Basic Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Nov 21, 2020; 26(43): 6822-6836
Published online Nov 21, 2020. doi: 10.3748/wjg.v26.i43.6822
Tissue microarray-chip featuring computerized immunophenotypical characterization more accurately subtypes ampullary adenocarcinoma than routine histology
Matteo Palmeri, Niccola Funel, Gregorio Di Franco, Niccolò Furbetta, Desirée Gianardi, Simone Guadagni, Matteo Bianchini, Luca E Pollina, Claudio Ricci, Marco Del Chiaro, Giulio Di Candio, Luca Morelli
Matteo Palmeri, Gregorio Di Franco, Niccolò Furbetta, Desirée Gianardi, Simone Guadagni, Matteo Bianchini, Giulio Di Candio, Luca Morelli, General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
Niccola Funel, Luca E Pollina, Division of Surgical Pathology, University-Hospital of Pisa, Pisa 56124, Italy
Claudio Ricci, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa 56124, Italy
Marco Del Chiaro, Department of Surgery, University of Colorado, Denver, CO 80045, United States
Author contributions: Palmeri M, Funel N, and Morelli L conceived and designed the study; Palmeri M, Di Franco G, Furbetta N, Gianardi D, Guadagni S, Bianchini M, Ricci C and Pollina LE acquired the data; Palmeri M, Funel N, Del Chiaro M and Morelli L interpreted and analyzed the data; Palmeri M, Di Franco G, Guadagni S, Furbetta N, Gianardi D, Funel N, Pollina LE and Di Candio G drafted the manuscript; Del Chiaro M and Morelli L made critical revisions; Palmeri M, Di Franco G, Guadagni S, Bianchini M, Furbetta N, Gianardi D, Funel N, Pollina LE, Di Candio G, Del Chiaro M and Morelli L provided final approval of the study; Palmeri M and Funel N contributed equally.
Supported by ARPA Foundation (
Institutional review board statement: The study was approved by Ethics committee of “Area Vasta Nord Ovest (CEAVNO)”.
Conflict-of-interest statement: The authors declare that there is no conflict of interest.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Niccola Funel, BSc, PhD, Academic Research, Postdoc, Research Scientist, Division of Surgical Pathology, University-Hospital of Pisa, Via Paradisa 2, Pisa 56124, Italy.
Received: May 29, 2020
Peer-review started: May 29, 2020
First decision: June 12, 2020
Revised: June 24, 2020
Accepted: August 27, 2020
Article in press: August 27, 2020
Published online: November 21, 2020

Ampullary adenocarcinomas (AACs) are heterogeneous tumors currently classified into three important sub-classes (SC): Intestinal (INT), Pancreato-Biliary (PB) and Mixed-Type (MT). The different subgroups have similar clinical presentation and are treated by pancreatoduodenectomy with curative intent. However, they respond differently to chemotherapy and have different prognostic outcomes. The SC are often difficult to identify with conventional histology alone. The clinical outcome of all three remains unclear, particularly for MT.


To identify two main subtypes of AACs, using an immunohistochemical (IHC) score based on CDX2, CK7 and CK20.


Tissue samples from 21 patients who had undergone resection of AAC were classified by HE histology and IHC expression of CDX2, CK7 and CK 20. An IHC score was obtained for each marker by counting the number of positive cells (0 = no stained cells; 1 < 25%; 2 < 50% and 3 > 50%) and their intensity (1 = weak; 2 = moderate and 3 = strong). A global score (GS) was then obtained by summation of the IHC scores of each marker. The MT tumors were grouped either with the INT or PB group based on the predominant immuno-molecular phenotype, obtaining only two AACs subtypes. The overall survival in INT and PB patients was obtained by Kaplan-Meier methods.


Histological parameters defined the AACs subtypes as follows: 15% INT, 45% PB and 40% MT. Using IHC expression and the GS, 75% and 25% of MT samples were assigned to either the INT or the PB group. The mean value of the GS was 9.5 (range 4-16). All INT samples had a GS above the average, distinct from the PB samples which had a GS score significantly below the average (P = 0.0011). The INT samples were identified by high expression of CDX2 and CK20, whereas PB samples exhibited high expression of CK7 and no expression of CK20 (P = 0.0008). The INT group had a statistically significant higher overall survival than in the PB group (85.7 mo vs 20.3 mo, HR: 8.39; 95%CI: 1.38 to 18.90; P = 0.0152).


The combination of histopathological and molecular criteria enables the classification of AACs into two clinically relevant histo-molecular phenotypes, which appear to represent distinct disorders with potentially significant changes to the current therapeutic strategies.

Keywords: Ampullary adenocarcinoma, Histo-molecular phenotype, Prognostic, CK7, CK20, CDX2

Core Tip: Ampullary adenocarcinomas are heterogeneous tumors with different responses to specific chemotherapy regimens and prognosis, probably because they are a heterogenous group including differing ampullary growth and overlapping histological phenotypes. Conventional histology does not allow a definitive identification of the three subgroups. We used an immunohistochemical score based on CDX2, CK7 and CK20 and identified only two sub-types, representing two groups of apparently separate neoplastic disorders with different oncological outcomes.