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Open Access Research article

Intestinal-type of differentiation predicts favourable overall survival: confirmatory clinicopathological analysis of 198 periampullary adenocarcinomas of pancreatic, biliary, ampullary and duodenal origin

Peter Bronsert1, Ilona Kohler1, Martin Werner1, Frank Makowiec2, Simon Kuesters2, Jens Hoeppner2, Ulrich Theodor Hopt2, Tobias Keck23, Dirk Bausch23 and Ulrich Friedrich Wellner23*

Author Affiliations

1 Institute of Pathology, University of Freiburg, Breisacher Str. 115a, Freiburg 79106, Germany

2 Clinic for General and Visceral Surgery, University of Freiburg, Hugstetter Str. 55, Freiburg 79106, Germany

3 Clinic for Surgery, University of Schleswig-Holstein Campus Lübeck, Ratzeburger Allee 160, Lübeck 23582, Germany

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BMC Cancer 2013, 13:428  doi:10.1186/1471-2407-13-428

Published: 22 September 2013

Abstract

Background

Periampullary adenocarcinomas comprise pancreatic, distal bile duct, ampullary and duodenal adenocarcinoma. The epithelia of these anatomical structures share a common embryologic origin from the foregut. With steadily increasing numbers of pancreatoduodenectomies over the last decades, pathologists, surgeons and oncologists are more often confronted with the diagnosis of “other than pancreatic” periampullary cancers. The intestinal subtype of ampullary cancer has been shown to correlate with better prognosis.

Methods

Histological subtype and immunohistochemical staining pattern for CK7, CK20 and CDX2 were assessed for n = 198 cases of pancreatic ductal, distal bile duct, ampullary and duodenal adenocarcinoma with clinical follow-up. Routine pathological parameters were included in survival analysis performed with SPSS 20.

Results

In univariate analysis, intestinal subtype was associated with better survival in ampullary, pancreatic ductal and duodenal adenocarcinoma. The intestinal type of pancreatic ductal adenocarcinoma was not associated with intraductal papillary mucinous neoplasm and could not be reliably diagnosed by immunohistochemical staining pattern alone. Intestinal differentiation and lymph node ratio, but not tumor location were independent predictors of survival when all significant predictor variables from univariate analysis (grade, TNM stage, presence of precursor lesions, surgical margin status, perineural, vascular and lymphatic vessel invasion, CK7 and CDX2 staining pattern) were included in a Cox proportional hazards model.

Conclusions

Intestinal type differentiation and lymph node ratio but not tumor location are independent prognostic factors in pooled analysis of periampullary adenocarcinomas. We conclude that differentiation is more important than tumor location for prognostic stratification in periampullary adenocarcinomas.