Abstract
BackgroundThe role of adjuvant chemoradiation therapy for ampullary carcinoma is unknown. Previous literature suggests that certain populations with high risk factors for recurrence may benefit from adjuvant chemoradiation. We combined the experience of two institutions to better delineate which patients may benefit from adjuvant chemoradiation.MethodsPatients who underwent curative surgery for ampullary carcinoma at the Johns Hopkins Hospital (n = 290; 1992-2007) and at the Mayo Clinic (n = 130; 1977-2005) were reviewed. Patients with <60 days of follow-up, metastatic disease at surgery, or insufficient pathologic data were excluded. The final combined study consisted of 186 patients (n = 104 Johns Hopkins, n = 82 Mayo). Most patients received 5-FU based chemoradiation with conformal radiation. Cox proportional hazards models were used for survival analysis.ResultsMedian overall-survival was 39.9 months with 2- and 5-year survival rates of 62.4% and 39.1%. On univariate analysis, adverse prognostic factors for overall survival included T3/T4 stage disease (RR = 1.86, p = 0.002), node positive status (RR = 3.18, p < 0.001), and poor histological grade (RR = 1.69, p = 0.011). Patients who received adjuvant chemoradiation (n = 66) vs. surgery alone (n = 120) showed a higher rate of T3/T4 stage disease (57.6% vs. 30.8%, P < 0.001), lymph node involvement (72.7% vs. 30.0%, P < 0.001), and close or positive margins (4.6% vs. 0.0%, P = 0.019). Five year survival rates among node negative and node positive patients were 58.7% and 18.4% respectively. When compared with surgery alone, use of adjuvant chemoradiation improved survival among node positive patients (mOS 32.1 vs. 15.7 mos, 5 yr OS: 27.5% vs. 5.9%; RR = 0.47, P = 0.004). After adjusting for adverse prognostic factors on multivariate analysis, patients treated with adjuvant chemoradiation demonstrated a significant survival benefit (RR = 0.40, P < 0.001). Disease relapse occurred in 37.1% of all patients, most commonly metastatic disease in the liver or peritoneum.ConclusionsNode-positive patients with resected ampullary adenocarcinoma may benefit from 5-FU based adjuvant chemoradiation. Since a significant proportion of patients develop metastatic disease, there is a need for more effective systemic treatment.
Highlights
The role of adjuvant chemoradiation therapy for ampullary carcinoma is unknown
This study demonstrated no survival benefit in patients with periampullary cancer at 2 or 5 years, but the number of patients with ampullary carcinoma was small, most of whom had favorable prognostic factors [14]
A third review from the Johns Hopkins Hospital (JHH) suggested a potential survival benefit from CRT in patients with resected ampullary carcinoma who had lymph node involvement, this finding was not statistically significant (p = 0.092) [17]. While these studies indicate that certain subsets of patients with ampullary carcinoma may benefit from postoperative CRT, they are limited by the small number of patients analyzed
Summary
The role of adjuvant chemoradiation therapy for ampullary carcinoma is unknown. Previous literature suggests that certain populations with high risk factors for recurrence may benefit from adjuvant chemoradiation. A third review from the Johns Hopkins Hospital (JHH) suggested a potential survival benefit from CRT in patients with resected ampullary carcinoma who had lymph node involvement, this finding was not statistically significant (p = 0.092) [17]. While these studies indicate that certain subsets of patients with ampullary carcinoma may benefit from postoperative CRT, they are limited by the small number of patients analyzed. We combine the experience of two of the aforementioned institutions, namely the Johns Hopkins Hospital and the Mayo Clinic, to compare surgery followed by modern conformal 5-FU based adjuvant CRT with surgery alone for patients with resectable carcinoma of the ampulla of Vater
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