Ampullary Cancer: Histological Subtypes, Markers, and Clinical Behaviour—State of the Art and Perspectives

Round 1

Reviewer 1 Report

Title: Different histological subtypes of ampullary cancer: histological aspects, immuno-phenotyping markers and clinical behaviours. State of the art and future perspectives

The manuscript deals with an interesting argument, the state of the art and future perspectives for the evaluation of patients with ampullary cancer (AACs) and the identification of the main subtypes of AACs.

The topic has a clinical relevance since the AACs are heterogeneous tumors currently classified into three important sub-classes: Intestinal (INT), Pancreato-Biliary (PB) and Mixed-Type (MT). The different subgroups have similar clinical presentation but they have different prognostic outcomes. The subtypes are often difficult to identify with conventional histology alone. The clinical outcome of all three remains unclear, particularly for MT. 

The manuscript is well written: the title reflects the main subject of the article, abstract well summarize the arguments. 

Each section is well articulated according to the most recent literature and the authors have clearly underlined the most vital points from the current knowledge. 

The tables/figures are representatives and of good quality.

The manuscript cites appropriately the latest and authoritative references.

Author Response

General Comment: The manuscript deals with an interesting argument, the state of the art and future perspectives for the evaluation of patients with ampullary cancer (AACs) and the identification of the main subtypes of AACs. The topic has a clinical relevance since the AACs are heterogeneous tumors currently classified into three important sub-classes: Intestinal (INT), Pancreato-Biliary (PB) and Mixed-Type (MT). The different subgroups have similar clinical presentation but they have different prognostic outcomes. The subtypes are often difficult to identify with conventional histology alone. The clinical outcome of all three remains unclear, particularly for MT. The manuscript is well written: the title reflects the main subject of the article, abstract well summarize the arguments. Each section is well articulated according to the most recent literature and the authors have clearly underlined the most vital points from the current knowledge. The tables/figures are representatives and of good quality. The manuscript cites appropriately the latest and authoritative references.

Reply: We would like to thank the reviewer for taking the time to read and comment on our work. We are very happy to receive this great evaluation. No addition consideration we have.

Reviewer 2 Report

Dear Authors

MY SUGGESTIONS ARE IN CAPITAL LETTERS

The title is too long. I would suggest something like:

AMPULLARY CANCER: HISTOLOGICAL SUBTYPES, MARKERS AND CLINICAL BEHAVIOUR. STATE OF THE ART AND PERSPECTIVES.

Abstract

There are different cancers in the peri-ampullary region including pancreatic ductal  adenocarcinoma (PDAC), duodenum cancers (DC) and ampullary adenocarcinoma (AACs), where, significant morphological-molecular characterizations should be necessary for the distinction of  primary tumor and classification of their subtype of cancers.

THIS SENTENCE IS TOO LONG. DIVIDE IT IN TWO SENTENCES.

up to five different variant  according different point of view

UP TO FIVE DIFFERENT VARIANTS ACCORDING TO DIFFERENT POINTS OF VIEW

concerning the prevalence of  the most two cellular component prevalently present in the ampullary district

ABOUT THE PREVALENCE OF THE TWO MORE CELLULAR COMPONENTS FOUND IN THE AMPULLA.

i AM UNHAPPY WITH THIS SENTENCE AND I DO NOT FULLY UNDERSTAND WHAT YOU WANT TO SAY.

In particular, looking in the AACs

IN PARTICULAR REGARDING AACs

had been impacting with clinical management

HAS BEEN IMPACTING CLINICAL MANAGEMENT

the responsiveness to therapeutic regimen and OS  survival after surgical treatment.

RESPONSE TO TREATMENT AND OVERALL SURVIVAL (OS) AFTER SURGERY

In fact, the PB identification is associated with a worse clinical outcome of AAC patients. 

PB IS ASSOCIATED WITH A WORSE CLINICAL OUTCOME

Otherwise, the criteria through them is possible to attribute their subtype classification are not well established

I DO NOT UNDERSTAND THE SENTENCE. DELETE.

A triad of immune-markers represented by CK7, CK20 and CDX-2 seems to represent the best compromise in order to split the cohort of AACs patients in INT and PB group. 

