UPPER GI ANZJSurg.com Prognostic factors for survival of patients with ampullary carcinoma after local resection Xiangqian Zhao, Jiahong Dong, Xiaoqiang Huang, Wenzhi Zhang and Kai Jiang Hospital and Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing, China Key words Abstract ampullary cancer, local resection, pathology, prognosis. Background: Local resection (LR) is a potentially effective alternative to Correspondence pancreaticoduodenectomy for treatment of ampullary cancer, but the prognostic Professor Jiahong Dong, Hospital and Institute of factors remain undefined. The purpose of this study was to identify the prognostic Hepatobiliary Surgery, Chinese PLA General Hospital, factors for ampullary cancer patients who had undergone LR. 28 Fuxing Road, Beijing 100853, China. Methods: We retrospectively reviewed the clinical, pathological data and surgical Email: [email protected] approach of 34 ampullary cancer patients who had undergone LR during 1996–2009 X. Zhao MD; J. Dong MD, PhD; X. Huang MD; at People’s Liberation Army General Hospital. Prognostic factors for survival and W. Zhang MD; K. Jiang MD. recurrence were analysed. Results: The 1-, 3- and 5-year survival rates of the patients were 97.1, 69.5 and 53.7%, Accepted for publication 3 March 2014. respectively. The gender, age, preoperative bilirubin levels, CA19-9 levels and preop- erative biopsy did not correlate with the survival rates. The survival rates of patient doi: 10.1111/ans.12600 with T1 and T2 tumours were superior to that of patients with T3 tumours (P = 0.000). Tumour size, surgical margin status and the extent of differentiation had no effect on survival rates (P = 0.464, P = 0.601 and P = 0.121, respectively). The survival rate of patients who had extraduodenal LR (12 cases) was superior to that of patients who had transduodenal LR (22 cases) (P = 0.026). Tumour recurrence occurred in 14 (41.2%) patients. Tumour infiltration (P = 0.014) correlated with the recurrence. Conclusion: The degree of tumour infiltration is the pathological factor that most affects the survival of ampullary cancer patients who undergo LR. Extraduodenal LR is a promising surgical procedure, the efficacy of which is superior to that of transduodenal LR. The depth of tumour invasion correlated with the recurrence. Introduction Transduodenal LR is the conventional surgical approach for ampullary cancer. Its main drawback is that the resection field is too Ampullary cancer is a rare cancer located in the duodenal papilla, small to permit complete resection of tumours at the distal end of the the mucosa around the papilla, the mucosa within the ampulla, the common bile duct, and extended resection is greatly limited. pancreatic duct opening, or the mucosa between the common bile However, the extraduodenal LR that we recently reported can expose duct and the duodenal wall. Ampullary cancer has a better prognosis the entire common bile duct, permit estimation of the resection than pancreatic cancer or cholangiocarcinoma,1 and surgical resec- length of the common bile duct according to the site of tumours and tion is associated with a satisfactory prognosis. The current surgical offer a better chance for complete removal of the tumours.5 In treatments for ampullary cancer are radical pancreatoduodenectomy addition, the extraduodenal approach permits excision of lymph (PD) and local resection (LR). Although PD is still the preferred nodes behind the pancreas and duodenum concurrently, if necessary. surgical procedure, it has a high rate of surgical trauma, post- However, predictive factors for survival of ampullary cancer operative mortality and complications;2 LR has a lower rate of these patients after operation vary in different reports. These factors outcomes. Nikfarjam et al.3 reported that the complication rate of include preoperative jaundice status,6 surgical margin status,7 the PD was as high as 71%, whereas the complication rate of LR was presence or absence of lymph node metastases,7–9 tumour size,10 20%. Feng et al.4 reported a complication rate of 34.8% and a blood vessel invasion,9 nerve invasion,8 tumour differentiation8 and mortality rate of 6.5% with PD compared with corresponding rates the degree of tumour infiltration.7,9–11 Additionally, the report about of 6.5 and 0% with LR. prognostic factors for LR is few. In view of this, we retrospectively © 2014 The Authors ANZ Journal of Surgery published by Wiley Publishing Asia Pty Ltd on behalf of Royal Australasian College of Surgeons ANZ J Surg 85 (2015) 567–571 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. 