28 patients (66.7%) had undergone one prior line of chemotherapy. At a median follow up of 9.0 months, the median progression-free survival (PFS) was 4.38 months (95% CI, 2.78-5.69) and the median overall survival (OS) was 9.57 months (95% CI 7.56-11.6). The objective response and disease control rates were 38.1% and 61.9%, respectively. Patients who received CAPOX as a second-line treatment had poorer PFS (HR = 2.62; 95% CI, 1.49-4.90, p = 0.003) and OS (HR = 2.82, 95% CI, 1.47-5.38, p = 0.001) compared to those who received CAPOX as a first-line chemotherapy. There were no statistically significant differences in PFS (p = 0.185) and OS (p = 0.097) between groups based on histologic subtypes. Neutropenia (14.3%) emerged as the predominant grade 3-4 toxicity. Notably, treatment cessation occurred in select instances owing to grade 3 fatigue (9.5%) and peripheral neuropathy (9.5%). CONCLUSIONS This study confirmed the therapeutic efficacy and safety of CAPOX in a real-world setting, consistent with prior phase II trial results. While CAPOX proved feasible for advanced AoV carcinoma regardless of histologic subtype, its reduced effectiveness in second-line settings necessitates further research to determine its optimal palliative use.
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Affiliation(s)
- Seunghwan Lee
- Division of Medical Oncology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Secho-gu, Seoul, Korea
| | - Se Jun Park
- Division of Medical Oncology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Secho-gu, Seoul, Korea
- Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kabsoo Shin
- Division of Medical Oncology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Secho-gu, Seoul, Korea
- Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Ho Hong
- Department of General Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In-Ho Kim
- Division of Medical Oncology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Secho-gu, Seoul, Korea
- Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung Ah Lee
- Division of Medical Oncology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Secho-gu, Seoul, Korea.
- Cancer Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Stålberg SM, Silwal-Pandit L, Bastani NE, Nebdal DJH, Lingjærde OC, Skålhegg BS, Kure EH. Preoperative profiles of plasma amino acids and derivatives distinguish periampullary cancer and benign disease. BMC Cancer 2024; 24:555. [PMID: 38702616 PMCID: PMC11067218 DOI: 10.1186/s12885-024-12320-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 04/29/2024] [Indexed: 05/06/2024] Open
Abstract
Periampullary cancers, including pancreatic ductal adenocarcinoma, ampullary-, cholangio-, and duodenal carcinoma, are frequently diagnosed in an advanced stage and are associated with poor overall survival. They are difficult to differentiate from each other and challenging to distinguish from benign periampullary disease preoperatively. To improve the preoperative diagnostics of periampullary neoplasms, clinical or biological markers are warranted.In this study, 28 blood plasma amino acids and derivatives from preoperative patients with benign (N = 45) and malignant (N = 72) periampullary disease were analyzed by LC-MS/MS.Principal component analysis and consensus clustering both separated the patients with cancer and the patients with benign disease. Glutamic acid had significantly higher plasma expression and 15 other metabolites significantly lower plasma expression in patients with malignant disease compared with patients having benign disease. Phenylalanine was the only metabolite associated with improved overall survival (HR = 0.50, CI 0.30-0.83, P < 0.01).Taken together, plasma metabolite profiles from patients with malignant and benign periampullary disease were significantly different and have the potential to distinguish malignant from benign disease preoperatively.
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Affiliation(s)
- Stina Margrethe Stålberg
- Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
- Department of Natural Sciences and Environmental Health, University of South-Eastern Norway, Bø i Telemark, Norway
- Department of Pathology, Skien Hospital, Vestfold og Telemark, Norway
| | - Laxmi Silwal-Pandit
- Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
| | - Nasser Ezzatkhah Bastani
- Division for Molecular Nutrition, Institute for Basic Medical Sciences, University of Oslo, Oslo, Norway
| | | | - Ole Christian Lingjærde
- Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway
- Department of Computer Science, University of Oslo, Oslo, Norway
| | - Bjørn Steen Skålhegg
- Division for Molecular Nutrition, Institute for Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Elin Hegland Kure
- Department of Cancer Genetics, Institute for Cancer Research, Oslo University Hospital, Oslo, Norway.
- Department of Natural Sciences and Environmental Health, University of South-Eastern Norway, Bø i Telemark, Norway.
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9
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Kuesters S, Sundheimer J, Wittel UA, Chikhladze S, Fichtner-Feigl S, Biesel EA. Pancreatic head resection for carcinoma of the ampulla vateri - better long-term prognosis, but more postoperative complications. Langenbecks Arch Surg 2024; 409:129. [PMID: 38632147 PMCID: PMC11024026 DOI: 10.1007/s00423-024-03319-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/10/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Pancreatoduodenectomies are complex surgical procedures with a considerable morbidity and mortality even in high-volume centers. However, postoperative morbidity and long-term oncological outcome are not only affected by the surgical procedure itself, but also by the underlying disease. The aim of our study is an analysis of pancreatoduodenectomies for patients with pancreatic ductal adenocarcinoma (PDAC) and ampullary carcinoma (CAMP) concerning postoperative complications and long-term outcome in a tertiary hospital in Germany. METHODS The perioperative and oncological outcome of 109 pancreatic head resections performed for carcinoma of the ampulla vateri was compared to the outcome of 518 pancreatic head resections for pancreatic ductal adenocarcinoma over a 20 year-period from January 2002 until December 2021. All operative procedures were performed at the University Hospital Freiburg, Germany. Patient data was analyzed retrospectively, using a prospectively maintained SPSS database. Propensity score matching was performed to adjust for differences in surgical and reconstruction technique. Primary outcome of our study was long-term overall survival, secondary outcomes were postoperative complications and 30-day postoperative mortality. Postoperative complications like pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH) and delayed gastric emptying (DGE) were graded following current international definitions. Survival was estimated using Kaplan Meier curves and log-rank tests. A p-value < 0.05 was considered statistically significant. RESULTS Operation time was significantly longer in PDAC patients (432 vs. 391 min, p < 0.001). The rate of portal vein resections was significantly higher in PDAC patients (p < 0.001). In CAMP patients, a pancreatogastrostomy as reconstruction technique was performed more frequently compared to PDAC patients (48.6% vs. 29.9%, p < 0.001) and there was a trend towards more laparoscopic surgeries in CAMP patients (p = 0.051). After propensity score matching, we found no difference in DGE B/C and PPH B/C (p = 0.389; p = 0.517), but a significantly higher rate of clinically relevant pancreatic fistula (CR-POPF) in patients with pancreatoduodenectomies due to ampullary carcinoma (30.7% vs. 16.8%, p < 0.001). Long-term survival was significantly better in CAMP patients (42 vs. 24 months, p = 0.003). CONCLUSION Patients with pancreatoduodenectomies due to ampullary carcinomas showed a better long-term oncological survival, by reason of the better prognosis of this tumor entity. However, these patients often needed a more elaborated postoperative treatment due to the higher rate of clinically relevant pancreatic fistula in this group.
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Affiliation(s)
- Simon Kuesters
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
- Current address: Clinic for General-, Visceral- and Vascular Surgery, Fürst-Stirum-Klinik, Bruchsal, Germany
| | - Johanna Sundheimer
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Uwe A Wittel
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Sophia Chikhladze
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Esther A Biesel
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany.
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10
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Chen R, Zhu L, Zhang Y, Cui D, Chen R, Guo H, Peng L, Xiao C. Predicting the unpredictable: a robust nomogram for predicting recurrence in patients with ampullary carcinoma. BMC Cancer 2024; 24:212. [PMID: 38360582 PMCID: PMC10870520 DOI: 10.1186/s12885-024-11960-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/05/2024] [Indexed: 02/17/2024] Open
Abstract
OBJECTIVE To screen the risk factors affecting the recurrence risk of patients with ampullary carcinoma (AC)after radical resection, and then to construct a model for risk prediction based on Lasso-Cox regression and visualize it. METHODS Clinical data were collected from 162 patients that received pancreaticoduodenectomy treatment in Hebei Provincial Cancer Hospital from January 2011 to January 2022. Lasso regression was used in the training group to screen the risk factors for recurrence. The Lasso-Cox regression and Random Survival Forest (RSF) models were compared using Delong test to determine the optimum model based on the risk factors. Finally, the selected model was validated using clinical data from the validation group. RESULTS The patients were split into two groups, with a 7:3 ratio for training and validation. The variables screened by Lasso regression, such as CA19-9/GGT, AJCC 8th edition TNM staging, Lymph node invasion, Differentiation, Tumor size, CA19-9, Gender, GPR, PLR, Drinking history, and Complications, were used in modeling with the Lasso-Cox regression model (C-index = 0.845) and RSF model (C-index = 0.719) in the training group. According to the Delong test we chose the Lasso-Cox regression model (P = 0.019) and validated its performance with time-dependent receiver operating characteristics curves(tdROC), calibration curves, and decision curve analysis (DCA). The areas under the tdROC curves for 1, 3, and 5 years were 0.855, 0.888, and 0.924 in the training group and 0.841, 0.871, and 0.901 in the validation group, respectively. The calibration curves performed well, as well as the DCA showed higher net returns and a broader range of threshold probabilities using the predictive model. A nomogram visualization is used to display the results of the selected model. CONCLUSION The study established a nomogram based on the Lasso-Cox regression model for predicting recurrence in AC patients. Compared to a nomogram built via other methods, this one is more robust and accurate.
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Affiliation(s)
- Ruiqiu Chen
- Medical School of Chinese PLA, Beijing, China
- Faculty of Hepato-Biliary-Pancreatic Surgery, the First Medical Centre, Chinese People s Liberation Army (PLA) General Hospital, Beijing, China
- The First School of Clinical Medicine, Lanzhou University, No. 1, Donggangxi Rd, Chengguan District, 730000, Lanzhou, Gansu, China
| | - Lin Zhu
- Medical School of Chinese PLA, Beijing, China
- Faculty of Hepato-Biliary-Pancreatic Surgery, the First Medical Centre, Chinese People s Liberation Army (PLA) General Hospital, Beijing, China
- The First School of Clinical Medicine, Lanzhou University, No. 1, Donggangxi Rd, Chengguan District, 730000, Lanzhou, Gansu, China
| | - Yibin Zhang
- Department of Hepatobiliary Surgery, Zhongshan Hospital of Xiamen University, Xiamen, Fujian, China
| | - Dongyu Cui
- The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | | | - Hao Guo
- The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Li Peng
- The Fourth Hospital of Hebei Medical University, Shijiazhuang, China.
| | - Chaohui Xiao
- Faculty of Hepato-Biliary-Pancreatic Surgery, the First Medical Centre, Chinese People s Liberation Army (PLA) General Hospital, Beijing, China.
- Key Laboratory of Digital Hepatobiliary Surgery PLA, Beijing, China.
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11
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Storandt MH, Tella SH, Wieczorek MA, Hodge D, Elrod JK, Rosenberg PS, Jin Z, Mahipal A. Projected Incidence of Hepatobiliary Cancers and Trends Based on Age, Race, and Gender in the United States. Cancers (Basel) 2024; 16:684. [PMID: 38398075 PMCID: PMC10886529 DOI: 10.3390/cancers16040684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/02/2024] [Accepted: 02/04/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Identifying the projected incidence of hepatobiliary cancers and recognizing patient cohorts at increased risk can help develop targeted interventions and resource allocation. The expected incidence of subtypes of hepatobiliary cancers in different age groups, races, and genders remains unknown. METHODS Historical epidemiological data from the Surveillance, Epidemiology, and End Results (SEER) database was used to project future incidence of hepatobiliary malignancies in the United States and identify trends by age, race, and gender. Patients ≥18 years of age diagnosed with a hepatobiliary malignancy between 2001 and 2017 were included. US Census Bureau 2017 National Population projects provided the projected population from 2017 to 2029. Age-Period-Cohort forecasting model was used to estimate future births cohort-specific incidence. All analyses were completed using R Statistical Software. RESULTS We included 110381 historical patients diagnosed with a hepatobiliary malignancy between 2001 and 2017 with the following subtypes: hepatocellular cancer (HCC) (68%), intrahepatic cholangiocarcinoma (iCCA) (11.5%), gallbladder cancer (GC) (8%), extrahepatic cholangiocarcinoma (eCCA) (7.6%), and ampullary cancer (AC) (4%). Our models predict the incidence of HCC to double (2001 to 2029) from 4.5 to 9.03 per 100,000, with the most significant increase anticipated in patients 70-79 years of age. In contrast, incidence is expected to continue to decline among the Asian population. Incidence of iCCA is projected to increase, especially in the white population, with rates in 2029 double those in 2001 (2.13 vs. 0.88 per 100,000, respectively; p < 0.001). The incidence of GC among the black population is expected to increase. The incidence of eCCA is expected to significantly increase, especially among the Hispanic population, while that of AC will remain stable. DISCUSSION The overall incidence of hepatobiliary malignancies is expected to increase in the coming years, with certain groups at increased risk. These findings may help with resource allocation when considering screening, treatment, and research in the coming years.