IMMUNO-MARKERS CK7, CK20 AND CDX-2 ARE USEFUL TO DISTINGUISH INT FROM PB.

 The test of choice for the sub-classification of AACs, is represented by the immuno- histochemical approach, in which, its molecular classification acquire its diagnostic predictive and prognostic value for both INT and PB patients.

REPETITIVE

INTRODUCTION

) in case of origin from pancreatobiliary epithelium

WHEN IT ORIGINATES FROM PANCREATOBILIARY EPITHELIUM

 in case of origin from the intestinal epithelium one

WHEN ORIGINATED FROM THE INTESTINAL EPITHELIUM

Aim of this article 

THE OBJECTIVE OF THIS ARTICLE

A great step forward into the understanding of ampullary adenocarcinoma was done in 1994 by Kimura et al. [4], firstly describing two distinct histological subtypes of ampullary cancer

A GREAT STEP FORWARD FOR THE UNDERSTANDING OF AMPULLARY ADENOCARCINOMA WAS THE PUBLICATION BY KIMURA ET AL., IN 1994 DESCRIBING FOR THE FIRST TIME TWO DISTINCT HISTOLOGICAL SUBTYPES 

 the intestinal one, originating from the intestinal epithelium of the papilla, and the pancreaticobiliary one,  originating from the epithelium of the Wirsung duct. 

1) THE INTESTINAL SUBTYPE ORIGINATED FROM INTESTINAL EPITHELIUM OF THE PAPILLA, AND

2) THE PANCREATOBILIARY SUBTYPE ORIGINATED FROM THE EPITHELIUM OF THE WIRSUNG DUCT.

From the publication of this study,  several studies adopted this distinction of ampullary a

SINCE THIS PUBLICATION, SEVERAL STUDIES HAVE ADOPTED THIS DISTINCION

These two kinds of ampullary cancer have evidently different histological

. The intestinal-subtype of AAC

THE INTESTINAL AAC SUBTYPE

a classical evolution through an adenoma–dysplasia–adenocarcinoma sequence, commonly observed in the pathogenesis of colo-rectal cancer 

IN THE REFERENCES YOU HAVE TO INCLUDE THE SEMINAL PAPER BY

Vogelstein B, Kinzler KW. The multistep nature of cancer. Trends in genetics. 1993 Apr 1;9(4):138-41.

AND

Fearon ER, Vogelstein B. A genetic model for colorectal tumorigenesis. cell. 1990 Jun 1;61(5):759-67.

precursor PanIn

INTRADUCTAL IN SITU CARCINOMA (PANIN)

ADD REFERENCE

Basturk O, Hong SM, Wood LD, Adsay NV, Albores-Saavedra J, Biankin AV, Brosens LA, Fukushima N, Goggins M, Hruban RH, Kato Y. A revised classification system and recommendations from the Baltimore consensus meeting for neoplastic precursor lesions in the pancreas. The American journal of surgical pathology. 2015 Dec;39(12):1730.

Generally, PB is more frequently observed if compared with INT (70% vs 30%, respectively);

REGARDING THE TWO SUBTYPES, PB HAS A HIGHER INCIDENCE (PB 70% VS. INT 30%)

 It’s important to note

IT IS IMPORTANT TO UNDERSCORE THAT THIS DISTINCTION OF AAC IS NOT ACCEPTED BY SOME AUTHORS

SEER database

SURVEILLANCE, EPIDEMIOLOGY, AND END RESULTS PROGRAM OF THE NATIONAL CANCER INSTITUTE OF USA (SEER) DATABASE

for this reason, often it’s difficult

THUS IT IS OFTEN DIFFICULT

 survival of PB patients was poorer than those within INT ones

SURVIVAL OF PATIENTS WITH PB WAS POORER THAN THOSE WITH INT.

on which median DFS was 25.3 month

IN WHICH....

