| BackgroundPeriampullary carcinomas(PACs)are relatively rare malignant cancers of the digestive system and account for 5%of all gastrointestinal tract malignancies.PACs originate within 2cm of radius of the major papilla in the duodenum.They are comprised of 4 subgroups:duodenal carcinoma,distal cholangiocarcinoma,ampullary carcinoma and pancreatic head carcinoma.In patients with localized periampullary cancer,pancreaticoduodenectomy is the only treatment modality to offer a chance for cure.Because of the complex regional anatomy and nonspecific clinical symptoms,it is difficult to make diagnose early.Many patients with PACs are found to have locally advanced or metastatic disease at diagnosis that precludes surgical resection.Jaundice is one of the most common clinical symptoms and the main cause of the patients to seek treatment.At present,there is still a lack of specific biomarkers in serological examination of PACs.Imaging examination is the main way of diagnosis of PACs,including abdominal ultrasound,CT,MRI/MRCP,EUS,ERCP and so on.It provides a reference for radical surgical treatment of patients with PACs.Pathological examination is the gold standard for the diagnosis of PACs.In recent years,according to the morphological characteristics and immunohistochemical results,PACs can be divided into two types are widely accepted:pancreaticobiliary type and intestinal type,which have important guiding significance for prognosis judgment and the choice of chemotherapy plan for patients with PACs.The prognosis of patients with periampullary cancers is affected by many factors,including age,gender,tumor stage,tumor thrombus in vessels,adjuvant therapy,etc.Early diagnosis and treatment can significantly improve the prognosis of PACs.Previous studies have shown that the TNM stage and prognosis of patients without jaundice at diagnosis are better than those of patients with jaundice,which means jaundice generally occurs with a more advanced local progression,therefore,the key to early diagnosis and treatment of PACs is to pay attention to the symptoms in internal medicine of the pre-jaundice stage and to further examine it in time.ObjectiveTo compare the differences of clinical symptoms,serological examination,imaging detection rate,pathological stage,resectable rate and long-term survival rate between patients of PACs with and without jaundice at diagnosis and confirm the relationship between jaundice and long-term survival in patients with PACs.Besides,to analyze the prognostic factors of PACs and provide a reference for the early clinical diagnosis and treatment of the disease.MethodsClinical data for 518 patients with PACs admitted to The First Affiliated Hospital of Zhengzhou University from January 2012 and December 2017 were collected.All cases were confirmed by pathologists for PACs using histopathologic diagnosis method.Patients in the present study were divided into two groups according to serum total bilirubin at diagnosis:<34.2 μ mol/L for pre-jaundice group,n=125 cases and≥34.2 μmol/L for jaundice group,n=393 cases.Analyze retrospectively the differences in terms of gender,age,clinical manifestation,physical examination,laboratory examination,imaging examination,pathological characteristics,operation method,postoperative complications,adjuvant treatment and follow-up data between two groups,and summarize clinicopathological characteristics,treatment and prognosis of PACs.Data were analyzed by SPSS21.0 statistical software.The difference of clinicopathological characteristics between two groups was compared by the t-test,Mann-Whitney U test,and χ2 test.Survival was estimated using the Kaplan-Meier method.Prognostic factors influencing the overall survival were performed using the log-rank test and the Cox proportional hazard model.ResultsCompared with the jaundice group,the pre-jaundice group had a lower proportion of men and manifested higher percentage of abdominal distention and pain with longer duration.The extent of the decrease of red blood cell count,Albumin,Pre-albumin and the increase of alanine aminotransferase,aspartate aminotransferase,y-glutamyl transpeptidase,alkaline phosphatase and CA19-9 were lower(P<0.05).The detected rates of tumor masses by US,CT,MRI/MRCP,ERCP for the pre-jaundice group were 45.0%,77.7%,79.2%,100%,respectively.Pathologically,the median tumor size in the pre-jaundice group was larger,the proportion of pancreatic head cancer was higher while the proportion of distal common bile duct cancer was lower,and the T stage and positive rate of pancreatic invasion were lower(P<0.05).There was no significant difference in cell differentiation,histopathologic type,TNM staging,lymph node status,metastasis,resection margin status,perineural,and intravascular invasion between the two groups(P>0.05).The positive rate of CDX2 and CK20 was 100%in intestinal type and MUC1 was 100%in pancreaticobiliary type.The resection rate of the pre-jaundice group was lower than that in the jaundice group(P<0.05).The incidences of postoperative complications and the percentage of adjuvant treatment were not significantly different between two groups(P>0.05).Univariate analysis showed that the level of CA19-9 and CEA,the proportion of primary sites,histopathologic type,cell differentiation,lymph node status,pancreas infiltration,intravascular invasion,operation methods and postoperative chemotherapy were potential prognostic factors.Multivariate analysis showed that cell differentiation and postoperative chemotherapy were independent prognostic factors for patients with PACs.There was no significant difference in the overall survival curve between the two groups,but the 5-year survival rate of the pre-jaundice group was significantly higher than the jaundice group(P<0.05).Conclusion1.It is easy to misdiagnose and miss diagnosis due to its insidious onset and lack of specific symptoms in patients with PACs in the pre-jaundice stage.2.The clinicopathological characteristics and long-term survival rate of PACs patients in the pre-jaundice stage are better than those in the jaundice stage,and the prognosis can be improved if the diagnosis is clear and the surgical resection rate is increased when there is no icterus.3.Multivariate analysis showed that cell differentiation and adjuvant chemotherapy were independent prognostic factors for patients with PACs.4.For patients with abdominal pain,irregular fever,weight loss,anemia,and other alarm signals,but no obvious US abnormality was found in the first diagnosis,liver function,tumor markers,and US re-diagnosis should be closely monitored.5.We should strengthen the close follow-up of CA19-9 and CEA,further improve CT,MRI/MRCP,and other imaging examinations,which is helpful for the early detection of ampullary tumors. |
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