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Affiliation(s)
| | - Sri Harsha Tella
- Department of Oncology, Mayo Clinic, Rochester, MN 55905, USA; (S.H.T.); (Z.J.)
| | - Mikolaj A. Wieczorek
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL 32224, USA; (M.A.W.); (D.H.)
| | - David Hodge
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL 32224, USA; (M.A.W.); (D.H.)
| | - Julia K. Elrod
- Department of Statistics and Data Science, Carnegie Mellon University, Pittsburgh, PA 15213, USA;
| | - Philip S. Rosenberg
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20814, USA;
| | - Zhaohui Jin
- Department of Oncology, Mayo Clinic, Rochester, MN 55905, USA; (S.H.T.); (Z.J.)
| | - Amit Mahipal
- Department of Oncology, Mayo Clinic, Rochester, MN 55905, USA; (S.H.T.); (Z.J.)
- University Hospitals Seidman Cancer Center, Case Western Reserve University, Cleveland, OH 44106, USA
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12
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Aaquist T, Fristrup CW, Hasselby JP, Hamilton-Dutoit S, Eld M, Pfeiffer P, Mortensen MB, Detlefsen S. Prognostic importance of margin clearance in ampullary adenocarcinoma following pancreaticoduodenectomy in a Danish population-based nationwide study. HPB (Oxford) 2024; 26:241-250. [PMID: 37996299 DOI: 10.1016/j.hpb.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 04/01/2023] [Accepted: 10/07/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND In this Danish nationwide population-based study, we evaluated the prognostically relevant minimum tumour-free margin width following pancreaticoduodenectomy (PD) for ampullary adenocarcinoma (AAC) and evaluated whether certain margins hold independent prognostic information. METHODS We included 128 patients who underwent PD for AAC from 2015 to 2019. Clinical and pathological data including well-known prognostic factors were retrieved from the Danish Pancreatic Cancer Database. Missing data were obtained by review of pathology reports and re-microscopy of resection specimens. All PD specimens were examined using a standardised pathological protocol including multicolour inking, axial slicing and exact reporting of margin widths. The cohort was dichotomised into involved and uninvolved groups, using different margin clearance definitions (0.5-≥3.0 mm). RESULTS Following PD for AAC, margin clearance of ≥1 mm was independently associated with improved chance of survival compared with <1 mm (HR: 0.30, 95 % CI: 0.14-0.64 (p = 0.002)). Posterior and anterior margin widths were narrower compared with superior mesenteric artery and vein margins. Posterior margin and anterior surface had isolated prognostic significance in multivariable analysis. CONCLUSION Following PD for AAC, margin clearance of at least 1 mm is independently associated with improved survival. Our data further indicate that anterior surface and posterior margin hold particular prognostic value.
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Affiliation(s)
- Trine Aaquist
- Department of Pathology, Odense University Hospital, Odense, Denmark; Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Odense Patient Data Exploratory Network-OPEN, Odense University Hospital, Odense, Denmark
| | - Claus W Fristrup
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark; Odense Patient Data Exploratory Network-OPEN, Odense University Hospital, Odense, Denmark; Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Jane P Hasselby
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Mikkel Eld
- Department of Pathology, Aalborg University Hospital, Aalborg, Denmark
| | - Per Pfeiffer
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Michael B Mortensen
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Sönke Detlefsen
- Department of Pathology, Odense University Hospital, Odense, Denmark; Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark; Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Odense Patient Data Exploratory Network-OPEN, Odense University Hospital, Odense, Denmark.
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13
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Hakoda H, Kawaguchi Y, Miyata Y, Togashi J, Nagai M, Suzuki Y, Nomura Y. Advanced Adenosquamous Carcinoma of the Ampulla of Vater Treated with Adjuvant Chemotherapy after Pancreaticoduodenectomy. Case Rep Gastroenterol 2024; 18:129-135. [PMID: 38501150 PMCID: PMC10948169 DOI: 10.1159/000537900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 02/09/2024] [Indexed: 03/20/2024] Open
Abstract
Introduction Adenosquamous carcinoma (ASC) of the ampulla of Vater (AmV) is rare. The prognosis is generally worse in patients undergoing resection of ASC of the AmV than in those undergoing resection of adenocarcinoma of the AmV because the former shows early recurrence after surgery. A treatment strategy for ASC of the AmV has not been established, and the efficacy of adjuvant chemotherapy after curative resection is unclear. Given the paucity of data, we report a case of ASC of the AmV that was curatively resected and treated with adjuvant chemotherapy. Case Presentation A 66-year-old man presented with pruritus and anorexia. Contrast-enhanced computed tomography revealed a tumor measuring 1.6 cm in diameter located at the AmV and distal bile duct. Biopsy revealed adenocarcinoma of the AmV. The patient underwent subtotal stomach-preserving pancreaticoduodenectomy. Histopathological examination contradictorily revealed ASC of the AmV and lymph node metastases. The postoperative course of the patient was uneventful, and he was discharged on day 25. The patient underwent S-1 adjuvant chemotherapy for 6 months and did not exhibit any postoperative recurrence for a follow-up duration of 28 months. Conclusion Although treatment strategy for ASC of the AmV has not been established, our case shows that surgery followed by S-1 adjuvant chemotherapy could improve prognosis of patients with such tumors. However, further research is required to determine the efficacy of adjuvant chemotherapy and treatment strategies for resectable ASC of the AmV.
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Affiliation(s)
| | - Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoichi Miyata
- Department of Surgery, Asahi General Hospital, Chiba, Japan
| | | | - Motoki Nagai
- Department of Surgery, Asahi General Hospital, Chiba, Japan
| | - Yoshio Suzuki
- Department of Pathology, Asahi General Hospital, Chiba, Japan
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14
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Tsagkalidis V, Langan RC, Ecker BL. Ampullary Adenocarcinoma: A Review of the Mutational Landscape and Implications for Treatment. Cancers (Basel) 2023; 15:5772. [PMID: 38136318 PMCID: PMC10741460 DOI: 10.3390/cancers15245772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/01/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Ampullary carcinomas represent less than 1% of all gastrointestinal malignancies with an incidence of approximately 6 cases per 1 million. Histologic examination and immunohistochemistry have been traditionally used to categorize ampullary tumors into intestinal, pancreatobiliary or mixed subtypes. Intestinal-subtype tumors may exhibit improved survival versus the pancreatobiliary subtype, although studies on the prognostic value of immunomorphologic classification have been inconsistent. Genomic classifiers hold the promise of greater reliability, while providing potential targets for precision oncology. Multi-institutional collaboration will be necessary to better understand how molecular classification can guide type and sequencing of multimodality therapy.
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Affiliation(s)
- Vasileios Tsagkalidis
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA; (V.T.); (R.C.L.)
| | - Russell C. Langan
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA; (V.T.); (R.C.L.)
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
| | - Brett L. Ecker
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA; (V.T.); (R.C.L.)
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
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15
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Shin DW. [Treatment of Ampullary Adenocarcinoma]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2023; 82:159-170. [PMID: 37876255 DOI: 10.4166/kjg.2023.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 09/28/2023] [Accepted: 10/03/2023] [Indexed: 10/26/2023]
Abstract
The ampulla of Vater is a small projection formed by the confluence of the main pancreatic duct and common bile duct in the second part of the duodenum. Primary ampullary adenocarcinoma is a rare malignancy, accounting for only 0.2% of gastrointestinal cancers and approximately 7% of all periampullary cancers. Jaundice from a biliary obstruction is the most common symptom of ampullary adenocarcinoma. In the early stages, radical pancreatoduodenectomy is the standard surgical approach. On the other hand, no randomized controlled trial has provided evidence to guide physicians on the choice of adjuvant/palliative chemotherapy because of the rarity of the disease and the paucity of related research. This paper reports the biology, histology, current therapeutic strategies, and potential future therapies of ampullary adenocarcinoma.
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Affiliation(s)
- Dong Woo Shin
- Division of Gastroenterology, Department of Internal Medicine, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
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16
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Kaliounji A, Kaliounji H, Farraj MA, Sharma N, McFarlane SI. A Rare Case of Metastatic Ampullary Adenocarcinoma Following the Whipple Procedure. Cureus 2023; 15:e46796. [PMID: 37954694 PMCID: PMC10634612 DOI: 10.7759/cureus.46796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
Ampullary carcinoma is an extremely rare type of gastrointestinal cancer that originates at the ampulla of Vater, distal to the junction between the pancreatic duct and the common bile duct (CBD). There are three subtypes depending on the histological findings: pancreatobiliary, intestinal, and mixed subtype. Symptoms can mimic other pathologies related to biliary obstruction, such as jaundice, diarrhea, steatorrhea, and weight loss. In this report, we present a case of a 40-year-old male who presented with painless jaundice and dizziness. Magnetic resonance cholangiopancreatography (MRCP) showed choledocholithiasis and CBD dilatation. Endoscopic ultrasound showed a 24 x 14 mm ampulla mass. Subsequently, he underwent the Whipple procedure that revealed an intestinal-type periampullary adenocarcinoma characterized as stage III (T3bN2M0), with lymphovascular and perineural invasion. He was lost to follow-up but was later found to have metastatic pancreatic adenocarcinoma to the lung and liver. In this report, we also discuss the clinical presentation, pathogenesis, and current evidence-based therapeutic options in the management of this tumor, highlighting the importance of treatment choice depending on the tumor type.
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Affiliation(s)
- Aboud Kaliounji
- Internal Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, USA
| | - Haya Kaliounji
- Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Michael A Farraj
- Internal Medicine, Touro College of Osteopathic Medicine, Middletown, USA
- Internal Medicine, Nassau University Medical Center, East Meadow, USA
| | - Nischal Sharma
- Internal Medicine, St. George's University, True Blue, GRD
| | - Samy I McFarlane
- Internal Medicine, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, USA
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17
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Shin DW, Lee JM, Lee JC, Lee HS, Yoon SB, Jang DK, Park JK, Jung MK, Lee YS, Hwang JH. Adjuvant Chemotherapy and Effect on Long-Term Survival in Ampullary Adenocarcinoma: A Multicenter Cohort Study. J Am Coll Surg 2023; 237:501-512. [PMID: 37222437 DOI: 10.1097/xcs.0000000000000769] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND The role of adjuvant chemotherapy (AC) in patients with ampullary adenocarcinoma (AA) remains controversial. This study aimed to determine if AC could improve the prognosis of patients with resected AA. STUDY DESIGN This study enrolled patients diagnosed with AA at 9 tertiary teaching hospitals. Patients who did and did not receive AC were matched 1:1 using propensity score. The overall survival (OS) and recurrence-free survival (RFS) were compared between the 2 groups. RESULTS Of the 1,057 patients with AA, 883 underwent curative-intent pancreaticoduodenectomy, and 255 received AC. Because patients with advanced-stage AA received AC more frequently, the no AC group unexpectedly had a longer OS (not reached vs 78.6 months; p < 0.001) and RFS (not reached vs 18.7 months; p < 0.001) than did the AC group in the unmatched cohort. In the propensity score-matched cohort (n = 296), no difference between the 2 groups in terms of OS (95.9 vs 89.8 months, p = 0.303) and RFS (not reached vs 25.5 months; p = 0.069) was found. By subgroup analysis, patients with advanced stage (pT4 or pN1-2) showed longer OS in the AC group than in the no AC group (not reached vs 15.7 months, p = 0.007: 89.8 vs 24.2 months, p = 0.006, respectively). There was no difference in RFS according to AC in the propensity score-matched cohort. CONCLUSIONS Given its favorable long-term outcomes, AC can be recommended for patients with resected AA, especially those in the advanced stage (pT4 or pN1-2).
