Abstract
BackgroundPeriampullary adenocarcinomas comprise pancreatic, distal bile duct, ampullary and duodenal adenocarcinoma. The epithelia of these anatomical structures share a common embryologic origin from the foregut. With steadily increasing numbers of pancreatoduodenectomies over the last decades, pathologists, surgeons and oncologists are more often confronted with the diagnosis of “other than pancreatic” periampullary cancers. The intestinal subtype of ampullary cancer has been shown to correlate with better prognosis.MethodsHistological subtype and immunohistochemical staining pattern for CK7, CK20 and CDX2 were assessed for n = 198 cases of pancreatic ductal, distal bile duct, ampullary and duodenal adenocarcinoma with clinical follow-up. Routine pathological parameters were included in survival analysis performed with SPSS 20.ResultsIn univariate analysis, intestinal subtype was associated with better survival in ampullary, pancreatic ductal and duodenal adenocarcinoma. The intestinal type of pancreatic ductal adenocarcinoma was not associated with intraductal papillary mucinous neoplasm and could not be reliably diagnosed by immunohistochemical staining pattern alone. Intestinal differentiation and lymph node ratio, but not tumor location were independent predictors of survival when all significant predictor variables from univariate analysis (grade, TNM stage, presence of precursor lesions, surgical margin status, perineural, vascular and lymphatic vessel invasion, CK7 and CDX2 staining pattern) were included in a Cox proportional hazards model.ConclusionsIntestinal type differentiation and lymph node ratio but not tumor location are independent prognostic factors in pooled analysis of periampullary adenocarcinomas. We conclude that differentiation is more important than tumor location for prognostic stratification in periampullary adenocarcinomas.
Highlights
Periampullary adenocarcinomas comprise pancreatic, distal bile duct, ampullary and duodenal adenocarcinoma
A fundamental observation is that survival after resection of adenocarcinoma of periampullary location differs greatly, with DUOAC and AMPAC displaying a much better survival than pancreatic head PDAC or DBDAC, implying several issues of continued debate [2,3,4]
Patients and data For the purpose of this study, periampullary adenocarcinomas were defined as pancreatic head PDAC, DBDAC, AMPAC or DUOAC
Summary
Periampullary adenocarcinomas comprise pancreatic, distal bile duct, ampullary and duodenal adenocarcinoma. The present WHO classification of tumors distinguishes between pancreatic ductal (PDAC), extrahepatic (distal) bile duct (DBDAC), ampullary (AMPAC) and small intestinal (including duodenal, DUOAC) adenocarcinoma [1]. A fundamental observation is that survival after resection of adenocarcinoma of periampullary location (pancreatic head, distal bile duct, ampulla, duodenum) differs greatly, with DUOAC and AMPAC displaying a much better survival than pancreatic head PDAC or DBDAC, implying several issues of continued debate [2,3,4]. There is still considerable debate on how localization of adenocarcinomas and their precursor lesions arising in this region should be assessed [2,5] Another aspect is the question of the biological basis of the observed differences in survival. The INT type proved to be associated with considerably better prognosis than the PB subtype, which has been confirmed by several recent series [3,4,7]
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