Abstract
Background: Current lymph node (LN) staging is controversial in predicting the survival of ampullary cancer (AC). We aimed to develop an alternative LN-classification-based nomogram to individualize AC prognosis.Methods: Using the data of patients diagnosed with AC between 2004 and 2015 from the SEER database, we determined the cut-off values for the number of LNs examined via the K-adaptive partitioning algorithm. A nomogram predicting the survival of AC patients was performed, internally and externally validated, and evaluated by calibration plot, C-index, and decision curve analysis (DCA), and was compared to the 7th TNM stage.Results: We included 2341 patients with detailed information. The optimal cut-off for examined LN number was 12, while the cut-off value for positive LNs was 0 and 4. The C-index for the nomogram was higher than that of the 7th TNM staging (internal: 0.686; 95% CI, 0.584-0.773 vs. 0.616; 95% CI, 0.533-0.754, P < 0.001; external: 0.713; 95% CI, 0.651-0.784 vs. 0.647; 95% CI, 0.551-0.719, P < 0.001). Additionally, the nomogram showed good agreement between internal and external validation. DCA analysis showed no matter in the internal cohort or external cohort; the nomogram showed a greater benefit across the period of follow-up than did the 7th TNM stage.Conclusion: We found that examined LNs that were more than 12 were beneficial for prognosis of patients. We also modified the current N staging into three groups based on number of metastatic LNs: N0, no LN metastasis; N1, 1–4 metastatic LNs; N2, >=5 metastatic LNs. A nomogram with greater benefit for predicting the survival of patients with AC than TNM staging was constructed.