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Affiliation(s)
- Dong Woo Shin
- From the Division of Gastroenterology, Department of Internal Medicine, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Gyeonggi-do, Republic of Korea (Shin)
| | - Jae Min Lee
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Korea University Anam Hospital, Seoul, Republic of Korea (JM Lee)
| | - Jong-Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea (JC Lee, Hwang)
| | - Hee Seung Lee
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea (HS Lee)
| | - Seung Bae Yoon
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (Yoon)
| | - Dong Kee Jang
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea (Jang)
| | - Joo Kyung Park
- Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (Park)
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea (Park)
| | - Min Kyu Jung
- Division of Gastroenterology, Department of Internal Medicine, Kyungpook National University School of Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea (Jung)
| | - Yoon Suk Lee
- Division of Gastroenterology, Department of Internal Medicine, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Gyeonggi-do, Republic of Korea (YS Lee)
| | - Jin-Hyeok Hwang
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Republic of Korea (JC Lee, Hwang)
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18
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Uijterwijk BA, Lemmers DHL, Bolm L, Luyer M, Koh YX, Mazzola M, Webber L, Kazemier G, Bannone E, Ramaekers M, Ielpo B, Wellner U, Koek S, Giani A, Besselink MG, Abu Hilal M. Long-term Outcomes After Laparoscopic, Robotic, and Open Pancreatoduodenectomy for Distal Cholangiocarcinoma: An International Propensity Score-matched Cohort Study. Ann Surg 2023; 278:e570-e579. [PMID: 36730852 DOI: 10.1097/sla.0000000000005743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study aimed to compare surgical and oncological outcomes after minimally invasive pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) for distal cholangiocarcinoma (dCCA). BACKGROUND A dCCA might be a good indication for MIPD, as it is often diagnosed as primary resectable disease. However, multicenter series on MIPD for dCCA are lacking. METHODS This is an international multicenter propensity score-matched cohort study including patients after MIPD or OPD for dCCA in 8 centers from 5 countries (2010-2021). Primary outcomes included overall survival (OS) and disease-free interval (DFI). Secondary outcomes included perioperative and postoperative complications and predictors for OS or DFI. Subgroup analyses included robotic pancreatoduodenectomy (RPD) and laparoscopic pancreatoduodenectomy (LPD). RESULTS Overall, 478 patients after pancreatoduodenectomy for dCCA were included of which 97 after MIPD (37 RPD, 60 LPD) and 381 after OPD. MIPD was associated with less blood loss (300 vs 420 mL, P =0.025), longer operation time (453 vs 340 min; P <0.001), and less surgical site infections (7.8% vs 19.3%; P =0.042) compared with OPD. The median OS (30 vs 25 mo) and DFI (29 vs 18) for MIPD did not differ significantly between MIPD and OPD. Tumor stage (Hazard ratio: 2.939, P <0.001) and administration of adjuvant chemotherapy (Hazard ratio: 0.640, P =0.033) were individual predictors for OS. RPD was associated with a higher lymph node yield (18.0 vs 13.5; P =0.008) and less major morbidity (Clavien-Dindo 3b-5; 8.1% vs 32.1%; P =0.005) compared with LPD. DISCUSSION Both surgical and oncological outcomes of MIPD for dCCA are acceptable as compared with OPD. Surgical outcomes seem to favor RPD as compared with LPD but more data are needed. Randomized controlled trials should be performed to confirm these findings.
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Affiliation(s)
- Bas A Uijterwijk
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, The Netherlands
| | - Daniël H L Lemmers
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, The Netherlands
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Misha Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Ye Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Michele Mazzola
- Division of Oncologic and Mini-invasive General Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Laurence Webber
- Department of Surgery, Fiona Stanley Hospital, Perth, Australia
| | - Geert Kazemier
- Cancer Center Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Elisa Bannone
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Mark Ramaekers
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Benedetto Ielpo
- Hepatobiliary and Pancreatic Surgery Unit, Hospital del Mar, Universitat Pompeu Fabra, Barcelona, Spain
| | - Ulrich Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Sharnice Koek
- Department of Surgery, Fiona Stanley Hospital, Perth, Australia
| | - Alessandro Giani
- Division of Oncologic and Mini-invasive General Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, The Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
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19
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Linscott MP, Markus H, Sennett M, Abendroth C, Yee NS. Nab-Paclitaxel and Gemcitabine as First-Line Treatment of Metastatic Ampullary Adenocarcinoma with a Novel R-Spondin2 RNA Fusion and NTRK3 Mutation. Biomedicines 2023; 11:2326. [PMID: 37626821 PMCID: PMC10452745 DOI: 10.3390/biomedicines11082326] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/14/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Ampullary adenocarcinoma is a rare malignancy that lacks standard systemic treatment. We describe a case of recurrent metastatic ampullary adenocarcinoma of the pancreaticobiliary subtype treated with nanoparticle albumin-bound (nab)-paclitaxel and gemcitabine as first-line treatment. This report also highlights the molecular profile of the ampullary adenocarcinoma and circulating tumor DNA (ctDNA). This is a case of pancreaticobiliary ampullary adenocarcinoma in a 67-year-old woman who initially presented with painless jaundice. Endoscopic and imaging evaluation revealed biliary ductal dilation secondary to an ampullary mass. Pathology confirmed the diagnosis of ampullary adenocarcinoma of the pancreaticobiliary subtype. She underwent surgical resection of the tumor, followed by adjuvant chemotherapy with gemcitabine and capecitabine. The tumor subsequently recurred in the liver. She received palliative chemotherapy with nab-paclitaxel and gemcitabine, resulting in an objective tumor response for 14 months. Molecular profiling of the tumor and ctDNA revealed a novel MATN2-RSPO RNA fusion and a novel NTRK3 mutation, respectively. Our report suggests that long-term durable response can be achieved in metastatic pancreaticobiliary ampullary adenocarcinoma using nab-paclitaxel and gemcitabine. Molecular profiling of the tumor identified a novel R-Spondin2 RNA fusion and NTRK3 mutation that can be potentially targeted for treatment.
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Affiliation(s)
- Maryknoll P. Linscott
- Medical Scientist Training Program, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA; (M.P.L.); (H.M.); (M.S.)
| | - Havell Markus
- Medical Scientist Training Program, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA; (M.P.L.); (H.M.); (M.S.)
| | - Mackenzie Sennett
- Medical Scientist Training Program, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA; (M.P.L.); (H.M.); (M.S.)
| | - Catherine Abendroth
- Department of Pathology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA;
| | - Nelson S. Yee
- Division of Hematology-Oncology, Department of Medicine, Pennsylvania State University College of Medicine, Hershey, PA 17033, USA
- Next-Generation Therapies Program, Penn State Cancer Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA
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20
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Uijterwijk BA, Kasai M, Lemmers DHL, Chinnusamy P, van Hilst J, Ielpo B, Wei K, Song KB, Kim SC, Klompmaker S, Jang JY, Herremans KM, Bencini L, Coratti A, Mazzola M, Menon KV, Goh BKP, Qin R, Besselink MG, Abu Hilal M. The clinical implication of minimally invasive versus open pancreatoduodenectomy for non-pancreatic periampullary cancer: a systematic review and individual patient data meta-analysis. Langenbecks Arch Surg 2023; 408:311. [PMID: 37581763 PMCID: PMC10427526 DOI: 10.1007/s00423-023-03047-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 08/03/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Most studies on minimally invasive pancreatoduodenectomy (MIPD) combine patients with pancreatic and periampullary cancers even though there is substantial heterogeneity between these tumors. Therefore, this study aimed to evaluate the role of MIPD compared to open pancreatoduodenectomy (OPD) in patients with non-pancreatic periampullary cancer (NPPC). METHODS A systematic review of Pubmed, Embase, and Cochrane databases was performed by two independent reviewers to identify studies comparing MIPD and OPD for NPPC (ampullary, distal cholangio, and duodenal adenocarcinoma) (01/2015-12/2021). Individual patient data were required from all identified studies. Primary outcomes were (90-day) mortality, and major morbidity (Clavien-Dindo 3a-5). Secondary outcomes were postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), blood-loss, length of hospital stay (LOS), and overall survival (OS). RESULTS Overall, 16 studies with 1949 patients were included, combining 928 patients with ampullary, 526 with distal cholangio, and 461 with duodenal cancer. In total, 902 (46.3%) patients underwent MIPD, and 1047 (53.7%) patients underwent OPD. The rates of 90-day mortality, major morbidity, POPF, DGE, PPH, blood-loss, and length of hospital stay did not differ between MIPD and OPD. Operation time was 67 min longer in the MIPD group (P = 0.009). A decrease in DFS for ampullary (HR 2.27, P = 0.019) and distal cholangio (HR 1.84, P = 0.025) cancer, as well as a decrease in OS for distal cholangio (HR 1.71, P = 0.045) and duodenal cancer (HR 4.59, P < 0.001) was found in the MIPD group. CONCLUSIONS This individual patient data meta-analysis of MIPD versus OPD in patients with NPPC suggests that MIPD is not inferior in terms of short-term morbidity and mortality. Several major limitations in long-term data highlight a research gap that should be studied in prospective maintained international registries or randomized studies for ampullary, distal cholangio, and duodenum cancer separately. PROTOCOL REGISTRATION PROSPERO (CRD42021277495) on the 25th of October 2021.
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Affiliation(s)
- Bas A Uijterwijk
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy.
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands.
| | - Meidai Kasai
- Department of Surgery, Meiwa Hospital, Hyogo, Japan
| | - Daniel H L Lemmers
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Palanivelu Chinnusamy
- Department of Surgical Gastroenterology and Hepatopancreatobiliary Surgery, GEM Hospital and Research Center, Ramanathapuram, Coimbatore, Tamil Nadu, India
| | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - Benedetto Ielpo
- Hepatobiliary and Pancreatic Surgery Unit, Hospital del Mar. Universitat Pompeu Fabra, Barcelona, Spain
| | - Kongyuan Wei
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Song C Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Sjors Klompmaker
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Kelly M Herremans
- Division of Surgical Oncology, General Surgery, University of Florida, Gainesville, USA
| | - Lapo Bencini
- Department of Surgery, Careggi University Hospital, Florence, Italy
| | - Andrea Coratti
- Department of Surgery, Misericordia Hospital of Grosseto, Grosseto, Italy
| | - Michele Mazzola
- Division of Oncologic and Mini-Invasive General Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Krishna V Menon
- Department of Liver Transplant and HPB Unit, King's College Hospital, London, UK
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Renyi Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy.
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21
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Vermeersch G, Cruyt N, D'Hondt E, Geers J, Hertveldt K, Stockman A, Lambrecht G. Granulomatous peritoneal disease associated with oxaliplatin-based chemotherapy for ampullary adenocarcinoma: a case report. Acta Gastroenterol Belg 2023; 86:499-501. [PMID: 37814569 DOI: 10.51821/86.3.11323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Adenocarcinomas of the ampulla of Vater represent only 0.2% of all gastrointestinal cancers. Due to the low incidence no large clinical trials evaluating efficacy of treatments are available. Adjuvant therapy is often administered in patients with stage IB or higher. Oxaliplatin is considered as an effective and well tolerated therapeutic option. Adverse events associated with this therapy include cardio-, neuro-, nephrotoxicity and myelosuppression. Previously granulomatous pulmonary and liver manifestations have been described in oxaliplatin-based chemotherapy. In this report peritoneal manifestation of granulomatous disease associated with oxaliplatin is described for the first time. Sarcoidlike reactions may be misinterpreted as tumour progression or metastatic disease, and may consequently result in over-treatment.
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Affiliation(s)
- G Vermeersch
- Department of Gastroenterology and Digestive Oncology, AZ Damiaan, Oostende, Belgium
- Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - N Cruyt
- Department of Gastroenterology and Digestive Oncology, AZ Damiaan, Oostende, Belgium
- Department of Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - E D'Hondt
- Department of Nuclear Medicine, AZ Damiaan, Oostende, Belgium
| | - J Geers
- Department of General and Abdominal Surgery, AZ Damiaan, Oostende, Belgium
| | - K Hertveldt
- Department of Anatomopathology, AZ Damiaan, Oostende, Belgium
| | - A Stockman
- Department of Radiology, AZ Damiaan, Oostende, Belgium
| | - G Lambrecht
- Department of Gastroenterology and Digestive Oncology, AZ Damiaan, Oostende, Belgium
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22
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Xu H, Chai CP, Miao X, Tang H, Hu JJ, Zhang H, Zhou WC. Establishment and characterization of a new human ampullary carcinoma cell line, DPC-X1. World J Gastroenterol 2023; 29:2642-2656. [PMID: 37213400 PMCID: PMC10198051 DOI: 10.3748/wjg.v29.i17.2642] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/17/2023] [Accepted: 04/13/2023] [Indexed: 05/23/2023] Open
Abstract
BACKGROUND An in-depth study of the pathogenesis and biological characteristics of ampullary carcinoma is necessary to identify appropriate treatment strategies. To date, only eight ampullary cancer cell lines have been reported, and a mixed-type ampullary carcinoma cell line has not yet been reported.
