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The Prognostic Influence of Lymph Node Ratio Following Pancreaticoduodenectomy for Ampullary Adenocarcinoma
Nigel B. Jamieson*1, Julie Campbell1, Karin Oien2, Alan K. Foulis2, Euan J. Dickson1, Clem W. Imrie1, Colin Mckay1, Ross Carter1
1West of Scotland Pancreatic Unit, Glasgow University Department of Surgery, Glasgow Royal Infirmary, Glasgow, United Kingdom; 2University Department of Pathology, Glasgow Royal Infirmary, Glasgow, United Kingdom
Background Survival after surgery for ampullary cancer remains poor. Prognostic factors including tumour stage, lymph node (LN) status, and tumour grade have been identified. Described as the lymph node ratio (LNR), the number of involved LNs compared to the number examined has been prognostic in pancreatic adenocarcinoma. We sought to assess the prognostic value of LNR on a consecutive series of ampullary adenocarcinomas undergoing pancreaticoduodenectomy.MethodsRetrospective review of a prospective database of pancreaticoduodenectomies performed between 1997 and 2008 was undertaken. Clinicopathologic data was collected and the LNR calculated. Patients with positive LN status were grouped into: (1) LNR=0; (2) LNR 0.01-0.2; (3) LNR ≥0.2-0.4 and (4) LNR ≥0.4. Pa Survival outcome was compared using Kaplar-Meier/Cox proportional hazards analysis.Results95 ampullary adenocarcinomas were identified with a median survival for the cohort being 31.2months (95%CI:18.2-67.4). The median number of LNs harvested was 20.0 (95%CI:18.5-22.1). LN involvement was associated with other aggressive tumour characteristics including lymphovascular invasion, tumour stage and notably an elevated pre-operative C-reactive protein concentration (p<0.05). Overall LN status influenced survival with median survival for the 38 (44.7%) negative resections being 124months (95%CI:96.8-152.8) versus 23.3months for node-positive disease (95%CI:18.1-36.5). Increasing LNR was associated with decreased survival: LNR 0.01-0.2; 40.0months; LNR ≥0.2-0.4; 18.3months and LNR ≥0.4; 10.1months. On multivariate analysis LN status (Hazard ratio 4.6; 95%CI 2.6-9.6) and perineural invasion (Hazard ratio 3.3; 95%CI 1.5-7.3) maintained significance.ConclusionPositive LN status in ampullary adenocarcinoma is a strongly independent predictor of poor outcome. Pancreaticoduodenectomy is curative in 65% of patients with node-negative disease. Amongst the LN positive ampullary adenocarcinoma resections LNR was inversely associated with outcome.
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