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JAMA Surg. 2019 May 29. doi: 10.1001/jamasurg.2019.1170. [Epub ahead of print]

Role of Adjuvant Multimodality Therapy After Curative-Intent Resection of Ampullary Carcinoma.

Author information

1
Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia.
2
Department of Surgery, University of Tennessee Health Science Center, Memphis.
3
Department of Surgery, University of Verona, Pancreas Institute, Verona, Italy.
4
Department of Surgery, Indiana University School of Medicine, Indianapolis.
5
Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
6
Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
7
Department of Surgery, Jefferson Medical College, Philadelphia, Pennsylvania.
8
Department of Surgery, Baylor College of Medicine, Houston, Texas.
9
Department of Surgery, University of Alabama School of Medicine, Birmingham.
10
Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
11
Department of Surgery, The Ohio State University Wexner Medical Center, Columbus.
12
Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Abstract

Importance:

Ampullary adenocarcinoma is a rare malignant neoplasm that arises within the duodenal ampullary complex. The role of adjuvant therapy (AT) in the treatment of ampullary adenocarcinoma has not been clearly defined.

Objective:

To determine if long-term survival after curative-intent resection of ampullary adenocarcinoma may be improved by selection of patients for AT directed by histologic subtype.

Design, Setting, and Participants:

This multinational, retrospective cohort study was conducted at 12 institutions from April 1, 2000, to July 31, 2017, among 357 patients with resected, nonmetastatic ampullary adenocarcinoma receiving surgery alone or AT. Cox proportional hazards regression was used to identify covariates associated with overall survival. The surgery alone and AT cohorts were matched 1:1 by propensity scores based on the likelihood of receiving AT or by survival hazard from Cox modeling. Overall survival was compared with Kaplan-Meier estimates.

Exposures:

Adjuvant chemotherapy (fluorouracil- or gemcitabine-based) with or without radiotherapy.

Main Outcomes and Measures:

Overall survival.

Results:

A total of 357 patients (156 women and 201 men; median age, 65.8 years [interquartile range, 58-74 years]) underwent curative-intent resection of ampullary adenocarcinoma. Patients with intestinal subtype had a longer median overall survival compared with those with pancreatobiliary subtype (77 vs 54 months; P = .05). Histologic subtype was not associated with AT administration (intestinal, 52.9% [101 of 191]; and pancreatobiliary, 59.5% [78 of 131]; P = .24). Patients with pancreatobiliary histologic subtype most commonly received gemcitabine-based regimens (71.0% [22 of 31]) or combinations of gemcitabine and fluorouracil (12.9% [4 of 31]), whereas treatment of those with intestinal histologic subtype was more varied (fluorouracil, 50.0% [17 of 34]; gemcitabine, 44.1% [15 of 34]; P = .01). In the propensity score-matched cohort, AT was not associated with a survival benefit for either histologic subtype (intestinal: hazard ratio, 1.21; 95% CI, 0.67-2.16; P = .53; pancreatobiliary: hazard ratio, 1.35; 95% CI, 0.66-2.76; P = .41).

Conclusions and Relevance:

Adjuvant therapy was more frequently used in patients with poor prognostic factors but was not associated with demonstrable improvements in survival, regardless of tumor histologic subtype. The value of a multimodality regimen remains poorly defined.

PMID:
31141112
PMCID:
PMC6547142
[Available on 2020-05-29]
DOI:
10.1001/jamasurg.2019.1170

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