AIM To establish a stable mixed-type ampullary carcinoma cell line originating from Chinese.
METHODS Fresh ampullary cancer tissue samples were used for primary culture and subculture. The cell line was evaluated by cell proliferation assays, clonal formation assays, karyotype analysis, short tandem repeat (STR) analysis and transmission electron microscopy. Drug resistances against oxaliplatin, paclitaxel, gemcitabine and 5-FU were evaluated by cell counting kit-8 assay. Subcutaneous injection 1 × 106 cells to three BALB/c nude mice for xenograft studies. The hematoxylin-eosin staining was used to detect the pathological status of the cell line. The expression of biomarkers cytokeratin 7 (CK7), cytokeratin 20 (CK20), cytokeratin low molecular weight (CKL), Ki67 and carcinoembryonic antigen (CEA) were determined by immunocytochemistry assay.
RESULTS DPC-X1 was continuously cultivated for over a year and stably passaged for more than 80 generations; its population doubling time was 48 h. STR analysis demonstrated that the characteristics of DPC-X1 were highly consistent with those of the patient’s primary tumor. Furthermore, karyotype analysis revealed its abnormal sub-tetraploid karyotype. DPC-X1 could efficiently form organoids in suspension culture. Under the transmission electron microscope, microvilli and pseudopods were observed on the cell surface, and desmosomes were visible between the cells. DPC-X1 cells inoculated into BALB/C nude mice quickly formed transplanted tumors, with a tumor formation rate of 100%. Their pathological characteristics were similar to those of the primary tumor. Moreover, DPC-X1 was sensitive to oxaliplatin and paclitaxel and resistant to gemcitabine and 5-FU. Immunohistochemistry showed that the DPC-X1 cells were strongly positive for CK7, CK20, and CKL; the Ki67 was 50%, and CEA was focally expressed.
CONCLUSION Here, we have constructed a mixed-type ampullary carcinoma cell line that can be used as an effective model for studying the pathogenesis of ampullary carcinoma and drug development.
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Affiliation(s)
- Hao Xu
- The Forth Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Chang-Peng Chai
- The Forth Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Xin Miao
- State Key Laboratory of Veterinary Etiological Biology, Key Laboratory of Animal Virology of the Ministry of Agriculture, Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural Sciences, Lanzhou 730000, Gansu Province, China
| | - Huan Tang
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Jin-Jing Hu
- The Forth Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Hui Zhang
- Department of General Surgery, The Second Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Wen-Ce Zhou
- The Second Clinical Medical College, Lanzhou University, Lanzhou 730000, Gansu Province, China
- Department of General Surgery, The Second Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
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Chun J, Kim YW, Seo-Rin J, Cho H, Kim KP, Hwang DW, Hong SM. Prognostic Significance of Extranodal Extension of Nodal Metastasis in Adenocarcinoma of the Ampulla of Vater. Hum Pathol 2023; 137:36-47. [PMID: 37088435 DOI: 10.1016/j.humpath.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 04/25/2023]
Abstract
Although nodal metastasis (NM) is an important prognostic factor of ampullary adenocarcinoma, the prognostic implication of extranodal extension (ENE) is not well characterized. NM with ENE status was investigated in 279 surgically resected ampullary adenocarcinoma patients and compared with other clinicopathologic factors, including overall survival (OS) and recurrence-free survival (RFS). Expression of epithelial-mesenchymal transition (EMT) markers, including E-cadherin, Twist, and Snail, was assessed in a subset of the cohort. NM was observed in 94 cases (33.7%), of which ENE was observed in 32 cases (34%). NM with ENE was more frequently associated with tumors with poor differentiation than NM without ENE (P=0.017). The 5-year OS and RFS rates of patients with NM and ENE was significantly worse (13.0% and 6.3%) than those with NM without ENE (37.7% and 21.4%) and those without NM (57.6% and 50.2%, respectively; P<0.001). When pN category was matched, the OS and RFS was worse in patients with ENE than in those without ENE (P<0.05). Moreover, the expression of E-cadherin and Twist was significantly different between NM areas with and without ENE (all, P<0.001). Since ENE was associated with poorly differentiated ampullary adenocarcinomas and showed different expression of EMT markers, EMT could be a possible mechanism of ENE. Ampullary adenocarcinoma patients with ENE had worse OS and RFS than those without ENE. Therefore, evaluation of ENE can provide additional survival information for patients with surgically resected ampullary carcinoma.
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Affiliation(s)
- Jihyun Chun
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeon Wook Kim
- Asan Institute for Life Sciences, Asan Medical Center, Seoul, Republic of Korea
| | - Jeong Seo-Rin
- Department of Statistics, Korea University, Seoul, Republic of Korea
| | - HyunhJun Cho
- Department of Statistics, Korea University, Seoul, Republic of Korea
| | - Kyu-Pyo Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Mo Hong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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24
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Park SJ, Shin K, Kim IH, Hong TH, Kim Y, Lee MA. Role of adjuvant chemotherapy on recurrence and survival in patients with resected ampulla of Vater carcinoma. World J Gastrointest Oncol 2023; 15:677-688. [PMID: 37123060 PMCID: PMC10134206 DOI: 10.4251/wjgo.v15.i4.677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/20/2023] [Accepted: 03/22/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Owing to rarity of disease and lack of prospective studies, data supporting the role of adjuvant chemotherapy in ampulla of Vater (AoV) carcinoma is limited.
AIM To evaluate whether adjuvant chemotherapy cases for AoV carcinoma had better disease-free survival (DFS) rates than cases of observation following curative surgery.
METHODS We retrospectively analyzed the association between adjuvant chemotherapy and DFS and overall survival (OS) in patients with stage IB-III AoV carcinoma who underwent curative surgical resection. Fluorouracil-based adjuvant chemotherapy was administered after surgery at the discretion of the physician. Adjusted multivariate regression models were used to evaluate the association between adjuvant chemotherapy and survival outcomes.
RESULTS Of the total 104 patients who underwent curative surgery, 52 received adjuvant chemotherapy. Multivariate analysis revealed that higher histologic grade [hazard ratio (HR) = 2.24, P = 0.046], advanced tumor stage (HR = 1.85, P = 0.030), and vascular invasion (HR = 2.14, P = 0.010) were associated with shorter DFS. Adjuvant chemotherapy improved DFS compared to the observation group (HR = 0.50, P = 0.015) and tended to be associated with a longer OS, although the difference was not statistically significant (HR = 0.58, P = 0.098).
CONCLUSION Among patients with resected AoV carcinoma, the adjuvant chemotherapy group was not associated with a significant survival benefit compared to the observation group. However, on multivariate analysis adjusting for prognostic factors, adjuvant chemotherapy following surgery was an independent prognostic factor for DFS in patients with resected AoV carcinoma. Further studies are needed to investigate the effectiveness of adjuvant chemotherapy according to histologic phenotype.
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Affiliation(s)
- Se Jun Park
- Division of Medical Oncology, Department of Internal Medicine, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul 06591, South Korea
| | - Kabsoo Shin
- Division of Medical Oncology, Department of Internal Medicine, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul 06591, South Korea
| | - In-Ho Kim
- Division of Medical Oncology, Department of Internal Medicine, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul 06591, South Korea
| | - Tae Ho Hong
- Department of General Surgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul 06591, South Korea
| | - Younghoon Kim
- Department of Pathology, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul 06591, South Korea
| | - Myung-ah Lee
- Division of Medical Oncology, Department of Internal Medicine, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul 06591, South Korea
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Lee S, Kim H, Sohn H, Lee M, Jung H, Jo Y, Han Y, Kwon W, Jang JY. The Optimal Cutoff Value of Tumor Markers for Prognosis Prediction in Ampullary Cancer. Cancers (Basel) 2023; 15:cancers15082281. [PMID: 37190211 DOI: 10.3390/cancers15082281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/03/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Carbohydrate antigen 19-9 (CA 19-9) is a representative tumor marker used for the diagnosis of pancreatic and biliary tract cancers. There are few published research results that can be applied to actual clinical practice for ampullary cancer (AC) alone. This study aimed to demonstrate the relationship between the prognosis of AC and the level of CA 19-9, and to determine the optimal thresholds. METHODS Patients who underwent curative resection (pancreaticoduodenectomy (PD) or pylorus preserving pancreaticoduodenectomy (PPPD)) for AC at the Seoul National University Hospital between January 2000 and December 2017 were enrolled. To determine the optimal cutoff values that could clearly stratify the survival outcome, the conditional inference tree (C-tree) method was used. After obtaining the optimal cutoff values, they were compared to the upper normal clinical limit of 36 U/mL for CA 19-9. Results In total, 385 patients were enrolled in this study. The median value of the tumor marker CA 19-9 was 18.6 U/mL. Using the C-tree method, 46 U/mL was determined to be the optimal cutoff value for CA 19-9. Histological differentiation, N stage, and adjuvant chemotherapy were significant predictors. CA 19-9 36 U/mL had marginal significance as a prognostic factor. In contrast, the new cutoff value, CA 19-9 46 U/mL, was found to be a statistically significant prognostic factor (HR: 1.37, p = 0.048). CONCLUSIONS The new cutoff value of CA 19-9 46 U/mL may be used for evaluating the prognosis of AC. Therefore, it may be an effective indicator for determining treatment strategies such as surgical treatments and adjuvant chemotherapy.
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Affiliation(s)
- Seungho Lee
- Departments of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Hongbeom Kim
- Departments of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Republic of Korea
| | - Heeju Sohn
- Departments of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Mirang Lee
- Departments of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Hyesol Jung
- Departments of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Youngjae Jo
- Departments of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Youngmin Han
- Departments of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Wooil Kwon
- Departments of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Jin-Young Jang
- Departments of Surgery, Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
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26
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de Bakker JK, Suurmeijer JA, Toennaer JGJ, Bonsing BA, Busch OR, van Eijck CH, de Hingh IH, de Meijer VE, Molenaar IQ, van Santvoort HC, Stommel MW, Festen S, van der Harst E, Patijn G, Lips DJ, Den Dulk M, Bosscha K, Besselink MG, Kazemier G. Surgical Outcome After Pancreatoduodenectomy for Duodenal Adenocarcinoma Compared with Other Periampullary Cancers: A Nationwide Audit Study. Ann Surg Oncol 2023; 30:2448-2455. [PMID: 36536196 PMCID: PMC10027630 DOI: 10.1245/s10434-022-12701-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 10/04/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical outcome after pancreatoduodenectomy for duodenal adenocarcinoma could differ from pancreatoduodenectomy for other cancers, but large multicenter series are lacking. This study aimed to determine surgical outcome in patients after pancreatoduodenectomy for duodenal adenocarcinoma, compared with other periampullary cancers, in a nationwide multicenter cohort. METHODS After pancreatoduodenectomy for cancer between 2014 and 2019, consecutive patients were included from the nationwide, mandatory Dutch Pancreatic Cancer Audit. Patients were stratified by diagnosis. Baseline, treatment characteristics, and postoperative outcome were compared between groups. The association between diagnosis and major complications (Clavien-Dindo grade III or higher) was assessed via multivariable regression analysis. RESULTS Overall, 3113 patients, after pancreatoduodenectomy for cancer, were included in this study: 264 (8.5%) patients with duodenal adenocarcinomas and 2849 (91.5%) with other cancers. After pancreatoduodenectomy for duodenal adenocarcinoma, patients had higher rates of major complications (42.8% vs. 28.6%; p < 0.001), postoperative pancreatic fistula (International Study Group of Pancreatic Surgery [ISGPS] grade B/C; 23.1% vs. 13.4%; p < 0.001), complication-related intensive care admission (14.3% vs. 10.3%; p = 0.046), re-interventions (39.8% vs. 26.6%; p < 0.001), in-hospital mortality (5.7% vs. 3.1%; p = 0.025), and longer hospital stay (15 days vs. 11 days; p < 0.001) compared with pancreatoduodenectomy for other cancers. In multivariable analysis, duodenal adenocarcinoma was independently associated with major complications (odds ratio 1.14, 95% confidence interval 1.03-1.27; p = 0.011). CONCLUSION Pancreatoduodenectomy for duodenal adenocarcinoma is associated with higher rates of major complications, pancreatic fistula, re-interventions, and in-hospital mortality compared with patients undergoing pancreatoduodenectomy for other cancers. These findings should be considered in patient counseling and postoperative management.
