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RECURRENCE PATTERNS AFTER RESECTION OF AMPULLA OF VATER CANCER: SIGNIFICANCE OF LYMPH NODE DISSECTION AROUNDSUPERIOR MESENTERY ARTERY AND NEOADJUVANT TREATMENT
Wooil Kwon*1, Hongbeom Kim1,2, Jin-Young Jang1, Sun-Whe Kim1
1Department of Surgery, Seoul National University College of Medicine, Seoul, Korea (the Republic of); 2Department of Surgery, Dongguk University Ilsan Medical Center, Koyang, Korea (the Republic of)
Purpose: Ampulla of Vater (AoV) cancer has a favorable prognosis compared to other periampullary cancers. Nevertheless, prognoses of AoV cancer differ according to the stages. Therefore, AoV cancer should be approached with different treatment strategy according to the stage. The purpose was to explore recurrence patterns according to the stage and to investigate the significance of superior mesenteric artery (SMA) LN dissection based on recurrence patterns in AoV cancer. Through the results, we tried to suggest optimal treatment of AoV cancer according to the stage.
Methods: From January 2000 to June 2012, 259 patients who underwent pancreaticoduodenectomy (PD) with R0 resection due to AoV cancer in Seoul National University Hospital were analyzed. Lymph node (LN) dissection was performed around right side of SMA and celiac axis. Survival and recurrence pattern was observed and the risk factors were analyzed.
Results: The median follow up duration was 40.7 month (range: 6-171) and the overall 5-year disease free survival rate was 62.1%. Recurrence occurred in 89 cases (34.4%) with median time of 15.3 months to recurrence. In 89 recurred patients, total 149 recurrence sites were identified. The most common recurrence site was liver (n=52) as systemic and SMA LN (n=21) as local recurrence. The risk factors of recurrence were poor differentiation (p=0.002), advanced T stage (0.032) and LN metastasis (p=0.010). Local recurrence developed in 19 patients (21.3%), distant in 14 (15.7%) and both local and distant in 56 (62.9%). Early T stage had a tendency of local recurrence especially around SMA, whereas advanced T stage was significantly associated with systemic recurrence (p=0.003). In T2 or above group, chemotherapy marginally reduced recurrence (p=0.072). In LN metastasis group, radiation therapy significantly reduced recurrence (p=0.028), especially local recurrence (p=0.005)
Conclusion: The recurrence pattern of AoV cancer is different according to the T stage. In early T stage, local recurrence, especially at SMA LN, mainly occurred. Therefore, meticulous SMA node dissection should be performed even in early AoV cancer. In advanced T stage, adjuvant systemic treatment plays an important role as distant recurrence is the main type of recurrence.
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