Predictors for patterns of failure after pancreaticoduodenectomy in ampullary cancer

Background: Ampullary cancer has the best prognosis in periampullary malignancy but unpredicted early recurrence after resection is frequent. The current study tried to find the predictors for recurrence to be used as determinative for postoperative adjuvant therapy. Methods: Information was collected from patients who underwent pancreaticoduodenectomy with regional lymphadenectomy for ampullary cancer in high-volume hospitals between January 1989 and April 2005. Recurrence patterns and survival rates were calculated and predictors were identified. Results: A total of 135 eligible patients were included. The 30-day operative mortality was 3%. Median followup for relapse-free patients was 52 months. Disease recurred in 57 (42%) patients, including 31 liver metastases, 26 locoregional recurrences, 9 peritoneal carcinomatoses, 7 bone metastases, and 6 other sites. Pancreatic invasion (P = 0.04) and tumor size (P = 0.05) were the predictors for locoregional recurrence, while lymph node metastasis was the sole predictor for liver metastasis (P = 0.01). The 5-year disease-specific survival rate was 45.7%; 77.7% for stage I, 28.5% for stage II, and 16.5% for stage III; and 63.7% for node-negative versus 19.1% for node-positive patients. Pancreatic invasion and lymph node involvement were both predictors for survival of patients with ampullary cancer. Conclusion: Pancreaticoduodenectomy with regional lymphadenectomy is adequate for early-stage ampullary cancer but a dismal outcome can be predicted in patients with lymph node metastasis and pancreatic invasion. Lymph node metastasis and pancreatic invasion can be used to guide individualized, risk-oriented adjuvant therapy.