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Affiliation(s)
- Jacob K de Bakker
- Amsterdam UMC, Vrije Universiteit, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - J Annelie Suurmeijer
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
| | - Jurgen G J Toennaer
- Amsterdam UMC, Vrije Universiteit, Department of Surgery, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Olivier R Busch
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Cancer Institute, Eindhoven, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital and University Medical Center, Utrecht, The Netherlands
| | - Martijn W Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Gijs Patijn
- Department of Surgery, Isala Clinics, Zwolle, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Marcel Den Dulk
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch ziekenhuis, Den Bosch, The Netherlands
| | - Marc G Besselink
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Amsterdam, The Netherlands.
| | - Geert Kazemier
- Amsterdam UMC, Vrije Universiteit, Department of Surgery, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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Iqbal H, Petrosyan A, Yoon J, Roytman M. A Complex Diagnosis of Ampullary Adenocarcinoma Presenting As Decompensated Cirrhosis. Cureus 2023; 15:e37566. [PMID: 37193458 PMCID: PMC10183155 DOI: 10.7759/cureus.37566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 05/18/2023] Open
Abstract
Neoplasms arising from the ampulla of Vater are exceedingly rare, and there is a paucity of literature regarding their diagnosis and management. Ampullary cancer typically presents with jaundice and signs of biliary obstruction. We present a case of ampullary adenocarcinoma with concomitant choledocholithiasis that proved complex and diagnostically challenging.
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Affiliation(s)
- Humzah Iqbal
- Internal Medicine, University of California, San Francisco, Fresno, USA
| | - Arpine Petrosyan
- Internal Medicine, University of California, San Francisco, Fresno, USA
| | - Jennifer Yoon
- Gastroenterology and Hepatology, University of California, San Francisco, Fresno, USA
| | - Marina Roytman
- Gastroenterology and Hepatology, University of California, San Francisco, Fresno, USA
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28
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Mauri G, Gori V, Patelli G, Roazzi L, Rizzetto F, De Carlis L, Mariani A, Cavallari U, Prada E, Cipani T, Aquilano MC, Bonoldi E, Vanzulli A, Siena S, Sartore-Bianchi A. Multimodal treatment with curative intent in a germline BRCA2 mutant metastatic ampullary adenocarcinoma: a case report. World J Surg Oncol 2023; 21:118. [PMID: 36998040 PMCID: PMC10064505 DOI: 10.1186/s12957-023-02976-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/27/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Cancers of the Vater ampulla (ampullary cancers, ACs) account for less than 1% of all gastrointestinal tumors. ACs are usually diagnosed at advanced stage, with poor prognosis and limited therapeutic options. BRCA2 mutations are identified in up to 14% of ACs and, differently from other tumor types, therapeutic implications remain to be defined. Here, we report a clinical case of a metastatic AC patient in which the identification of a BRCA2 germline mutation drove a personalized multimodal approach with curative-intent. CASE PRESENTATION A 42-year-old woman diagnosed with stage IV BRCA2 germline mutant AC underwent platinum-based first line treatment achieving major tumor response but also life-threatening toxicity. Based on this, as well as on molecular findings and expected low impact of available systemic treatment options, the patient underwent radical complete surgical resection of both primary tumor and metastatic lesions. Following an isolated retroperitoneal nodal recurrence, given the expected enhanced sensitivity to radiotherapy in BRCA2 mutant cancers, the patient underwent imaging-guided radiotherapy leading to long-lasting complete tumor remission. After more than 2 years, the disease remains radiologically and biochemically undetectable. The patient accessed a dedicated screening program for BRCA2 germline mutation carriers and underwent prophylactic bilateral oophorectomy. CONCLUSIONS Even considering the intrinsic limitations of a single clinical report, we suggest that the finding of BRCA germline mutations in ACs should be taken into consideration, together with other clinical variables, given their potential association with remarkable response to cytotoxic chemotherapy that might be burdened with enhanced toxicity. Accordingly, BRCA1/2 mutations might offer the opportunity of personalizing treatment beyond PARP inhibitors up to the choice of a multimodal approach with curative-intent.
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Affiliation(s)
- Gianluca Mauri
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy
- Department of Hematology, Oncology, and Molecular Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Viviana Gori
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy
- Department of Hematology, Oncology, and Molecular Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giorgio Patelli
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy
- Department of Hematology, Oncology, and Molecular Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Laura Roazzi
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy
- Department of Hematology, Oncology, and Molecular Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Rizzetto
- Department of Services, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Luciano De Carlis
- Department of Surgery and Transplantation, Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Anna Mariani
- Department of Surgery and Transplantation, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Ugo Cavallari
- Department of Laboratory Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Elisabetta Prada
- Department of Laboratory Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Tiziana Cipani
- Department of Hematology, Oncology, and Molecular Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maria Costanza Aquilano
- Department of Hematology, Oncology, and Molecular Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Emanuela Bonoldi
- Department of Hematology, Oncology, and Molecular Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Angelo Vanzulli
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy
- Department of Services, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Salvatore Siena
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy
- Department of Hematology, Oncology, and Molecular Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andrea Sartore-Bianchi
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy.
- Department of Hematology, Oncology, and Molecular Medicine, Grande Ospedale Metropolitano Niguarda, Milan, Italy.
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29
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Russell TB, Labib PL, Denson J, Ausania F, Pando E, Roberts KJ, Kausar A, Mavroeidis VK, Marangoni G, Thomasset SC, Frampton AE, Lykoudis P, Maglione M, Alhaboob N, Bari H, Smith AM, Spalding D, Srinivasan P, Davidson BR, Bhogal RH, Croagh D, Dominguez I, Thakkar R, Gomez D, Silva MA, Lapolla P, Mingoli A, Porcu A, Shah NS, Hamady ZZR, Al-Sarrieh B, Serrablo A, Aroori S. Predictors of actual five-year survival and recurrence after pancreatoduodenectomy for ampullary adenocarcinoma: results from an international multicentre retrospective cohort study. HPB (Oxford) 2023:S1365-182X(23)00096-5. [PMID: 37149485 DOI: 10.1016/j.hpb.2023.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/06/2023] [Accepted: 03/15/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND Pancreatoduodenectomy (PD) is recommended in fit patients with a resectable ampullary adenocarcinoma (AA). We aimed to identify predictors of five-year recurrence/survival. METHODS Data were extracted from the Recurrence After Whipple's (RAW) study, a multicentre retrospective study of PD patients with a confirmed head of pancreas or periampullary malignancy (June 1st, 2012-May 31st, 2015). Patients with AA who developed recurrence/died within five-years were compared to those who did not. RESULTS 394 patients were included and actual five-year survival was 54%. Recurrence affected 45% and the median time-to-recurrence was 14 months. Local only, local and distant, and distant only recurrence affected 34, 41 and 94 patients, respectively (site unknown: 7). Among those with recurrence, the most common sites were the liver (32%), local lymph nodes (14%) and lung/pleura (13%). Following multivariable tests, number of resected nodes, histological T stage > II, lymphatic invasion, perineural invasion (PNI), peripancreatic fat invasion (PPFI) and ≥1 positive resection margin correlated with increased recurrence and reduced survival. Furthermore, ≥1 positive margin, PPFI and PNI were all associated with reduced time-to-recurrence. CONCLUSIONS This multicentre retrospective study of PD outcomes identified numerous histopathological predictors of AA recurrence. Patients with these high-risk features might benefit from adjuvant therapy.
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Affiliation(s)
- Thomas B Russell
- University Hospitals Plymouth NHS Trust, Plymouth, UK; University of Plymouth, Plymouth, UK
| | - Peter L Labib
- University Hospitals Plymouth NHS Trust, Plymouth, UK; University of Plymouth, Plymouth, UK
| | | | | | - Elizabeth Pando
- Hospital Clinic de Barcelona, Barcelona, Spain; Hospital Universitari Vall D'Hebron, Barcelona, Spain
| | - Keith J Roberts
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Vasileios K Mavroeidis
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK; The Royal Marsden NHS Foundation Trust, London, UK
| | | | | | | | | | | | | | - Hassaan Bari
- Shaukat Khanum Memorial Cancer Hospital, Lahore, Pakistan
| | | | | | | | | | | | | | - Ismael Dominguez
- Salvador Zubiran National Institute of Health Sciences and Nutrition, Mexico City, Mexico
| | - Rohan Thakkar
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Dhanny Gomez
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Michael A Silva
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Andrea Mingoli
- Policlinico Umberto I University Hospital Sapienza, Rome, Italy
| | - Alberto Porcu
- Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | - Nehal S Shah
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Zaed Z R Hamady
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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30
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Chen RQ, Zhang ZL, Jia YM, Chen RX, Peng L. Preoperative CA19-9 and GGT ratio as a prognostic indicator in ampullary carcinoma. BMC Gastroenterol 2023; 23:72. [PMID: 36915042 PMCID: PMC10012447 DOI: 10.1186/s12876-022-02623-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/15/2022] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND AND AIMS In recent years, more and more inflammatory indicators have been studied to predict the long-term survival of patients with ampullary carcinoma (AC) after radical resection, but these prognostic indicators are still controversial. Therefore, based on previous inflammation scores, this study established a novel, easily accessible, more feasible and more predictive prognostic marker [Carbohydrate antigen199 to gamma-glutamyltransferase ratio (CA19-9/GGT)] to better assess the prognostic significance in AC patients undergoing radical resection. METHODS Overall survival (OS) and recurrence-free survival (RFS) were analyzed by Cox regression model. Correlation between CA19-9/GGT and clinicopathological variables were analyzed by Chi-squared test, Fisher ' s exact test, independent sample t test and Mann-Whitney U test. The performance of prognostic indexes is compared by the consistency index (C-index). The prediction accuracy of nomogram is further confirmed by calibration curve and decision curve analysis (DCA). RESULTS CA19-9/GGT was an independent risk factor affecting OS [P = 0.001, hazard ratio (HR) 2.459, 95% confidence intervals (CI) 1.450-4.167] and RFS (P = 0.002, HR 2.333, 95% CI 1.371-3.971) in multivariate analysis. The optimal cut-off value of CA19-9/GGT was 0.14. In CA19-9/GGT correlation analysis, high risk group (> 0.14) was significantly associated with poor prognosis. The predictive performance of CA19-9/GGT (OS: C-index = 0.753, RFS: C-index = 0.745) was confirmed to be superior to other prognostic indicators according to the C-index. Compared with the simple AJCC staging system, the Nomogram prediction model (OS: C-index = 0.787, RFS: C-index = 0.795) established by the combination of CA19-9/GGT and AJCC 8th TNM staging system has higher prediction accuracy. CONCLUSIONS CA19-9/GGT was an independent prognostic indicator after radical resection of AC. Incorporating CA19-9/GGT into the AJCC TNM staging system optimized the prediction accuracy of the TNM staging system, and further verified the predictive value of CA19-9/GGT.
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Affiliation(s)
- Rui-Qiu Chen
- Department of Hepatobiliary Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Hebei, China
| | - Zhi-Lei Zhang
- Department of Hepatobiliary Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Hebei, China
| | - Yu-Ming Jia
- Department of Hepatobiliary Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Hebei, China
| | - Rui-Xiang Chen
- grid.256883.20000 0004 1760 8442Jianhua Campus, Hebei Medical University, shijiazhuang, China
| | - Li Peng
- Department of Hepatobiliary Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Hebei, China
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31
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Russell TB, Labib PLZ, Aroori S. Five-year follow-up after pancreatoduodenectomy performed for malignancy: A single-centre study. Ann Hepatobiliary Pancreat Surg 2023; 27:76-86. [PMID: 36168824 PMCID: PMC9947371 DOI: 10.14701/ahbps.22-039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/13/2022] [Accepted: 07/21/2022] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims The aim of this study was to describe short- and long-term outcomes of patients who underwent pancreatoduodenectomy (PD) at a typical United Kingdom hepatopancreatobiliary unit. Methods A retrospective analysis of all PD patients with histologically-confirmed pancreatic ductal adenocarcinoma (PDAC), ampullary adenocarcinoma (AA), or distal cholangiocarcinoma (CC) from September 1st, 2006 to May 31st, 2015 was carried out. The following information was obtained: demographics, comorbidities, preoperative investigations, neoadjuvant treatment, operative details, postoperative management, complications, adjuvant treatment, five-year recurrence, and five-year survival. Effects of selected preoperative variables on short- and long-term outcomes were investigated. Results Of 271 included patients, 57.9% had PDAC, 25.8% had AA, and 16.2% had CC. In total, 67.9% experienced morbidity and 17.3% developed a Clavien-Dindo grade ≥ III complication. The 90-day mortality was 3.3%. Clinically-relevant postoperative pancreatic fistula, bile leak, gastrojejunal leak, postpancreatectomy haemorrhage and delayed gastric emptying affected 8.1%, 4.1%, 0.0%, 9.2%, and 19.9% of patients, respectively. American Society of Anesthesiologists grade III-VI correlated with overall morbidity (p = 0.002) and major morbidity (p = 0.009), but not 90-day mortality or five-year survival. The same pattern was observed in patients with a preoperative serum bilirubin > 29 μmol/L and/or a neutrophil/lymphocyte ratio > 3.1. Five-year cancer recurrence and five-year survival were 68.3% and 22.5%, respectively. PDAC patients had higher five-year recurrence but lower five-year survival rates (both p = 0.001). Conclusions In our series, the majority of patients experienced a complication. However, few patients experienced major morbidity. Surgical risk factors did not affect five-year survival.
