title: Determining pattern of recurrence following pancreaticoduodenectomy and adjuvant 5-flurouracil-based chemoradiation therapy: effect of number of metastatic lymph nodes and lymph node ratio.
abstract: BACKGROUND
  There are limited data on patterns of recurrence and factors associated with local recurrence following pancreaticoduodenectomy for pancreatic adenocarcinoma and adjuvant 5-flurouracil-based chemoradiation therapy.
  
  
  METHODS
  Between 1995 and 2005, 905 patients underwent pancreaticoduodenectomy for pancreatic adenocarcinoma; 154 patients had complete pattern of recurrence data available.
  
  
  RESULTS
  At median follow-up of 20.2 months, 103 (66.9%) patients recurred with median time to recurrence of 16.2 months. Most patients recurred with distant disease only (68.9%), while 21.4% patients recurred with local disease only; ten (9.7%) patients recurred with local and distant disease. Several factors were associated with local recurrence: poor tumor differentiation (hazards ration [HR] 2.39) and presence of metastatic lymph nodes (HR 1.89, both p < 0.05). Among N1 patients, poor tumor differentiation (HR 3.92), >5 metastatic LN (HR 3.75), and lymph node ratio (LNR) >0.4 (HR 2.96) had the highest risk of local recurrence (all p < 0.05). Increasing LNR was associated with an incremental increased risk of local recurrence (LNR <0.2, 21.3% versus LNR >or=0.2 to 0.4, 25.2% versus LNR >0.4, 40.4%; p < 0.05).
  
  
  CONCLUSIONS
  Although most patients who receive standard 5-flurouracil-based chemoradiation therapy will ultimately succumb to distant disease, about 30% recur locally. Poor tumor differentiation, a high number of metastatic LN (>5), and LNR >0.4 are associated with the highest risk of local failure. In these patients, radiation dose escalation and/or a combination of radiation with novel chemotherapeutic agents may be necessary to improve outcomes.
authors.affiliation: Department of Surgery, Johns Hopkins Hospital, 600 North Wolfe Street, Halsted 614, Baltimore, MD 22187-6681, USA.
authors.forename: Bolanle
authors.initials: B
authors.lastname: Asiyanbola
authors.forename: Ana
authors.initials: A
authors.lastname: Gleisner
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Herman
authors.forename: Michael A
authors.initials: MA
authors.lastname: Choti
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Wolfgang
authors.forename: Michael
authors.initials: M
authors.lastname: Swartz
authors.forename: Barish H
authors.initials: BH
authors.lastname: Edil
authors.forename: Richard D
authors.initials: RD
authors.lastname: Schulick
authors.forename: John L
authors.initials: JL
authors.lastname: Cameron
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000230:Adenocarcinoma / Q000188:drug therapy / Q000473:pathology* / Q000532:radiotherapy / Q000601:surgery*; D000964:Antimetabolites, Antineoplastic / Q000627:therapeutic use; D017024:Chemotherapy, Adjuvant; D019583:Dose Fractionation, Radiation; D005260:Female; D005472:Fluorouracil / Q000627:therapeutic use; D006801:Humans; D008198:Lymph Nodes / Q000473:pathology; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology / Q000473:pathology*; D010190:Pancreatic Neoplasms / Q000188:drug therapy / Q000473:pathology* / Q000532:radiotherapy / Q000601:surgery*; D016577:Pancreaticoduodenectomy; D011379:Prognosis; D018714:Radiotherapy, Adjuvant; D012307:Risk Factors
chemical_list: D000964:Antimetabolites, Antineoplastic; D005472:Fluorouracil