RECURRENT DISEASE AFTER RADICAL RESECTION FOR PANCREATIC AND PERIAMPULLARY ADENOCARCINOMA: SHOULD ALL PATIENTS RECEIVE ADJUVANT THERAPY?
Publishing Number: 193
Steve de Castro, K. F. D. Kuhlmann, O. R. C. Busch, G. Johan Offerhaus, T. M. van Gulik, Huug Obertop, D. J. Gouma, Academic Medical Center, Amsterdam, Netherlands
Long-term outcome after resection for pancreatic or periampullary cancer
(ampulla of Vater and distal bile duct) is dismal. Recent advances in adjuvant therapeutic regimens are promising. Controversy exists whether patients with periampullary carcinoma should also receive these treatments. We analyzed predictive factors for recurrence in a consecutive cohort of patients with microscopic tumor free resection margins, who did not receive adjuvant therapy. The aim of the study is to identify patients with periampullary cancer who might benefit from adjuvant therapy.Between January 1992 and December 2002, 207 patients of 337 patients (61%) underwent a pancreatoduodenectomy with microscopic tumor free resection margins (Ro). A Ro resection was achieved in 80 of the 168 patients (48%) with pancreatic adenocarcinoma, 98 of the 115 patients (85%) with adenocarcinoma of the ampulla of Vater and 35 of the 60 patients (58%) with adenocarcinoma of the distal bile duct. Oncological factors were analyzed by logistic regression to predict recurrent disease.
Overall 5-year survival was 15% for pancreatic, 40% for ampulla of Vater and 14% distal bile duct adenocarcinoma. The median time of recurrence was 10.4 (range, 3-58), 14.8 (range, 0-53) and 16.8 (range, 5-51) months, respectively (p<0.001). Median survival thereafter was 2.8 (range, 0-22), 3.1 (range 0-28) and 3.3 (range, 0-20) months, respectively (p=0.842). Overall recurrence occurred in 117 of 207 patients (56%) with a median follow up of 3 years. No significant predictive factors for the development of recurrence were identified for pancreatic adenocarcinoma. Significant predictive factors for the development of recurrence for patients with ampulla of Vater adenocarcinoma were T-Stage (p<0.001), N-Stage (<0.001), disease stage according to the UJCC (P<0.001) and perineural ingrowth (0.02). The differentiation grade (p=0.003) was a significant predictor for recurrence of distal bile duct adenocarcinoma. Of the patients with ampulla of Vater adenocarcinoma with T1,T2 and N0 disease, recurrence after 5 years was seen in 27% compared with 85% of the patients with T3N0 or any N1 disease (p<0.001).
Patients with advanced periampullary malignancies (ampulla of Vater and distal bile duct) should be selected according to the identified predictive factors and treated with the same modalities as pancreatic cancer. These patients have a high recurrence rate after 5 years (up to 85%) and could benefit from these trials.
