Predictors and Patterns of recurrence after radical surgery in ampulla of vater cancer: Comparison analysis between early and late recu rrence.

Transcription

1 Predictors and Patterns of recurrence after radical surgery in ampulla of vater cancer: Comparison analysis between early and late recu rrence. Division of Hepatobiliary & Pancreatic Surgery Department of Surgery Asan Medical Center, Seoul, Korea Jeong-Su Nam, Zhou Zunqiang, Kwang- Min Park, Young-Joo Lee,Song-Cheol Kim, Ki-Byung Song, Jae-Hoon Lee, Ji-Woong Hwang, Jong-Hee Yoon

2 Introduction Ampulla of Vater cancer - relatively higher resection rate. - more favorable prognosis than other periampullary ca. (35~67% of 5 yr- survival rate) But Tumor recurrence after resection remains crucial problem. Many studies were focused on Survival analysis not much information about recurrence.

3 Purpose To know the recurrence pattern and evaluate predictors of recurrence.

4 Patients and methods Duration: from Jan, 1994 to Dec 2008 Surgery (328 patient) Palliative op. (42 patient) Radical resection (PD or PPPD) (286 patients) Non recurrence (158 patients,55.2%) Early recurrence (65 patients, 22.7% ) Late recurrence (63 patients, 22.1%)

5 Cut off value for early & late recurrence : 12 months ( reason: median time of recurrence : 11 month) Retrospective analysis of patients demographics & lab findings & histopatholgic finding etc. Criteria for recurrence - Locoregional ; retroperitoneal mass or regional node - Metastasis ; distant visceral organ or non-regional LN

6 Results (1): Demographics and periop. Lab data operative procedure Non-recurrence recurrence P value Early recurrence Late recurrence P value Patients,n(%) Age,mean+SD Gender,(F/M) BMI, mean+sd 158(55.2%) 128(44.8%) 65(50.8%) 63(49.2%) 65.1± ± ± ± /84 53/ /44 32/ ± ± ± ± Total bilirubin(mg/ dl) 6.1( ) 4.8( ) ± ± Operative procedu re, n(%) Whipple PPPD Adjuvant chemotherapy < CA19-9(pre-operat ion) (U/dL) CA19-9(post-opera tion)(u/dl) (6-4480) 8.9 ( ) ( ) 246 ( ) 0.002* 0.008* 57.6 ( ) 15.3 ( ) 32.6 ( ) 10.7 ( ) Follow up (months,/ median(range)) 59(1-178) 31.5(2-111) 16(2-47) 46(15-111) 0.051* 0.411*

7 Results (2): Histopathologic findings in patients. Non-recurrence recurrence P value Early recurrence Late recurrence P value Tumor size(cm), median(range) Tumor stage, n(%) 2.2± ± ± ± <0.001 <0.001 T1 45(28.5%) 11(8.6%) 2(3.1%) 9(14.3%) T2 (duodenal invasion) 48(30.4%) 35(27.3%) (23.1%) 20(31.7%) T3 (pancreas invasion) 37(23.4%) 56(43.8%) < (52.3%) 22(34.9%) T4 28(17.7%) 26(20.3%) 14(21.5%) 12(19%) Resection margin, n(%) R R Resected lymph node (n),median 9(0-50) 9(0-55) (0-55) 9(0-24) 0.864

8 Result (2): Histopathologic findings in patients. -continue Non-recurrence recurrence P value Early recur Late recur P value Lymph node status, n (%) Negative Positive Lymphovascular i nvasion Negative Positive Perineural invasio n Negative Positive Differentiation, n ( %) Well Moderate Poor AJCC TNM Stage, n (%) StageⅠ Stage Ⅱ Stage Ⅲ Stage Ⅳ < (80.4%) 77(60.2%) 32(49.2%) 44(69.8%) 31(19.6%) 51(39.8%) 33(50.8%) 19(30.2%) Histopathologic factors related to recurrence (Multivariate analysis) Lymph node involvement Lymphovascular invasion Histologic differentiation TNM stage 120(75.9%) 78(60.9%) 32(49.2%) 46(73%) 38(24.1%) 50(39.1%) 33(50.8%) 17(27%) (87.3%) 92(71.9%) 42(64.6%) 50(79.4%) 20(12.7%) 36(28.1%) 23(35.4%) 13(20.6%) < (50%) 27(21.1%) 5(7.7%) 22(34.9%) 71(44.9%) 85(66.4%) 47(72.3%) 38(60.3%) 8(5.1%) 16(12.5%) 13(20%) 3(4.8%) < (51.3%) 36(28.1%) 11(16.9%) 25(39.7%) 49(31.1%) 64(50%) 38(58.5%) 26(41.3%) 28(17.7%) 26(20.3%) 14(21.5%) 12(19%) 0 2 2(3.1%) 0

9 Result(3) Recurrence patterns in 128 patients. Early recurrence Late recurrence P value Local recurrence Metastasis Liver metastasis Peritoneal carcinomatosis Lung metastasis Paraaortic/SMA LN Multiple metastasis Others* 13(20%) 20(31.8%) (52.3%) 29(46.0%) (24.6%) 10(15.9%) (3.1%) 4(6.3%) 0.381

10 Result(4) Recurrence patterns Perineural invasion P value Lymphovascular invasion P value (+) (-) (+) (-) Local recurrence Metastasis Liver metastasis Peritoneal carcinomatosis Lung metastasis Paraaortic/SMA LN Multiple metastasis others

11 Result(5) Recurrence patterns T2(duodenal invasion) vs T3 (Pancreas invasion) Tumor stage T1 T2 T3 T4 P value* Local recurrence Metastasis Liver metastasis Peritoneal seeding Lung metastasis Paraaortic/SMA LN Multiple metastasis others

12 Result(6) Histopathologic factors and impact on disease specific survival Variable No. patients Mean survival time (months) Tumor stage,n(%) P*< year Survival rate (%) T T T T Resection margin,n(%) P*=0.005 R R Lymph node status, n (%) P*<0.001 Negative Positive Lymphovascular invasion P*<0.001 Negative Positive Perineural invasion P*<0.001 Negative Positive Differentiation, n (%) P*<0.001 Well Moderate Poor AJCC TNM Stage, n (%) P*<0.001 StageⅠ Stage Ⅱ Stage Ⅲ Stage Ⅳ year

13 Result (7) Mean survival time and survival rate of recurrent patients. Local recurrence Chemotherapy No Yes Liver metastasis Chemotherapy No Yes Peritoneal carcinomatosis Chemotherapy No Yes Lung metastasis Chemotherapy No Yes Numbers of patients (n) Estimate mean time (mont hs) 3-year Survival rate(%) 5-year P *Value Paraaortic/SMAlymph no de Chemotherapy No Yes Multiple metastasis Chemotherapy No Yes

14 Conclusion (1) Depth of invasion is pivotal factor (esp. When tumor penetrate sphinter of oddi Lymphatic spread ) Most common relapse pattern - Locoregional lymph node (usually combined with distant metastasis) Among Distant metastasis - Liver metastasis is most common

15 Conclusion (2) Recurrence pattern was similar in early and late recurrence. Patient who has risk factor for recurrence ( LN invovlement, Lymphovascular invasion, advanced TNM stage, poor histologic differntiation) Careful follow-up