. In confirmation of these results, 

CONFIRMING THESE RESULTS

due to rarity of disease, most of published studies

DUE TO THE RARITY OF THE DISEASE MOST PUBLISHED STUDIES

as compared with those

COMPARED TO PATIENTS WITH INT

 Strengths of this meta-analysis were

THE STRENGTH OF THIS META-ANALYSIS WAS 

in a large reported patient cohort

In conclusion, we can state that

WE CAN CONCLUDE THAT

that PB type

THAT PB SUBTYPE

If compared with INT one,

WHEN COMPARED WITH INT,

 on MIX type could be  done,

ON MIX TYPE COULD BE REACHED 

The needed of adjuvant therapy after resection

THE NEED ...

 that no high-level of evidence studies have been published on the available literature. 

THAT THERE IS NO ENOUGH AVAILABLE EVIDENCE

 however, it’s important to note

HOWEVER, IT IS IMPORTANT TO UNDERSCORE

specifically for  AC,

SPECIFICALLY FOR ACC 

with the aim to evaluate the role.

WITH THE OBJECTIVE OF EVALUATING THE ROLE

 it’s impossible to state

IT IS IMPOSIBLE TO KNOW

In conclusion, there is no consensus on the efficacy of adjuvant therapy for AAC, due  to the lack of evidence of the available literature, even if it seems to give some benefit if compared with surgery group alone

IN CONCLUSION, THERE IS NO CONSENSUS ON THE EFFICACY OF ADJUVANT THERAPY. ALTHOUGH SOME BENEFITS CAN BE REACHED WHEN COMPARED WITH THE ONLY-SURGERY GROUP.

"Can we better classify ampullary carcinomas?"

CAN WE IMPROVE AMPULLARY CARCINOMA CLASSIFICATION?

As well reported previously, 

based on five subtype

BASED ON FIVE SUBTYPES

analyses

ANALYSIS

Nevertheless, in order to simplify this classification is not too easy and the efforts of pathologists supported by the biomarkers utilization, are fundamental for the following clinical management of AACs patients

IT IS NOT EASY TO SIMPLIFY THIS CLASSIFICATION.

PATHOLOGISTS WITH THE SUPPORT OF BIOMARKERS ARE FUNDAMENTAL PLAYERS IN CLINICAL MANAGEMENT.

IT WOULD BE USEFUL TO INCLUDE A FIGURE WITH HISTOLOGICAL SAMPLES REPRESENTING THE DIFFERENT ACCS.

In the 1994 some authors

IN 1994, KIMURA ET AL. WERE THE FIRST...

based on histological observations only

BASED SOLELY ON HISTOLOGICAL FINDINGS

 In this study, the authors higllighted a different prognostic impact between two subtypes, with a long-term survival after Surgery significantly greater in patients with intestinal type (INT) of AACs than in those with pancreatobiliary type (PB) 

IN THIS STUDY THE AUTHORS FOUND A LONGER SURVIVAL AFTER SURGERY IN PATIENTS WITH INTESTINAL SUBTYPE COMPARED TO THE PANCREATOBILIARY SUBTYPE.

Just about 10 years ago,

 the utility of IHC inside the histological classification of sub-types of AAC

THE USEFULNESS OF IHC FOR HISTOLOGICAL CLASSIFICATION.

A different immuno-histochemical panels

The INT group of tumor usually express

TUMORS OF THE INT GROUP USUALLY EXPRESS

PB phenotype stains for CK7 247 and MUC1, MUC5A

PB PHENOTYPE EXPRESSES CK7, MUC1, AND MUC5A. 

 Nevertheless, the hybrid cellular implications in ampullary tumors, collaborate in a mixed histomorphologic phenotype of the two subgroups

THE HYBRID CELLULAR TUMORS SHOW HISTOMORPHOLOGIC FEATURES OF BOTH SUBGROUPS.

 Conclusions 

The AAC ampullary tumors are a heterogeneous group of malignancies in which, probably, the protagonists of the game are two tumor subtypes: the intestinal type (INT)  and the pancreatobiliary type (PB). However, their identification did not emerge  immediately through histo-pathological analyses, where immunoimmune-phenotypic 304 characterization seems to be the goal of clinicians, who manage to place patients on both 305 sides of the river.  In fact, immunoimmuno-characterization performed using the best triage of 307 biomarkers (CK7, CK20 and CDX2), seems to acquire its perfect role as a prognostic and 308 Curr. Oncol. 2023, 30, FOR PEER REVIEW 9 predictive diagnostic factors. However, CDX2 may be the "judge" of the fate of  patients. Indeed, CDX2 appears to be choosing between Dr. Jakill and Mr. Hide in AAC,  but who's who? 

