Selective reoperation for locally recurrent or metastatic pancreatic ductal adenocarcinoma following primary pancreatic resection

Abstract

Background: Resection of certain recurrent malignancies can prolong survival, but resection of recurrent pancreatic ductal adenocarcinoma is typically contraindicated because of poor outcomes.

Methods: All patients from 1992 to 2010 with recurrent pancreatic cancer after intended surgical cure were retrospectively evaluated. Clinicopathologic features were compared from patients who did and did not undergo subsequent reoperation with curative intent to identify factors associated with prolonged survival.

Results: Twenty-one of 426 patients (5 %) with recurrent pancreatic cancer underwent potentially curative reoperation for solitary local-regional (n = 7) or distant (n = 14) recurrence. The median disease-free interval after initial resection among reoperative patients was longer for those with lung or local-regional recurrence (52.4 and 41.1 months, respectively) than for those with liver recurrence (7.6 months, p = 0.006). The median interval between reoperation and second recurrence was longer in patients with lung recurrence (median not reached) than with liver or local-regional recurrence (6 and 9 months, respectively, p = 0.023). Reoperative patients with an initial disease-free interval >20 months had a longer median survival than those who did not (92.3 versus 31.3 months, respectively; p = 0.033).

Conclusion: Patients with a solitary pulmonary recurrence of pancreatic cancer after a prolonged disease-free interval should be considered for reoperation, as they are more likely to benefit from resection versus other sites of solitary recurrence.

Fig. 1

Profile of the patient population. The “Selected” cohort is defined as those individuals selected for a second, potentially curable operation for recurrent pancreatic ductal adenocarcinoma (PDAC). The “Not Selected” cohort is defined as those individuals who were not selected for reoperation

Fig. 2

Median first and second DFI among patients selected for reoperation stratified by pattern of initial recurrence. The recurrence pattern of those selected for reoperation was divided into three categories to elucidate differences in disease-free interval (DFI, displayed in months). The first DFI is defined as the interval from the initial resection of the primary PDAC to first recurrence. The second DFI is defined as the interval from reoperation for recurrence to second recurrence. A statistically significant difference in the first DFI is seen between the lung and locoregional recurrence groups versus the liver recurrence group (p=0.006). The second DFI for patients with an initial lung recurrence who underwent reoperation was longer than those with a liver or local-regional recurrence (p=0.023). The median period for the second DFI for the lung recurrence group has not been reached and is reported as the mean interval (asterisk)

Fig. 3

Kaplan–Meier analysis for DFI and OS between the various study cohorts. The median first DFI for those selected for reoperation versus those who were not selected was 21.7 and 7.85 months, respectively (p<0.001, a). When those selected for reoperation are sub-categorized by recurrence location, patients with hepatic recurrence had a significantly shorter median first DFI than patients with lung or locoregional recurrence (p=0.006, b). The median OS after initial resection in those selected for reoperation was significantly shorter in patients with a hepatic recurrence than in those with a lung or locoregional recurrence (p=0.034, c). Those patients with a median first DFI >20 months and underwent reoperation for recurrence had a significantly longer OS than those with a first DFI <20 months who underwent reoperation (p=0.033, d)