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Affiliation(s)
- Thomas Brendon Russell
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | | | - Somaiah Aroori
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom,Corresponding author: Somaiah Aroori, MD, FRCS Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth PL6 8DH, United Kingdom Tel: +44-7837388342, E-mail: ORCID: https://orcid.org/0000-0002-5613-6463
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32
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Li X, Chen L, Li J. Comparing the predictive performance of different lymph node staging systems for postoperative overall survival in patients with ampullary carcinoma. Front Surg 2023; 10:1002411. [PMID: 36923383 PMCID: PMC10008877 DOI: 10.3389/fsurg.2023.1002411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 01/10/2023] [Indexed: 03/01/2023] Open
Abstract
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.
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Affiliation(s)
- Xun Li
- Department of Blood Transfusion, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
| | - Lin Chen
- Department of Gastroenterology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
| | - Junli Li
- Department of Blood Transfusion, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, China
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Usenko OY, Kropelnytskyi VO, Shkarban VP, Tumasova KP, Pidopryhora OO. Morphological characteristics of the duodenal papilla magna tumors. KLINICHESKAIA KHIRURGIIA 2022. [DOI: 10.26779/2522-1396.2022.7-8.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Objective. Studying of morphological characteristics of the duodenal papilla magna malignant tumors on the own material of the Division of Pathological Anatomy and Cytology of the Shalimov National Institute of Surgery and Transplantology.
Materials and methods. Into the investigation 82 patients were included, to whom pancreaticoduodenectomy was performed for duodenal papilla magna malignant tumors in 2019 – 2021 yrs with further conduction of morphological analysis of the specimen excised. The average age of the patients have constituted (61.1 ± 8.1) yrs old.
Results. There were revealed 8 histological types of the tumors, most frequent of them – adenocarcinomas of pancreatobiliary and intestinal types. These two variants were compared. They did not differ for the age and gender (р>0,05), but statistically significantly differed for the histological differentiation degree and tumoral spread: р =0.039 and р = 0.003, accordingly. Thus, in the pancreatobiliary type of adenocarcinoma the tumors with low differentiation level (G3) were in 1.9 times more frequent, than in adenocarcinomas of intestinal type: 22.9 and 11.8%, and in 2.8 times more frequently the more spread tumors were revealed (рТ3а–Т3b): 65.7 and 23.5%, accordingly. As well, in the patients with adenocarcinomas of pancreatobiliary type a positive status of regional lymph nodes was revealed more frequently – in 57.1%, than in patients with adenocarcinomas of intestinal type – 44.1%.
Conclusion. Duodenal papilla magna malignant tumors – a heterogeneous group of tumors. Adenocarcinomas of pancreatobiliary and intestinal types are the most prevalent. Pancreatobiliary adenocarcinoma, as a histological type, is more aggressive, than intestinal adenocarcinoma.
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Apurva, Abdul Sattar RS, Ali A, Nimisha, Kumar Sharma A, Kumar A, Santoshi S, Saluja SS. Molecular pathways in periampullary cancer: An overview. Cell Signal 2022; 100:110461. [PMID: 36096460 DOI: 10.1016/j.cellsig.2022.110461] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/19/2022] [Accepted: 08/29/2022] [Indexed: 11/22/2022]
Abstract
Molecular alterations in oncogenes and tumor suppressors in various signaling pathways are basis for personalized therapy in cancer. Periampullary carcinoma behaves differently from pancreatic carcinoma both in prognosis and outcome, therefore it needs special attention. Pancreatic cancer have higher incidence of nodal spread and perineural &lymphovascular invasion suggesting it biologically more aggressive tumor compared to periampullary cancer. Since PAC tumors consist of heterogenous tissue of origin, they might contain different mutations in tumor associated genes and other changes in tissue composition among different subgroups clubbed together. Significant progress has been made in understanding the molecular nature of PAC in the previous two decades, and a large number of mutations and other genetic changes have been identified as being responsible for the disease. This review article targets to collate and discuss the molecular evolution of PAC and their implication in its outcome. As per literature, mitogen-activated protein kinase (MAPK), phosphatidylinositol-4,5-bisphosphate 3-kinase (PI3K), and Wnt signaling are the most common pathways involved in PAC. Mutations in KRAS, TP53, CTNNB1, SMAD4 and APC genes were the most frequently reported. I-subtype resembles colorectal cancer while the morphology of PB-type shows close resemblance to pancreatic tumors. The frequency of driver gene mutations is higher in I-type compared to PB-type of PAC indicating I-type to be genetically more unstable. The genetic landscape of PAC obtained from WES data highlighted PI3/AKT pathway to be a primary target in I-type and RAS/RAF in PB-type.
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Affiliation(s)
- Apurva
- Central Molecular Lab, GovindBallabhPant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India; Amity University, Noida, India
| | - Real Sumayya Abdul Sattar
- Central Molecular Lab, GovindBallabhPant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Asgar Ali
- Central Molecular Lab, GovindBallabhPant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Nimisha
- Central Molecular Lab, GovindBallabhPant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Abhay Kumar Sharma
- Central Molecular Lab, GovindBallabhPant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | - Arun Kumar
- Central Molecular Lab, GovindBallabhPant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India
| | | | - Sundeep Singh Saluja
- Central Molecular Lab, GovindBallabhPant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India; Department of GI Surgery, GovindBallabh Pant Institute of Postgraduate Medical Education and Research (GIPMER), New Delhi, India.
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Nishio K, Kimura K, Murata A, Ohira G, Shinkawa H, Kodai S, Amano R, Tanaka S, Shimizu S, Takemura S, Kanazawa A, Kubo S, Ishizawa T. Comparison of clinicopathological characteristics between resected ampullary carcinoma and carcinoma of the second portion of the duodenum. World J Gastrointest Surg 2022; 14:1219-1229. [PMID: 36504514 PMCID: PMC9727577 DOI: 10.4240/wjgs.v14.i11.1219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/10/2022] [Accepted: 10/20/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Few studies compared the oncological and biological characteristics between ampullary carcinoma (AC) and cancer of the second portion of the duodenum (DC-II), although both tumors arise from anatomically close locations.
AIM To elucidate differences in clinicopathological characteristics, especially the patterns of lymph node metastasis (LNM), between AC and DC-II.
METHODS This was a retrospective cohort study of 80 patients with AC and 27 patients with DC-II who underwent pancreaticoduodenectomy between January 1998 and December 2018 in two institutions. Clinicopathological factors, LNM patterns, and prognosis were compared between the two groups.
RESULTS The patients with AC and DC-II did not exhibit significant differences in 5-year overall survival (66.0% and 67.1%, respectively) and 5-year relapse-free survival (63.5% and 62.2%, respectively). Compared to the patients with DC-II, the rate of preoperative biliary drainage was higher (P = 0.042) and the rates of digestive symptoms (P = 0.0158), ulcerative-type cancer (P < 0.0001), large tumor diameter (P < 0.0001), and advanced tumor stage (P = 0.0019) were lower in the patients with AC. The LNM rates were 27.5% and 40.7% in patients with AC and DC-II, respectively, without significant difference (P = 0.23). The rates of LNM to hepatic nodes (N-He) and pyloric nodes (N-Py) were significantly higher in patients with DC-II than in those with AC (metastasis to N-HE: 18.5% and 5% in patients with DC-II and AC, respectively; P = 0.0432; metastasis to N-Py: 11.1% and 0% in patients with DC-II and AC, respectively; P = 0.0186)
CONCLUSION Although there were no significant differences in the prognosis and recurrence rates between the two groups, metastases to N-He and N-Py were more frequent in patients with DC-II than in those with AC.
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Affiliation(s)
- Kohei Nishio
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University, Osaka 5458585, Japan
| | - Kenjiro Kimura
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University, Osaka 5458585, Japan
| | - Akihiro Murata
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City General Hospital, Osaka 5340021, Japan
| | - Go Ohira
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University, Osaka 5458585, Japan
| | - Hiroji Shinkawa
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University, Osaka 5458585, Japan
| | - Shintaro Kodai
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City General Hospital, Osaka 5340021, Japan
| | - Ryosuke Amano
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University, Osaka 5458585, Japan
| | - Shogo Tanaka
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University, Osaka 5458585, Japan
| | - Sadatoshi Shimizu
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City General Hospital, Osaka 5340021, Japan
| | - Shigekazu Takemura
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University, Osaka 5458585, Japan
| | - Akishige Kanazawa
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka City General Hospital, Osaka 5340021, Japan
| | - Shoji Kubo
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University, Osaka 5458585, Japan
| | - Takeaki Ishizawa
- Department of Hepato-Biliary-Pancreatic Surgery, Osaka Metropolitan University, Osaka 5458585, Japan
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Utility of PET Scans in the Diagnosis and Management of Gastrointestinal Tumors. Dig Dis Sci 2022; 67:4633-4653. [PMID: 35908126 DOI: 10.1007/s10620-022-07616-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2022] [Indexed: 12/14/2022]
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Kantode VV, Sharma R, Wanjari MB, Munjewar PK, Tivaskar SP, Nakhale A. Adenocarcinoma of the Ampulla of Vater: A Case Report on a Rare Condition. Cureus 2022; 14:e29398. [PMID: 36304373 PMCID: PMC9585799 DOI: 10.7759/cureus.29398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/21/2022] [Indexed: 12/03/2022] Open
Abstract
An ampullary carcinoma (AC) is defined as cancer that arises in the ampulla of Vater (AV). It is a tiny opening in the beginning segment of the small intestine called the duodenum. Pancreatic and bile duct fluids are pumped into the intestines via the AV. There are various factors listed as the causes of AC. A 45-year-old male presented to the emergency department with complaints of pain in the abdomen for two months, vomiting for two days, and a history of fever for four days, which was persistent in nature. He had been operated on for endoscopic retrograde cholangiopancreatography (ERCP) stenting two months back due to pain in the abdomen. The patient underwent investigations such as blood tests, histopathology, ultrasonography, abdominal contrast-enhanced computed tomography (CECT), and ampullary mass biopsy, based on which a final diagnosis was made. The patient was operated on by the Whipple surgical procedure and was later treated with antibiotics and analgesics. Surgical management for AC is a novel treatment chosen instead of chemotherapy. Although early-stage AC can be cured with radical surgery, around half of the patients experience tumor recurrence. The prognosis of our patient was good.
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NCCN News. J Natl Compr Canc Netw 2022. [DOI: 10.6004/jnccn.2022.0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Xia MX, Shi ZM, Xing L, Gao DJ, Ye X, Wang TT, Wu J, Qian YW, Qin WH, Hu B. Endoscopic radiofrequency ablation may improve overall survival in patients with inoperable ampullary carcinoma. Dig Endosc 2022; 34:587-595. [PMID: 34233037 DOI: 10.1111/den.14078] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 06/25/2021] [Accepted: 07/06/2021] [Indexed: 12/08/2022]
Abstract
OBJECTIVES Patients with advanced ampullary carcinoma (AC) who are unsuitable for surgery are most likely to have poor outcomes. The role of endoscopic radiofrequency ablation (RFA) in this population has not been fully defined. We aimed to assess the short- and long-term outcomes of RFA in a large cohort of AC patients. METHODS In this retrospective study, data of consecutive patients with pathologically proven AC who underwent successful endobiliary RFA and/or stent placement were collected. All patients did not undergo surgical resection. The primary outcome was overall survival (OS). The secondary outcomes included clinical success and adverse events. RESULTS A total of 85 patients, 50 in the RFA plus stenting group and 35 in the stenting alone group, were identified. The median OS was significantly longer in the RFA group than in the stenting alone group (16.9 vs. 9.8 months, P < 0.001). In multivariable Cox analysis, RFA (hazards ratio 0.408; 95% confidence interval 0.235-0.706; P = 0.001) was the only independent OS predictor. Eight patients with stage II tumors, exclusively from the RFA group, survived for more than 3 years. Clinical success was comparable between the two groups (96% vs. 100%, P = 0.231). Early adverse events between the two groups were similar (10% vs. 2.9%, P = 0.206); however, late biliary/pancreatic stenoses occurred in three RFA patients who were successfully managed with endoscopic interventions. CONCLUSIONS Endoscopic RFA appears to prolong patients' survival with acceptable safety; it may therefore be a feasible treatment option for patients with inoperable ampullary cancers.
