Distant metastasis risk stratification for patients undergoing curative resection followed by adjuvant chemoradiation for extrahepatic bile duct cancer.
OBJECTIVE
To analyze the prognostic factors predicting distant metastasis in patients undergoing adjuvant chemoradiation for extrahepatic bile duct (EHBD) cancer.


METHODS
Between January 1995 and August 2006, 166 patients with EHBD cancer underwent resection with curative intent, followed by adjuvant chemoradiation. There were 120 males and 46 females, and median age was 61 years (range, 34-86). Postoperative radiotherapy was delivered to tumor bed and regional lymph nodes (median dose, 40 Gy; range, 34-56 Gy). A total of 157 patients also received fluoropyrimidine chemotherapy as a radiosensitizer, and fluoropyrimidine-based maintenance chemotherapy was administered to 127 patients. Median follow-up duration was 29 months.


RESULTS
The treatment failed for 97 patients, and the major pattern of failure was distant metastasis (76 patients, 78.4%). The 5-year distant metastasis-free survival rate was 49.4%. The most common site of distant failure was the liver (n = 36). On multivariate analysis, hilar tumor, tumor size ≥ 2 cm, involved lymph node, and poorly differentiated tumor were associated with inferior distant metastasis-free survival (p = 0.0348, 0.0754, 0.0009, and 0.0078, respectively), whereas T stage was not (p = 0.8081). When patients were divided into four groups based on these risk factors, the 5-year distant metastasis-free survival rates for patients with 0, 1, 2, and 3 risk factors were 86.4%, 59.9%, 32.5%, and 0%, respectively (p < 0.0001).


CONCLUSIONS
Despite maintenance chemotherapy, distant metastasis was the major pattern of failure in patients undergoing adjuvant chemoradiation for EHBD cancer after resection with curative intent. Intensified chemotherapy is warranted to improve the treatment outcome, especially in those with multiple risk factors.
Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea.
Kyubo
K
Kim
Eui Kyu
EK
Chie
Jin-Young
JY
Jang
Sun Whe
SW
Kim
Sae-Won
SW
Han
Do-Youn
DY
Oh
Seock-Ah
SA
Im
Tae-You
TY
Kim
Yung-Jue
YJ
Bang
Sung W
SW
Ha
D000230:Adenocarcinoma / Q000401:mortality / Q000556:secondary / Q000601:surgery / Q000628:therapy; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001650:Bile Duct Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D017734:Bile Ducts, Extrahepatic / Q000601:surgery; D059186:Chemoradiotherapy, Adjuvant / Q000009:adverse effects / Q000379:methods*; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary*; D060046:Maintenance Chemotherapy / Q000379:methods; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011743:Pyrimidines / Q000627:therapeutic use; D011838:Radiation-Sensitizing Agents / Q000627:therapeutic use; D011879:Radiotherapy Dosage; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D017211:Treatment Failure; D047368:Tumor Burden
D011743:Pyrimidines; D011838:Radiation-Sensitizing Agents; C030986:pyrimidine