Development and external validation of a prediction model for survival in patients with resected ampullary adenocarcinoma

Eur J Surg Oncol. 2020 Sep;46(9):1717-1726. doi: 10.1016/j.ejso.2020.04.011. Epub 2020 May 25.


Introduction: Ampullary adenocarcinoma (AAC) is a rare malignancy with great morphological heterogeneity, which complicates the prediction of survival and, therefore, clinical decision-making. The aim of this study was to develop and externally validate a prediction model for survival after resection of AAC.

Materials and methods: An international multicenter cohort study was conducted, including patients who underwent pancreatoduodenectomy for AAC (2006-2017) from 27 centers in 10 countries spanning three continents. A derivation and validation cohort were separately collected. Predictors were selected from the derivation cohort using a LASSO Cox proportional hazards model. A nomogram was created based on shrunk coefficients. Model performance was assessed in the derivation cohort and subsequently in the validation cohort, by calibration plots and Uno's C-statistic. Four risk groups were created based on quartiles of the nomogram score.

Results: Overall, 1007 patients were available for development of the model. Predictors in the final Cox model included age, resection margin, tumor differentiation, pathological T stage and N stage (8th AJCC edition). Internal cross-validation demonstrated a C-statistic of 0.75 (95% CI 0.73-0.77). External validation in a cohort of 462 patients demonstrated a C-statistic of 0.77 (95% CI 0.73-0.81). A nomogram for the prediction of 3- and 5-year survival was created. The four risk groups showed significantly different 5-year survival rates (81%, 57%, 22% and 14%, p < 0.001). Only in the very-high risk group was adjuvant chemotherapy associated with an improved overall survival.

Conclusion: A prediction model for survival after curative resection of AAC was developed and externally validated. The model is easily available online via

Keywords: Adjuvant chemotherapy; Ampullary cancer; Nomogram; Prediction model.

Publication types

  • Validation Study

MeSH terms

  • Adenocarcinoma / pathology
  • Adenocarcinoma / surgery*
  • Aged
  • Ampulla of Vater*
  • Chemotherapy, Adjuvant
  • Clinical Decision Rules
  • Common Bile Duct Neoplasms / pathology
  • Common Bile Duct Neoplasms / surgery*
  • Duodenal Neoplasms / pathology
  • Duodenal Neoplasms / surgery*
  • Female
  • Humans
  • Lymph Node Excision
  • Lymph Nodes / pathology*
  • Male
  • Margins of Excision
  • Middle Aged
  • Neoplasm Grading
  • Neoplasm Invasiveness
  • Neoplasm Staging
  • Nomograms
  • Pancreaticoduodenectomy*
  • Proportional Hazards Models
  • Survival Rate