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Affiliation(s)
- Ming-Xing Xia
- Departments of, Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Zhi-Mei Shi
- Departments of, Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Ling Xing
- Departments of, Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Dao-Jian Gao
- Departments of, Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Xin Ye
- Departments of, Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Tian-Tian Wang
- Departments of, Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Jun Wu
- Department of Gastroenterology, Third Affiliated Hospital, Second Military Medical University, Shanghai, China
| | - You-Wen Qian
- Department of, Pathology, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Wen-Hao Qin
- Departments of, Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | - Bing Hu
- Departments of, Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China.,Department of Gastroenterology, Third Affiliated Hospital, Second Military Medical University, Shanghai, China
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Rațiu I, Lupușoru R, Lungeanu D, Popescu A, Sporea I, Goldiș A, Dănilă M, Miuțescu B, Moga T, Barbulescu A, Tăban S, Dema A, Șirli R. Diagnosis of malignant biliary obstruction: pondering over the ERCP, MRCP and histology. J Int Med Res 2022; 50:3000605221076924. [PMID: 35170356 PMCID: PMC8855398 DOI: 10.1177/03000605221076924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective To compare the diagnostic accuracy of endoscopic retrograde
cholangiopancreatography (ERCP), magnetic resonance pancreatography (MRCP)
and histological examination for malignant biliary obstruction. Methods This retrospective study included patients admitted for biliary obstruction
caused by biliary tree malignancy that underwent ERCP, MRCP and histological
examination. Data were collected from the medical records. The primary
endpoints were the area under the receiver operating characteristic (AUROC)
curve value, sensitivity, specificity and overall diagnostic accuracy of the
three procedures in terms of a final diagnosis of obstructive biliary
malignancy; and the agreement between ERCP, MRCP and histological
examination with the final diagnosis. Results A total of 160 patients were included in the study (85 males, 53.1%;
mean ± SD age, 69.31 ± 10.96 years). Considering the final diagnosis, the
performance of MRCP, ERCP and histology in assessing biliary tumours
produced AUROC values of 0.88 (95% confidence interval [CI] 0.75, 0.90),
0.94 (95% CI 0.85, 0.99) and 0.80 (95% CI 0.70, 0.82), respectively. ERCP
presented higher sensitivity, overall diagnostic accuracy and agreement with
the final diagnosis than MRCP and histological examination. Conclusion These current data suggest that invasive methods such as ERCP with biopsy
remain more reliable than non-invasive methods.
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Affiliation(s)
- Iulia Rațiu
- Advanced Regional Research Centre in Gastroenterology and Hepatology, Department of Internal Medicine II, Discipline of Gastroenterology and Hepatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Romania
| | - Raluca Lupușoru
- Advanced Regional Research Centre in Gastroenterology and Hepatology, Department of Internal Medicine II, Discipline of Gastroenterology and Hepatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Romania.,Centre for Modelling Biological Systems and Data Analysis, Department of Functional Sciences, "Victor Babes" University of Medicine and Pharmacy Timisoara, Romania
| | - Diana Lungeanu
- Centre for Modelling Biological Systems and Data Analysis, Department of Functional Sciences, "Victor Babes" University of Medicine and Pharmacy Timisoara, Romania
| | - Alina Popescu
- Advanced Regional Research Centre in Gastroenterology and Hepatology, Department of Internal Medicine II, Discipline of Gastroenterology and Hepatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Romania
| | - Ioan Sporea
- Advanced Regional Research Centre in Gastroenterology and Hepatology, Department of Internal Medicine II, Discipline of Gastroenterology and Hepatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Romania
| | - Adrian Goldiș
- Advanced Regional Research Centre in Gastroenterology and Hepatology, Department of Internal Medicine II, Discipline of Gastroenterology and Hepatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Romania
| | - Mirela Dănilă
- Advanced Regional Research Centre in Gastroenterology and Hepatology, Department of Internal Medicine II, Discipline of Gastroenterology and Hepatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Romania
| | - Bogdan Miuțescu
- Advanced Regional Research Centre in Gastroenterology and Hepatology, Department of Internal Medicine II, Discipline of Gastroenterology and Hepatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Romania
| | - Tudor Moga
- Advanced Regional Research Centre in Gastroenterology and Hepatology, Department of Internal Medicine II, Discipline of Gastroenterology and Hepatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Romania
| | - Andreea Barbulescu
- Advanced Regional Research Centre in Gastroenterology and Hepatology, Department of Internal Medicine II, Discipline of Gastroenterology and Hepatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Romania
| | - Sorina Tăban
- ANAPATMOL Research Centre, Discipline of Morphopathology, Department of Microscopic Morphology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Romania
| | - Alis Dema
- ANAPATMOL Research Centre, Discipline of Morphopathology, Department of Microscopic Morphology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Romania
| | - Roxana Șirli
- Advanced Regional Research Centre in Gastroenterology and Hepatology, Department of Internal Medicine II, Discipline of Gastroenterology and Hepatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Romania
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Kang J, Lee W, Shin J, Park Y, Kwon JW, Jun E, Song KB, Lee JH, Hwang DW, Park SY, Kim SC. Controversial benefit of 5-fluorouracil/leucovorin-based adjuvant chemotherapy for ampullary cancer: a propensity score-matched analysis. Langenbecks Arch Surg 2022; 407:1091-1097. [PMID: 35013798 DOI: 10.1007/s00423-021-02414-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 12/14/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although surgery is the primary treatment for ampullary cancer (AC), the benefit of adjuvant chemotherapy (CTx) has not yet been confirmed. METHODS AC patients who were administered 5-fluorouracil(FU)/leucovorin(LV)-based CTx after curative intent surgery between 2011 and 2019 were included. Prognosis was compared between the observation (OB) and CTx groups after propensity score matching (PSM) using perioperative variables to control differences in patient characteristics. RESULTS Before PSM, of 475 patients, those in the CTx group (n = 281) had worse 5-year overall survival (OS) (82.1% vs. 78.5%, p = 0.017) and worse 5-year recurrence-free survival (RFS) (54.9% vs. 75.7%, p < 0.001) than those in the OB group (n = 194). In addition, the CTx group had a higher rate of poor prognostic factors such as a high T stage (p < 0.001), node metastasis (p < 0.001), and poor differentiation (p < 0.001). After PSM, perioperative outcomes were comparable. In addition, there were no significant differences in OS (hazard ratio [HR], 1.085; 95% confidence interval [CI], 0.688-1.710; p = 0.726) or RFS (HR, 0.883; 95% CI, 0.613 1.272; p = 0.505) between the CTx (n = 123) and OB (n = 123) groups even after stratification by TNM stage. Intestinal subtype showed better 5-year OS (83.7% vs 33.2%, p = 0.015) and RFS (46.5% vs 24.9%, p = 0.035) rate compared with pancreatobiliary/mixed subtype. CONCLUSION Patients who received adjuvant chemotherapy based on 5-FU/LV showed comparable oncologic outcomes to patients in the OB group even after stratification by tumor stage. The patients with intestinal subtype showed oncologic benefit for adjuvant 5-FU/LV CTx compared with pancreatobiliary or mixed subtypes.
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Affiliation(s)
- Jaecheol Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Woohyung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea.
| | - Jaehoon Shin
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Yejong Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Jae Woo Kwon
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Eunsung Jun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Seo Young Park
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.,Department of Statistics and Data Science, Korea National Open University, Seoul, Republic of Korea
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, 05505, Republic of Korea
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Rare Orbital Metastasis Originating from Ampullary Adenocarcinoma. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57111238. [PMID: 34833456 PMCID: PMC8624159 DOI: 10.3390/medicina57111238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/12/2021] [Indexed: 12/13/2022]
Abstract
Background: Orbital metastasis from ampullary carcinoma is rare, with no previously reported cases. Case presentation: We report the case of a 60-year-old man who complained of a right-sided headache, blurred vision, progressive proptosis, ptosis, and right eye pain for 3 months. His past medical history included an ampullary adenocarcinoma stage IIIA treated via the Whipple procedure and adjuvant chemoradiotherapy 1 year ago. However, he was lost to follow-up. Computed tomography of the orbit showed a soft tissue lesion in the right orbital fossa measuring 3.3 × 2 × 2 cm. An orbital mass biopsy demonstrated an intestinal-type adenocarcinoma that tested positive for cytokeratins 7 and 20 and CDX2 on immunohistochemical staining. The pathologic diagnosis was metastatic adenocarcinoma from the ampulla of Vater. Despite oncological treatment, the patient’s illness progressed. He received palliative treatment and died 1 month later. Conclusions: We presented a rare case of orbital metastasis from ampullary adenocarcinoma. This should be considered in the differential diagnosis of patients with a history of ampullary adenocarcinoma who present with symptoms referring to the relevant locations.
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Mo W, Li J, Dai Y, Chen J, Xu X. A duodenal ampullary tumor with malignant transformation of papillary polyps: a case report and literature review. J Int Med Res 2021; 49:3000605211053230. [PMID: 34719989 PMCID: PMC8562643 DOI: 10.1177/03000605211053230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Periampullary carcinoma refers to a malignant tumor within 2 cm of the duodenal ampulla. Primary ampullary carcinoma is very rare, accounting for only 0.2% of malignant gastrointestinal tumors. The small intestine accounts for 75% of the length of the gastrointestinal tract, and primary tumors in the small intestine account for only 2% of all gastrointestinal tumors. Here, we report the case of a duodenal ampullary tumor with malignant transformation of parapapillary polyps. The patient had both a primary ampullary tumor and high-grade intraepithelial neoplasia of juxtapapillary adenomatous duodenal polyps.
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Affiliation(s)
- Wenhui Mo
- Department of Gastroenterology, Shidong Hospital of Shanghai, Shanghai 200433, People's Republic of China
| | - Jingjing Li
- Department of Gastroenterology, 12476Tongji University, Shanghai Tenth People's Hospital, Tongji University, Shanghai 200072, People's Republic of China
| | - Ying Dai
- Department of Gastroenterology, Shidong Hospital of Shanghai, Shanghai 200433, People's Republic of China
| | - Jianqing Chen
- Department of Gastroenterology, Shidong Hospital of Shanghai, Shanghai 200433, People's Republic of China
| | - Xuanfu Xu
- Department of Gastroenterology, Shidong Hospital of Shanghai, Shanghai 200433, People's Republic of China
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Ampullary Carcinoma: An Overview of a Rare Entity and Discussion of Current and Future Therapeutic Challenges. Curr Oncol 2021; 28:3393-3402. [PMID: 34590592 PMCID: PMC8482111 DOI: 10.3390/curroncol28050293] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 12/29/2022] Open
Abstract
Ampullary carcinomas (ACs) represent a rare entity, accounting for approximately 0.2% of all gastrointestinal solid tumors and 20% of all periampullary cancers (PACs). Unfortunately, few data are available regarding the optimal therapeutic strategy for ACs due to their rarity, and physicians frequently encounter significant difficulties in the management of these malignancies. In this review, we will provide an overview of current evidence on AC, especially focusing on biological features, histological characteristics, and available data guiding present and future therapeutic strategies for these rare, and still barely known, tumors.
