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Recurrence Patterns And Post-recurrence Survival In Pancreatic Ductal Adenocarcinoma
*Hordur M Kolbeinsson1, *Aqieda Bayat2, *Allison M Hoppe2, *Benjamin D Kogelschatz2, *Chineze Mbanugo2, *Murwarid Assifi1, *Andrea Wolf1, *Mathew Chung1, Gerald P Wright1
1Spectrum Health/Michigan State University, Grand Rapids, MI;2Michigan State University, Grand Rapids, MI

OBJECTIVE(S): Pancreatic ductal adenocarcinoma (PDAC) has a high rate of recurrence after resection and remains highly lethal despite multimodality therapy. The aim of our study was to investigate patterns of recurrence of PDAC after resection to identify opportunities for targeted intervention toward improving survival.
METHODS: This study was a retrospective analysis of 221 consecutive patients that underwent surgery for PDAC between 2007-2015. Disease characteristics and treatment received were recorded from date of diagnosis through recurrence, date of last follow-up, or death. Incidence of first recurrence was categorized along with treatments received and survival from this time point. Patients were stratified for analysis based on site of recurrence.
RESULTS: There were 221 patients included for study with median follow-up of 83 months. Median age was 69 (IQR 61-76). Surgical technique included: pancreaticoduodenectomy (74.4%), distal pancreatectomy (22.2%), and total pancreatectomy (2.7%). R0 resection was obtained in 138 (62.4%) cases. Ninety-day morbidity and mortality were 32.1% and 3.6%, respectively. Most patients received perioperative chemotherapy (70.1%) while radiation therapy was utilized in 45.2%. At last follow-up 191 (86.4%) had died. Of 30 living patients, 8 were lost to follow-up leaving 22 (10.0%) documented survivors with median follow-up of 74 months. Median overall survival was 19 months (95% CI 16.1-21.9) with recurrence free survival of 13 months (95% CI 10.1-15.9). Recurrence was observed in 159 patients; 39 patients died without documented recurrence. Local recurrence only occurred in 16.4%, distant recurrence only in 67.3%, and both in 16.4%. The most common site of distant recurrence was the liver (49.7%) followed by lung (31.8%) and peritoneum (16.6%). Time to recurrence was shorter for patients with liver disease (Table 1). Median survival from first recurrence was 6 months (95% CI 4.3 - 7.7). Survival after recurrence was significantly longer for isolated lung recurrence (Table 1). CONCLUSIONS: PDAC has high recurrence rates. Liver metastasis occurs most frequently, earliest after surgery, and is often rapidly fatal. Adjuvant liver-directed therapies represent a target for future study.

Table 1
Median (95% CI)P value
Time to first recurrenceLiver5 months (1.7-8.3)<0.001
Peritoneal8 months (5.9-10.1)
Lung18 months (10.5-25.5)
Local15 months (12.9-17.1)
Survival from first recurrenceLiver only4 months (1.9-6.1)<0.001
Peritoneal only1 month (0-3.1)
Lung only15 months (8.0-22.0)
Multi-site4 months (1.1-6.9)

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