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Predictors of Outcome in Resected Ampullary Carcinoma, a Single Institution Experience
Joyce Wong*2,1, Zachary Thompson2, Barbara a. Centeno2, Evita B. Henderson-Jackson2, Christy Chai2, Pamela Hodul2
1Surgery, Penn State Hershey Medical Center, Hershey, PA; 2Moffitt Cancer Center, Tampa, FL
Introduction: Ampullary carcinomas are uncommon neoplasms, with surgical resection considered the main treatment. This study aims to evaluate factors which contribute to the overall survival (OS) and progression free survival (PFS) in patients undergoing resection.
Methods: From 1996-2013, a single institution database of patients with resected ampullary carcinomas was reviewed. Clinical and pathologic factors were correlated with outcome and disease recurrence using Kaplan Meier curves and Cox proportional hazard models where applicable.
Results: 91 patients were included in this study. There was a slight male predominance (55%), and the median age was 70 years (range 40-86). The most common presenting symptom was jaundice or increased liver function enzymes (50%), followed by abdominal pain (23%) and bleeding (10%). The median body mass index (BMI) was 26 (range 20-44), and the median hospital length of stay (LOS) was 13 days (range 6-43). 90 (99%) underwent pancreaticoduodenectomy and one (1%) underwent ampullectomy. The complication rate was 37%, of which pancreatic or bile leak was most common (41%), followed by intra-abdominal abscess (21%).
Median follow-up for the cohort was 18 months, with a median OS of 54 months. Number of examined lymph nodes (LN) impacted OS, with a LN count >10 having an improved OS compared to <10, p=0.025. Additionally, one or more positive LN and a LN ratio >=0.1 adversely affected OS. Well-differentiated tumors demonstrated the best OS, compared to moderate or poorly differentiated tumors, p=0.021. Pre-operative albumin, BMI, pathologic stage, presence of perineural or lymphovascular invasion, hospital LOS, and post-operative complications did not affect OS.
17 patients (19%) developed disease recurrence, most commonly with distant disease (N=12, 71%). Median PFS was 25 months. One or more positive LN, LN ratio, and tumor differentiation affected PFS. There was a trend towards worse PFS with higher pathologic stage, p=0.077. Patients with post-operative complications had worse PFS vs. those without a complication, p=0.026. Multivariate analysis demonstrated older age, lower number of examined LN, presence of positive LN, tumor location (periampullary duodenum), and poor tumor differentiation was associated with a worse OS. Older age, presence of positive LN, poor tumor differentiation, and post-operative complications adversely affected PFS. Adjuvant chemotherapy or radiation following resection did not affect either OS or PFS.
Conclusions: In this study, surgical detail, with avoidance of complications and retrieval of a greater number of lymph nodes, affected overall and disease-free survival to a greater degree than pathologic variables, except tumor differentiation. Adjuvant therapy did not appear to affect outcome.
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