AAC AMPULATORY TUMORS REPRESENT A GROUP OF HETEROGENEOUS MALIGNANCIES IN WHICH TWO SUBTYPES ARE THE MAJOR PLAYERS: INT AND PB. INTERESTINGLY, THE SOURCE OF THIS CLASSIFICATION IS NOT THE HISTOLOGICAL STUDY BUT THE IMMUNOMARKER CHARACTERIZATION.

TISSUE BIOMARKERS SUCH AS CK7, CK20 AND CDX2 PERMIT ESTABLISHING A PROGNOSTIC AND PREDICTIVE FORECAST.

Comments on English language have been included in the previous segment.

Author Response

General Comment: Dear Authors, MY SUGGESTIONS ARE IN CAPITAL LETTERS

The title is too long. I would suggest something like:

• AMPULLARY CANCER: HISTOLOGICAL SUBTYPES, MARKERS AND CLINICAL BEHAVIOUR. STATE OF THE ART AND PERSPECTIVES.

Abstract.

2) There are different cancers in the peri-ampullary region including pancreatic ductal  adenocarcinoma (PDAC), duodenum cancers (DC) and ampullary adenocarcinoma (AACs), where, significant morphological-molecular characterizations should be necessary for the distinction of  primary tumor and classification of their subtype of cancers. THIS SENTENCE IS TOO LONG. DIVIDE IT IN TWO SENTENCES.

3) up to five different variant  according different point of view. UP TO FIVE DIFFERENT VARIANTS ACCORDING TO DIFFERENT POINTS OF VIEW

4) concerning the prevalence of  the most two cellular component prevalently present in the ampullary district. ABOUT THE PREVALENCE OF THE TWO MORE CELLULAR COMPONENTS FOUND IN THE AMPULLA.

i AM UNHAPPY WITH THIS SENTENCE AND I DO NOT FULLY UNDERSTAND WHAT YOU WANT TO SAY.

5) In particular, looking in the AACs. IN PARTICULAR REGARDING AACs

6) had been impacting with clinical management. HAS BEEN IMPACTING CLINICAL MANAGEMENT

7) the responsiveness to therapeutic regimen and OS  survival after surgical treatment. RESPONSE TO TREATMENT AND OVERALL SURVIVAL (OS) AFTER SURGERY

8) In fact, the PB identification is associated with a worse clinical outcome of AAC patients. PB IS ASSOCIATED WITH A WORSE CLINICAL OUTCOME

9) Otherwise, the criteria through them is possible to attribute their subtype classification are not well established. I DO NOT UNDERSTAND THE SENTENCE. DELETE.

10) A triad of immune-markers represented by CK7, CK20 and CDX-2 seems to represent the best compromise in order to split the cohort of AACs patients in INT and PB group.  IMMUNO-MARKERS CK7, CK20 AND CDX-2 ARE USEFUL TO DISTINGUISH INT FROM PB.

 The test of choice for the sub-classification of AACs, is represented by the immuno- histochemical approach, in which, its molecular classification acquire its diagnostic predictive and prognostic value for both INT and PB patients. REPETITIVE

INTRODUCTION

11) in case of origin from pancreatobiliary epithelium. WHEN IT ORIGINATES FROM PANCREATOBILIARY EPITHELIUM

 12) in case of origin from the intestinal epithelium one. WHEN ORIGINATED FROM THE INTESTINAL EPITHELIUM

13) Aim of this article . THE OBJECTIVE OF THIS ARTICLE

14) A great step forward into the understanding of ampullary adenocarcinoma was done in 1994 by Kimura et al. [4], firstly describing two distinct histological subtypes of ampullary cancer. A GREAT STEP FORWARD FOR THE UNDERSTANDING OF AMPULLARY ADENOCARCINOMA WAS THE PUBLICATION BY KIMURA ET AL., IN 1994 DESCRIBING FOR THE FIRST TIME TWO DISTINCT HISTOLOGICAL SUBTYPES 

 15) the intestinal one, originating from the intestinal epithelium of the papilla, and the pancreaticobiliary one,  originating from the epithelium of the Wirsung duct. a) THE INTESTINAL SUBTYPE ORIGINATED FROM INTESTINAL EPITHELIUM OF THE PAPILLA, AND b) THE PANCREATOBILIARY SUBTYPE ORIGINATED FROM THE EPITHELIUM OF THE WIRSUNG DUCT.