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Establishment of Pancreatobiliary Cancer Zebrafish Avatars for Chemotherapy Screening. Cells 2021; 10:cells10082077. [PMID: 34440847 PMCID: PMC8393525 DOI: 10.3390/cells10082077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/06/2021] [Accepted: 08/10/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Cancers of the pancreas and biliary tree remain one of the most aggressive oncological malignancies, with most patients relying on systemic chemotherapy. However, effective biomarkers to predict the best therapy option for each patient are still lacking. In this context, an assay able to evaluate individual responses prior to treatment would be of great value for clinical decisions. Here we aimed to develop such a model using zebrafish xenografts to directly challenge pancreatic cancer cells to the available chemotherapies. Methods: Zebrafish xenografts were generated from a Panc-1 cell line to optimize the pancreatic setting. Pancreatic surgical resected samples, without in vitro expansion, were used to establish zebrafish patient-derived xenografts (zAvatars). Upon chemotherapy exposure, zAvatars were analyzed by single-cell confocal microscopy. Results: We show that Panc-1 zebrafish xenografts are able to reveal tumor responses to both FOLFIRINOX and gemcitabine plus nanoparticle albumin-bound (nab)-paclitaxel in just 4 days. Moreover, we established pancreatic and ampullary zAvatars with patient-derived tumors representative of different histological types. Conclusion: Altogether, we provide a short report showing the feasibility of generating and analyzing with single-cell resolution zAvatars from pancreatic and ampullary cancers, with potential use for future preclinical studies and personalized treatment.
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Lapisatepun W, Wongsa W, Chanthima P, Junrungsee S, Lapisatepun W. Higher cumulative fluid follows a pancreaticoduodenectomy as a single modifiable factor for post-operative pancreatic fistula: Risk factor analysis. Asian J Surg 2021; 45:401-406. [PMID: 34315667 DOI: 10.1016/j.asjsur.2021.06.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/24/2021] [Accepted: 06/30/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is one of the major complications after pancreaticoduodenectomy. There have been many studies into the risk factors determining POPF. Some studies have reported a higher peri-operative fluid balance associated with POPF, however, the pertinent findings remain controversial. The aims of this study were to determine risk factors of clinically relevant-post operative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy and an association between peri-operative fluid balance and the incidence of CR-POPF. MATERIALS AND METHODS This is a retrospective cohort study included all adult patients who underwent an elective open pancreaticoduodenectomy in our center from 2005 to 2018. Patients who did not have POPF related data were excluded from study. We divided patients into CR-POPF and no CR-POPF group. Peri-operative data including amount and type of fluid were compared between two groups. Logistic regression analysis was used to identify the independent risk factors of CR-POPF. RESULTS There were 223 pancreaticoduodenectomies done in our center during that period. The incidence of CR-POPF was 15.2 %. Patients in CR-POPF group had significant higher BMI, higher serum globulin level, smaller pancreatic duct diameter and higher cumulative fluid balance per body weight (FBPBW) at post-operative day 3. Multivariable analysis showed BMI >23 kg/m2, diagnosis other than pancreatic duct adenocarcinoma or chronic pancreatitis and higher cumulative FBPBW at post-operative day 3 were the independent risk factors for CR-POPF. CONCLUSIONS Post-operative fluid balance was the post-operative modifiable risk factor to reduce CR-POPF. Higher positive post-operative fluid balance should be avoided especially in higher CR-POPF risk patients.
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Affiliation(s)
- Warangkana Lapisatepun
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Weerapong Wongsa
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Phuriphong Chanthima
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Sunhawit Junrungsee
- Division of Hepatobiliary and pancreatic surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand
| | - Worakitti Lapisatepun
- Division of Hepatobiliary and pancreatic surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.
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Pothuri V, Herndon J, Ballentine SJ, Lim KH, Fields RC. A Case of a Pathological Complete Response to Neoadjuvant Nivolumab plus Ipilimumab in Periampullary Adenocarcinoma. Oncologist 2021; 26:722-726. [PMID: 33982365 DOI: 10.1002/onco.13821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 04/30/2021] [Indexed: 12/16/2022] Open
Abstract
Herein, we report on a patient with known Lynch syndrome and periampullary adenocarcinoma that exhibited a pathological complete response to neoadjuvant nivolumab plus ipilimumab. Two MSH2 mutations, high microsatellite instability, high tumor mutational burden, and elevated PD-L1 expression were identified by next-generation sequencing and immunohistochemistry. Following FOLFIRINOX (Fluorouracil/Leucovorin/Irinotecan/Oxaliplatin) administration and disease progression, nivolumab (1 mg/kg) and ipilimumab (3 mg/kg) were administered every 3 weeks for four total cycles. The patient responded well with minimal adverse effects and significant improvement in epigastric pain, appetite, and body weight. She then underwent resection consisting of pancreaticoduodenectomy, which demonstrated pathological complete response. Complete genomic profiling of periampullary carcinomas is crucial for optimal treatment selection as true ampullary masses and pancreatic ductal adenocarcinoma have different genetic profiles. This case provides an example of a patient who may have further benefited from first-line nivolumab plus ipilimumab to avoid the reduced efficacy and significant side effects associated with chemotherapy. KEY POINTS: A patient with known Lynch syndrome and ampullary adenocarcinoma harboring two MSH2 mutations, high microsatellite instability (MSI-high), high tumor mutational burden (TMB), and elevated PD-L1 expression achieved pathological complete response with neoadjuvant nivolumab plus ipilimumab. The combination of nivolumab plus ipilimumab may be a better first-line option for patients with ampullary adenocarcinomas harboring deficient mismatch repair, MSI-high, and high TMB. Complete genomic profiling of periampullary adenocarcinomas is crucial for optimal treatment selection as true ampullary masses and pancreatic ductal adenocarcinoma have different genetic profiles. The presence of either MSI-high or high TMB could be an appropriate predictive biomarker for response to nivolumab plus ipilimumab in the context of Lynch syndrome.
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Affiliation(s)
- Vikram Pothuri
- Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - John Herndon
- Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Samuel J Ballentine
- Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Kian-Huat Lim
- Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Ryan C Fields
- Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri, USA
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Comparison of Oncologic Outcomes between Transduodenal Ampullectomy and Pancreatoduodenectomy in Ampulla of Vater Cancer: Korean Multicenter Study. Cancers (Basel) 2021; 13:cancers13092038. [PMID: 33922504 PMCID: PMC8122928 DOI: 10.3390/cancers13092038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/19/2021] [Indexed: 12/15/2022] Open
Abstract
Simple Summary This study used multicenter data to compare the oncological safety of transduodenal ampullectomy (TDA) with that of pylorus-preserving pancreatoduodenectomy (PPPD) in early ampulla of Vater (AoV) cancer. Data for patients who underwent surgical resection for AoV cancer (pTis–T2 stage) from 2000 to 2019 were collected from 15 institutions. A total of 486 patients were enrolled (PPPD, 418; TDA, 68). The oncologic behavior (tumor size, T stage, differentiation, lymphovascular invasion) in the PPPD group was more aggressive than that in the TDA group at all T stages. The 5-year disease-free survival and overall survival did not differ between the two groups when considering all T stages or only the Tis + T1 group. In T1 patients, PPPD had survival outcomes superior to those in the TDA group. In the TDA group, lymph node dissection did not affect survival. In conclusion, PPPD should be the standard procedure for early AoV cancer. Abstract This study used multicenter data to compare the oncological safety of transduodenal ampullectomy (TDA) with that of pylorus-preserving pancreatoduodenectomy (PPPD) in early ampulla of Vater (AoV) cancer. Data for patients who underwent surgical resection for AoV cancer (pTis–T2 stage) from January 2000 to September 2019 were collected from 15 institutions. The clinicopathologic characteristics and survival outcomes were compared between the PPPD and TDA groups. A total of 486 patients were enrolled (PPPD, 418; TDA, 68). The oncologic behavior in the PPPD group was more aggressive than that in the TDA group at all T stages: larger tumor size (p = 0.034), advanced T stage (p < 0.001), aggressive cell differentiation (p < 0.001), and more lymphovascular invasion (p = 0.002). Five-year disease-free survival (DFS) and overall survival (OS) did not differ between the two groups when considering all T stages or only the Tis+T1 group. Among T1 patients, PPPD produced significantly better DFS (PPPD vs. TDA, 84.8% vs. 66.6%, p = 0.040) and superior OS (PPPD vs. TDA, 89.1% vs. 68.0%, p = 0.056) than TDA. Lymph node dissection (LND) in the TDA group did not affect DFS or OS (TDA + LND vs. TDA-only, DFS, p = 0.784; OS, p = 0.870). In conclusion, PPPD should be the standard procedure for early AoV cancer.
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Montoro-Huguet MA, Belloc B, Domínguez-Cajal M. Small and Large Intestine (I): Malabsorption of Nutrients. Nutrients 2021; 13:1254. [PMID: 33920345 PMCID: PMC8070135 DOI: 10.3390/nu13041254] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 02/06/2023] Open
Abstract
Numerous disorders can alter the physiological mechanisms that guarantee proper digestion and absorption of nutrients (macro- and micronutrients), leading to a wide variety of symptoms and nutritional consequences. Malabsorption can be caused by many diseases of the small intestine, as well as by diseases of the pancreas, liver, biliary tract, and stomach. This article provides an overview of pathophysiologic mechanisms that lead to symptoms or complications of maldigestion (defined as the defective intraluminal hydrolysis of nutrients) or malabsorption (defined as defective mucosal absorption), as well as its clinical consequences, including both gastrointestinal symptoms and extraintestinal manifestations and/or laboratory abnormalities. The normal uptake of nutrients, vitamins, and minerals by the gastrointestinal tract (GI) requires several steps, each of which can be compromised in disease. This article will first describe the mechanisms that lead to poor assimilation of nutrients, and secondly discuss the symptoms and nutritional consequences of each specific disorder. The clinician must be aware that many malabsorptive disorders are manifested by subtle disorders, even without gastrointestinal symptoms (for example, anemia, osteoporosis, or infertility in celiac disease), so the index of suspicion must be high to recognize the underlying diseases in time.
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Affiliation(s)
- Miguel A. Montoro-Huguet
- Departamento de Medicina, Psiquiatría y Dermatología, Facultad de Ciencias de la Salud y del Deporte, University of Zaragoza, 50009 Zaragoza, Spain
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge de Huesca, 22004 Huesca, Spain; (B.B.); (M.D.-C.)
- Aragonese Institute of Health Sciences (IACS), 50009 Zaragoza, Spain
| | - Blanca Belloc
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge de Huesca, 22004 Huesca, Spain; (B.B.); (M.D.-C.)
- Aragonese Institute of Health Sciences (IACS), 50009 Zaragoza, Spain
| | - Manuel Domínguez-Cajal
- Unidad de Gastroenterología, Hepatología y Nutrición, Hospital Universitario San Jorge de Huesca, 22004 Huesca, Spain; (B.B.); (M.D.-C.)
- Aragonese Institute of Health Sciences (IACS), 50009 Zaragoza, Spain
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Histopathologic Predictors of Survival and Recurrence in Resected Ampullary Adenocarcinoma: International Multicenter Cohort Study. Ann Surg 2020; 272:1086-1093. [PMID: 30628913 DOI: 10.1097/sla.0000000000003177] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of the study was to define histopathologic characteristics that independently predict overall survival (OS) and disease-free survival (DFS), in patients who underwent resection of an ampullary adenocarcinoma with curative intent. SUMMARY BACKGROUND DATA A broad range of survival rates have been described for adenocarcinoma of the ampulla of Vater, presumably due to morphological heterogeneity which is a result of the different epitheliums ampullary adenocarcinoma can arise from (intestinal or pancreaticobiliary). Large series with homogenous patient selection are scarce. METHODS A retrospective multicenter cohort analysis of patients who underwent pancreatoduodenectomy for ampullary adenocarcinoma in 9 European tertiary referral centers between February 2006 and December 2017 was performed. Collected data included demographics, histopathologic details, survival, and recurrence. OS and DFS analyses were performed using Kaplan-Meier curves and Cox proportional hazard models. RESULTS Overall, 887 patients were included, with a mean age of 66 ± 10 years. The median OS was 64 months with 1-, 3-, 5-, and 10-year OS rates of 89%, 63%, 52%, and 37%, respectively. Histopathologic subtype, differentiation grade, lymphovascular invasion, perineural invasion, T-stage, N-stage, resection margin, and adjuvant chemotherapy were correlated with OS and DFS. N-stage (HR = 3.30 [2.09-5.21]), perineural invasion (HR = 1.50 [1.01-2.23]), and adjuvant chemotherapy (HR = 0.69 [0.48-0.97]) were independent predictors of OS in multivariable analysis, whereas DFS was only adversely predicted by N-stage (HR = 2.65 [1.65-4.27]). CONCLUSIONS Independent predictors of OS in resected ampullary cancer were N-stage, perineural invasion, and adjuvant chemotherapy. N-stage was the only predictor of DFS. These findings improve predicting survival and recurrence after resection of ampullary adenocarcinoma.
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