568 Zhao et al. analysed the clinical, pathological data and surgical approach of to the site entering the duodenum to find the tumour. A further ampullary cancer patients who had undergone LR at the Chinese circumferential incision along the duodenal papilla was made to People’s Liberation Army General Hospital from February 1996 to locate the main pancreatic duct at the connection between the duo- February 2009. We assessed the efficacy of LR and explored the denum and pancreas. The pancreatic duct was severed, the lower part prognostic factors for long-term survival and recurrence after the of the common bile duct and the papilla were excised. The pancre- operation. atic and common bile ducts were anastomosed to the duodenum.5 Pathology and follow-up Methods The general data (including surgical approach, gender, age, preop- Patients erative bilirubin levels, CA19-9 levels and preoperative biopsy) of Between 1996 and 2009, LR was performed on 35 ampullary carci- all 35 patients were reviewed. The gross specimens, the original noma patients at our hospital. pathology reports and the specimens were examined by two experi- enced pathologists who were blind to any prior knowledge regarding Inclusion criteria the clinical data. The histological type, diameter, degree of differen- All patients reviewed had histologically confirmed duodenal papilla tiation, depth of invasion, lymph node metastases, vascular invasion or ampullary adenocarcinoma. and surgical margin of the tumours were evaluated and recorded. Follow-up results were obtained for 34 of the 35 patients who had Exclusion criteria undergone LR, with a 97.1% follow-up rate. One patient was lost to Patients who had duodenal cancer, distal cholangiocarcinoma, pan- follow-up. Follow-up visits were performed once every 3 months creatic cancer, involvement of these cancers in the ampulla or duo- during the first year, re-examined once every 6 months during the denal papilla, and tumours of ambiguous origin. second and third years, and re-examined once a year later. Items checked during the follow-up visits included routine laboratory tests, Surgical indications and contraindications tumour markers, chest roentgenogram, abdominal ultrasound and computed tomography/magnetic resonance imaging. The follow-up LR was considered for patients who met one of the following con- deadline was 1 March 2011, and the follow-up duration ranged from ditions: (i) preoperative diagnosis of benign tumour or malignant 10 to 152 months, with a median duration of 36 months. transformation of benign tumour; negative biopsy of the base after local tumour resection; (ii) tumour diameter ≤3 cm; no infiltration outside the papilla of Vater; biopsy of the base after local tumour Statistical analysis resection was negative; (iii) well-differentiated cancer; histological All data were presented as figures and percentages and analysed by confirmation intraoperatively; negative biopsy of the base after local non-parametric tests, using SPSS 16.0 statistical software (SPSS, tumour resection; (iv) the patient was old or had poor general con- Inc., Chicago, IL, USA). Survival of ampullary carcinoma patients dition or other associated diseases that prevented PD but likely could was calculated using the Kaplan–Meier method, log-rank test and tolerate LR; (v) patients who refused PD but his or her physical Cox regression analysis. Logistic regression analysis was also per- condition allowed LR. formed to evaluate the prognostic parameters for recurrence. A value Patients with any of the following conditions were not considered of P < 0.05 was considered statistically significant. suitable for LR: (i) poor general condition, high risk of operative complications, unable to tolerate laparotomy; (ii) the presence of metastases to parenchymal organs or lymph nodes; (iii) duodenal Results obstruction; (iv) ulcerated bleeding tumour; (v) tumour invasion into the pancreas; (vi) positive basilar biopsy after LR; (vii) tumour Patient characteristics recurrence after LR. Patients’ clinical data are presented in Table 1. Of the 34 patients, 16 were men and 18 women, aged 30–75 years. There were 22 CA19- Surgery 9-negative patients and 12 CA19-9 positive. Preoperative jaundice Before 2000, LR was performed via the transduodenal approach; was present in 22 patients. Twenty-two patients were operated via after 2000, the patients were randomized to be operated via either the transduodenal approach and 12 via the extraduodenal approach. the transduodenal or the extraduodenal approach. Duodenoscopic biopsy of the papilla of Vater was performed before The transduodenal LR method has been described.12 For surgery in 22 patients. After LR, one patient received chemotherapy, extraduodenal