16) From the publication of this study,  several studies adopted this distinction of ampullary a SINCE THIS PUBLICATION, SEVERAL STUDIES HAVE ADOPTED THIS DISTINCION

17) These two kinds of ampullary cancer have evidently different histological. The intestinal-subtype of AAC. THE INTESTINAL AAC SUBTYPE

18) a classical evolution through an adenoma–dysplasia–adenocarcinoma sequence, commonly observed in the pathogenesis of colo-rectal cancer . IN THE REFERENCES YOU HAVE TO INCLUDE THE SEMINAL PAPER BY

Vogelstein B, Kinzler KW. The multistep nature of cancer. Trends in genetics. 1993 Apr 1;9(4):138-41.

AND

Fearon ER, Vogelstein B. A genetic model for colorectal tumorigenesis. cell. 1990 Jun 1;61(5):759-67.

precursor PanIn

19) INTRADUCTAL IN SITU CARCINOMA (PANIN)

ADD REFERENCE

Basturk O, Hong SM, Wood LD, Adsay NV, Albores-Saavedra J, Biankin AV, Brosens LA, Fukushima N, Goggins M, Hruban RH, Kato Y. A revised classification system and recommendations from the Baltimore consensus meeting for neoplastic precursor lesions in the pancreas. The American journal of surgical pathology. 2015 Dec;39(12):1730.

20) Generally, PB is more frequently observed if compared with INT (70% vs 30%, respectively); REGARDING THE TWO SUBTYPES, PB HAS A HIGHER INCIDENCE (PB 70% VS. INT 30%)

 21) It’s important to note. IT IS IMPORTANT TO UNDERSCORE THAT THIS DISTINCTION OF AAC IS NOT ACCEPTED BY SOME AUTHORS

21) SEER database. SURVEILLANCE, EPIDEMIOLOGY, AND END RESULTS PROGRAM OF THE NATIONAL CANCER INSTITUTE OF USA (SEER) DATABASE

22) for this reason, often it’s difficult. THUS IT IS OFTEN DIFFICULT

 23) survival of PB patients was poorer than those within INT ones. SURVIVAL OF PATIENTS WITH PB WAS POORER THAN THOSE WITH INT.

24) on which median DFS was 25.3 month, IN WHICH....

25) In confirmation of these results, CONFIRMING THESE RESULTS

26) due to rarity of disease, most of published studies. DUE TO THE RARITY OF THE DISEASE MOST PUBLISHED STUDIES

27) as compared with those. COMPARED TO PATIENTS WITH INT

 28) Strengths of this meta-analysis were. THE STRENGTH OF THIS META-ANALYSIS WAS 

30) in a large reported patient cohort

31) In conclusion, we can state that. WE CAN CONCLUDE THAT

32) that PB type. THAT PB SUBTYPE

33) If compared with INT one, WHEN COMPARED WITH INT,

 34) on MIX type could be  done, ON MIX TYPE COULD BE REACHED 

35) The needed of adjuvant therapy after resection. THE NEED ...

 36) that no high-level of evidence studies have been published on the available literature.  THAT THERE IS NO ENOUGH AVAILABLE EVIDENCE

 37) however, it’s important to note. HOWEVER, IT IS IMPORTANT TO UNDERSCORE

38) specifically for  AC, SPECIFICALLY FOR ACC 

39) with the aim to evaluate the role. WITH THE OBJECTIVE OF EVALUATING THE ROLE

 40) it’s impossible to state. IT IS IMPOSIBLE TO KNOW

41) In conclusion, there is no consensus on the efficacy of adjuvant therapy for AAC, due  to the lack of evidence of the available literature, even if it seems to give some benefit if compared with surgery group alone. IN CONCLUSION, THERE IS NO CONSENSUS ON THE EFFICACY OF ADJUVANT THERAPY. ALTHOUGH SOME BENEFITS CAN BE REACHED WHEN COMPARED WITH THE ONLY-SURGERY GROUP.

