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
Research background

Ampullary adenocarcinomas (AACs) are heterogeneous tumors currently classified into the three most 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 have different responses to specific chemotherapeutics, with different prognoses.

Research motivation

Conventional histology does not allow a definitive identification of the three subgroups.

Research objectives

In this study using an immunohistochemical (IHC) score based on CDX2, CK7 and CK20 evaluation through three tissue microarray platforms, we identified two clinically relevant histo-molecular sub-phenotypes of AACs.

Research methods

Tissue samples from 21 patients who had undergone AAC resection were arranged on three tissue microarray platforms and were classified by histology and IHC expression of CDX2, CK7 and CK20. An IHC score was obtained for each marker summing 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 summing the IHC scores of each marker. The MT tumors were re-located to either the INT or PB group on the basis of the predominant immune-molecular phenotype, identifying only two AACs subtypes. The overall survival of INT and PB patients was obtained by Kaplan-Meier methods.

Research results

Histological parameters defined the AACs subtypes as follows: 15% INT, 45%PB and 40% MT. Using the IHC expression and the GS, 75% and 25% of MT samples were assigned to the INT and PB group, respectively. The mean value of GS was 9.5 (range 4-16). All INT samples had a GS above the average, while all PB sample had a GS below the average (P = 0.0011). In particular, the INT samples were identified by high expression of CDX2 and CK20, while PB samples showed high expression of CK7 and negative expression of CK20 (P = 0.0008). The overall survival analysis was statistically significantly better for INT than PB patients (85.7 vs 20.3 mo, HR: 8.39; 95%CI: 1.38 to 18.90; P = 0.0152).

Research conclusions

The combination of histopathological and molecular criteria enables the definition of only two clinically relevant histo-molecular phenotypes of AACs that potentially represent distinct disorders with different management and chemotherapeutic strategies.

Research perspectives

A preoperative biopsy of the ampulla could provide a AACs subtype classification, allowing the tailoring of oncological treatment and planning the extension of surgical resection.