E. C. Poli1,2, S. J. Stocker2, C. Wang2, V. Parini4, R. Marsh3, R. Prinz2, C. R. Hall2, M. S. Talamonti2 1University Of Chicago,Department Of General Surgery,Chicago, IL, USA 2Northshore University Health System,Department Of Surgery,Evanston, IL, USA 3Northshore University Health System,Section Of Gastrointestinal Oncology,Evanston, IL, USA 4Northwestern University,Comprehensive Cancer Center,Chicago, IL, USA
Introduction: Carcinoma of the ampulla of Vater accounts for 6.8-20% of all periampullary tumors. The purpose of this study was to determine prognostic factors affecting disease-free and overall survival following pancreaticoduodenectomy for localized, non-metastatic disease.
Methods: This was an IRB approved retrospective review of a prospectively maintained database of patients operated on for ampullary carcinoma from 1997-2014 at Northwestern Memorial and NorthShore University HealthSystem hospitals. Regression analyses were performed on clinical and pathologic data to determine significant predictors of recurrence and mortality.
Results: A total of 104 patients were included in the study: 52 (50%) were female; mean age of all patients was 64, and 90 (87%) were Caucasian. Eighty-one patients (78%) had a biliary stent placed prior to surgery. Tumor characteristics are as follows: T0/Tis 4 (4%), T1 10 (10%), T2 32 (31%), T3 39 (38%), T4 19 (18%); N0 51 (49%), N1 53 (51%). Lymphovascular invasion was present in 49 (49%) and perineural invasion in 31 (57%) patients. There was a positive resection margin in 3 (3%) patients. The median number of positive nodes was 2 and the median LN ratio was 0.13. Eighteen patients (34%) had a LN ratio >20%. Pathologic data with IHC staining was gathered for 63 patients; 20 (32%) had intestinal type, 37 (59%) had biliary type, and 4 (6%) had mixed tumors. Median follow-up was 39 months and 57 (56%) patients died during follow-up. The 5-year disease-free survival rate was 42% and the 5-year overall survival rate was 50%. On univariate analysis, factors that were significant predictors of recurrence included elevated serum bilirubin level (p=0.005, HR=1.1), AJCC Stage 3 (p=0.007, HR=3.1), tumor size > 20mm (p=0.029, HR= 2.1), positive node status (p=0.048, HR=1.9), perineural invasion (p=0.05, HR=2.5), and positive resection margin (p=0.003, HR=5.4). On multivariate analysis, elevated serum bilirubin and positive resection margin were significant for recurrence. Factors that were significant predictors of mortality on univariate analysis included tumor size >20mm (p=0.005, HR=2.3), positive node status (p=0.034, HR=1.8), major vessel involvement (p=0.014, HR=3.5), and AJCC stage (p=0.13, HR= 2.4). When controlling for T category, tumor size, major vessel involvement, and positive resection margin were significant on multivariate analysis and positive node status approached significance.
Conclusion: In this cohort of patients with ampullary cancers treated by surgical resection, the predominant determinants of recurrence and overall-survival included biologic and pathologic factors that reflect the extent of local and regional disease. The effectiveness of surgical intervention was driven by the ability to achieve a complete margin-negative extirpation of localized disease. These findings may help guide treatment recommendations for patients with poor prognostic factors as delineated in this series.