42) "Can we better classify ampullary carcinomas?" CAN WE IMPROVE AMPULLARY CARCINOMA CLASSIFICATION?

42) As well reported previously, 

43) based on five subtype. BASED ON FIVE SUBTYPES

44) analyses. ANALYSIS

45) Nevertheless, in order to simplify this classification is not too easy and the efforts of pathologists supported by the biomarkers utilization, are fundamental for the following clinical management of AACs patients. IT IS NOT EASY TO SIMPLIFY THIS CLASSIFICATION.

PATHOLOGISTS WITH THE SUPPORT OF BIOMARKERS ARE FUNDAMENTAL PLAYERS IN CLINICAL MANAGEMENT.

IT WOULD BE USEFUL TO INCLUDE A FIGURE WITH HISTOLOGICAL SAMPLES REPRESENTING THE DIFFERENT ACCS.

46) In the 1994 some authors. IN 1994, KIMURA ET AL. WERE THE FIRST...

47) based on histological observations only. BASED SOLELY ON HISTOLOGICAL FINDINGS

 48) In this study, the authors higllighted a different prognostic impact between two subtypes, with a long-term survival after Surgery significantly greater in patients with intestinal type (INT) of AACs than in those with pancreatobiliary type (PB). IN THIS STUDY THE AUTHORS FOUND A LONGER SURVIVAL AFTER SURGERY IN PATIENTS WITH INTESTINAL SUBTYPE COMPARED TO THE PANCREATOBILIARY SUBTYPE.

49) Just about 10 years ago,

50) the utility of IHC inside the histological classification of sub-types of AAC. THE USEFULNESS OF IHC FOR HISTOLOGICAL CLASSIFICATION.

51) A different immuno-histochemical panels

52) The INT group of tumor usually express. TUMORS OF THE INT GROUP USUALLY EXPRESS

53) PB phenotype stains for CK7 247 and MUC1, MUC5A. PB PHENOTYPE EXPRESSES CK7, MUC1, AND MUC5A. 

55) Nevertheless, the hybrid cellular implications in ampullary tumors, collaborate in a mixed histomorphologic phenotype of the two subgroups. THE HYBRID CELLULAR TUMORS SHOW HISTOMORPHOLOGIC FEATURES OF BOTH SUBGROUPS.

 Conclusions 

56) The AAC ampullary tumors are a heterogeneous group of malignancies in which, probably, the protagonists of the game are two tumor subtypes: the intestinal type (INT)  and the pancreatobiliary type (PB). However, their identification did not emerge  immediately through histo-pathological analyses, where immunoimmune-phenotypic 304 characterization seems to be the goal of clinicians, who manage to place patients on both 305 sides of the river.  In fact, immunoimmuno-characterization performed using the best triage of 307 biomarkers (CK7, CK20 and CDX2), seems to acquire its perfect role as a prognostic and 308 Curr. Oncol. 2023, 30, FOR PEER REVIEW 9 predictive diagnostic factors. However, CDX2 may be the "judge" of the fate of  patients. Indeed, CDX2 appears to be choosing between Dr. Jakill and Mr. Hide in AAC,  but who's who? AAC AMPULATORY TUMORS REPRESENT A GROUP OF HETEROGENEOUS MALIGNANCIES IN WHICH TWO SUBTYPES ARE THE MAJOR PLAYERS: INT AND PB. INTERESTINGLY, THE SOURCE OF THIS CLASSIFICATION IS NOT THE HISTOLOGICAL STUDY BUT THE IMMUNOMARKER CHARACTERIZATION.

57) TISSUE BIOMARKERS SUCH AS CK7, CK20 AND CDX2 PERMIT ESTABLISHING A PROGNOSTIC AND PREDICTIVE FORECAST.

Reply: We would like to thank the reviewer for taking the time to read and comment on our work. At the same time we thank you very much for the positive feedback and the important review to improve our article. Indeed, looking at the lines reported above, we would like to follow the reviewer's suggestion point by point regarding the polishing of the English language.