Influence of Preoperative Therapy on Short- and Long-Term Outcomes of Patients with Adenocarcinoma of the Ampulla of Vater

Abstract

Although these data do not support the routine administration of preoperative therapy to all patients with ampullary cancer, the delivery of preoperative therapy represents an alternative strategy that is associated with excellent short- and long-term outcomes and appears appropriate for a subset of patients.

Pathologic Response to Preoperative Therapy as a Novel Prognosticator for Ampullary and Duodenal Adenocarcinoma

“…11 However, this finding must be viewed in light of a possible selection bias: resectable patients with advanced disease were thought to possibly benefit from preoperative therapy due their comparatively higher disease burden. In fact, pathologic review of specimens following preoperative therapy and resection confirmed that poorly differentiated tumors were more common in patients with preoperative therapy compared to patients without preoperative therapy.…”

“…In general, patients were considered candidates for up-front resection when they were medically fit and able to undergo macroscopically curative resection. For patients with 1) pre-existing comorbidity, 2) disease perceived to be biologically advanced due to one or more well-defined clinical parameters (e.g., regional lymphadenopathy, advanced T stage, indeterminate liver/lung lesions), or 3) treatment of disease believed to be pancreatic ductal adenocarcinoma on the basis of existing clinical workup, 11, 22, 23 preoperative therapy (chemotherapy alone or chemoradiation) was administered. 11, 12, 24 Preoperative chemotherapy primarily consisted of regimens containing fluorouracil, capecitabine, or gemcitabine administered for 4 to 6 months.…”

“…For patients with 1) pre-existing comorbidity, 2) disease perceived to be biologically advanced due to one or more well-defined clinical parameters (e.g., regional lymphadenopathy, advanced T stage, indeterminate liver/lung lesions), or 3) treatment of disease believed to be pancreatic ductal adenocarcinoma on the basis of existing clinical workup, 11, 22, 23 preoperative therapy (chemotherapy alone or chemoradiation) was administered. 11, 12, 24 Preoperative chemotherapy primarily consisted of regimens containing fluorouracil, capecitabine, or gemcitabine administered for 4 to 6 months. 25, 26 When administered, external beam radiation was delivered using either a hypofractionated (10 fractions) or standard fractionated (28 fractions) regimen with concurrent fluorouracil, capecitabine, or gemcitabine.…”

“…In general, these therapeutic modalities were recommended for patients with high risk features associated with their cancer, such as positive lymph nodes, advanced T stage, R1 margin status, poor tumor differentiation or lymphovascular/perineural invasion. 11 Patients were followed routinely after surgery with history, physical examination, laboratory evaluations, and axial imaging every 3 to 4 months for the first 2 years and every 4 to 6 months for the subsequent 3 years.…”

“…2, 3 Previous retrospective study regarding localized AMPA demonstrated safety and feasibility of preoperative chemotherapy and/or chemoradiation, but suggested a limited role for the routine administration of preoperative therapies prior to intended resection. 11 In clinical practice at our institution, patients with DA or AMPA who frequently have bulky disease and/or regional adenopathy are likely to undergo preoperative therapy as recommended by the multidisciplinary care team. 12 …”