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Substaging Nodal Status in Ampullary Carcinomas has Significant Prognostic Value: Proposed Revised Staging Based on an Analysis of 313 Well-Characterized Cases

  • Pancreatic Tumors
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Abstract

Background

Current nodal staging (N-staging) of ampullary carcinoma in the TNM staging system distinguishes between node-negative (N0) and node-positive (N1) disease but does not consider the metastatic lymph node (LN) number.

Methods

Overall, 313 patients who underwent pancreatoduodenectomy for ampullary adenocarcinoma were categorized as N0, N1 (1–2 metastatic LNs), or N2 (≥3 metastatic LNs), as proposed by Kang et al. Clinicopathological features and overall survival (OS) of the three groups were compared.

Results

The median number of LNs examined was 11, and LN metastasis was present in 142 cases (45 %). When LN-positive cases were re-classified according to the proposed staging system, 82 were N1 (26 %) and 60 were N2 (19 %). There was a significant correlation between proposed N-stage and lymphovascular invasion, perineural invasion, increased tumor size (each p < 0.001), and surgical margin positivity (p = 0.001). The median OS in LN-negative cases was significantly longer than that in LN-positive cases (107.5 vs. 32 months; p < 0.001). Patients with N1 and N2 disease had median survivals of 40 and 24.5 months, respectively (p < 0.0001). In addition, 1-, 3-, and 5-year survivals were 88, 76, 62 %, respectively, for N0; 90, 55, 31.5 %, respectively, for N1; and 68, 34, 30 %, respectively for N2 (p < 0.001). Even with multivariate modeling, the association between higher proposed N stage and shorter survival persisted (hazard ratio 1.6 for N1 and 1.9 for N2; p = 0.018).

Conclusions

Classification of nodal status in ampullary carcinomas based on the number of metastatic LNs has a significant prognostic value. A revised N-staging classification system should be incorporated into the TNM staging of ampullary cancers.

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Acknowledgment

The authors would like to thank Allyne Manzo and Lorraine Biedrzycki for assistance with the figures.

Disclosures

None of the authors have no affiliation with, or financial involvement in, any organization with a direct financial interest in the subject matter or materials discussed in the manuscript.

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Authors and Affiliations

  1. Department of Pathology and Laboratory Medicine, Emory University, Atlanta, GA, USA

    Serdar Balci MD, Pelin Bagci MD, Alyssa Krasinskas MD, Gizem Akkas MD, Michelle D. Reid MD & Volkan Adsay MD

  2. Department of Pathology, New York University, New York, NY, USA

    Olca Basturk MD

  3. Department of Pathology, İstanbul Medipol University, İstanbul, Turkey

    Burcu Saka MD

  4. Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA

    Lauren M. Postlewait MD, David A. Kooby MD & Shishir K. Maithel MD

  5. Department of Pathology, Tokai University Hachiouji Hospital, Tokyo, Japan

    Takuma Tajiri MD

  6. Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

    Kee-Taek Jang MD & Hyejeong Choi MD

  7. Department of Pathology, Showa University Fujigaoka Hospital, Tokyo, Japan

    Nobuyuki Ohike MD

  8. Department of Pathology, University of California San Francisco, San Francisco, CA, USA

    Grace E. Kim MD

  9. Division of General and Gastrointstinal Surgery, Emory University, Atlanta, GA, USA

    Juan M. Sarmiento MD

  10. Department of Oncology, Emory University, Atlanta, GA, USA

    Bassel F. El-Rayes MD

  11. Department of Epidemiology, Emory University, Atlanta, GA, USA

    Jessica H. Knight MPH & Michael Goodman MD, PhD

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  1. Serdar Balci MD
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  2. Olca Basturk MD
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Balci, S., Basturk, O., Saka, B. et al. Substaging Nodal Status in Ampullary Carcinomas has Significant Prognostic Value: Proposed Revised Staging Based on an Analysis of 313 Well-Characterized Cases. Ann Surg Oncol 22, 4392–4401 (2015). https://doi.org/10.1245/s10434-015-4499-y

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