Carcinoma of the Ampulla of Vater: Patterns of Failure Following Resection and Benefit of Chemoradiotherapy

Abstract

Purpose Ampullary carcinoma is a rare malignancy. Despite radical resection, survival rates remain low with high rates of local failure. We performed a single institution outcomes analysis to define the role of concurrent chemoradiotherapy (CRT) in addition to surgery. Methods A retrospective analysis was performed of all patients undergoing potentially curative pancreaticoduodenectomy for adenocarcinoma of the ampulla of Vater at Duke University Hospitals between 1976 and 2009. Time to event analysis was performed comparing all patients who underwent surgery alone to the cohort of patients receiving CRT in addition to surgery. Local control (LC), overall survival (OS), disease-free survival (DFS), and metastases-free survival (MFS) were estimated using the Kaplan-Meier Method. Results One hundred thirty-seven patients with ampullary carcinoma underwent Whipple procedure. Sixty-one patients undergoing resection received adjuvant (n= 43) or neoadjuvant (n=18) CRT. Patients receiving chemoradiotherapy were more likely to have poorly differentiated tumors (p=0.03). Of 18 patients receiving neoadjuvant therapy, 67% were downstaged on final pathology with 28% achieving pathologic complete response (pCR). With a median follow up of 8.8 years, three-year local control was improved in patients receiving CRT (88% vs. 55%, p= 0.001) with trend toward 3-year DFS (66% vs 48%, p=0.09) and OS (62% vs. 46%, p=0.074) benefit in patients receiving CRT. Conclusions Long term survival rates are low and local failure rates high following radical resection alone. Given patterns of relapse with surgery alone and local control benefit in patients receiving CRT, the use of chemoradiotherapy in selected patients should be considered.

Patterns of Failure for Stage I Ampulla of Vater Adenocarcinoma: A Single Institutional Experience

“…While this possible benefit was seen on secondary endpoint multivariate analysis (correcting for prognostic variables), approximately 47% of patients in this trial were diagnosed with T1/T2 tumors, and 41% were lymph node negative, although specific analysis of stage I patients was not pursued. The poor disease-related outcomes may potentially be explained by persistent locoregional/nodal disease outside the surgical resection field as demonstrated by Palta et al (5). In the present analysis of early stage patients from a larger group of patients, we hypothesized that adjuvant CRT may lead to improvements in LC and possibly OS, even in patients with relatively early stage tumors.…”

“…Given the location of these tumors, patients often present with relatively early stage disease with symptoms related to biliary obstruction. Given higher potential for surgical resection compared with other hepatobiliary tumors, prognosis is favorable, with multiple studies demonstrating 5-year overall survival (OS) rates ranging from 30% to 60% (2)(3)(4)(5)(6)(7)(8). Risk factors adversely impacting prognosis include positive surgical margins, nodal involvement, and tumor differentiation and size (9)(10)(11).…”

Prognostic Factors and Adjuvant Treatments for Surgically Treated Cancers of the Biliary Tract: A Multicentre Study of the Anatolian Society of Medical Oncology (ASMO)

“…Kim et al found that chemoradiotherapy decreases loco-regional relapse, but has no effect on survival when administrated for extrahepatic bile duct tumors (Kim et al, 2012). In another study, chemoradiotherapy increased the local control of ampulla vateri tumors, and it is observed that it could be used in the selected cases (Palta et al, 2012). Besides, in a study on gall bladder tumors performed by Wang et al, chemoradiotherapy increased survival especially in the patients with ≥T2 tumors or lymph node positivity (Wang et al, 2011).…”

Clinical implication of surgical resection for recurrent biliary tract cancer: Does it work or not?

“…Ampullary cancer has more favorable prognosis after surgical resection, with reported 5‐year overall survival rates of 37‐68% compared to only 10‐30% for resectable pancreatic cancer 55, 56. However, up to 50% of patients relapse after curative resection for ampullary cancer 57. Unfortunately, there are no standard options available in the postoperative management as a result of the rarity of the malignancy and the absence of prospective trials.…”