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Has Survival Following Pancreaticoduodenectomy for Pancreas Adenocarcinoma Improved Over Time?
Ahmed I. Salem*, Mina Alfi, Emily Winslow, Clifford S. Cho, Sharon M. Weber
General Surgery, University of Wisconsin, Madison, WI
Background: Survival following resection of pancreas cancer is poor, and it is uncertain whether improvements in outcome have occurred over time. Due to the recent advances in surgical techniques, diagnostic evaluation, and systemic treatment of pancreas cancer, we hypothesize that pancreas cancer outcome has improved over time.
Methods: Prospectively collected data on patients who underwent pancreaticoduodenectomy for pathologically confirmed pancreatic adenocarcinoma from (1999 to 2012) were analyzed. Patients were divided into era 1 (1999 - 2005), and compared to era 2 (2006 - 2012). Patient demographics, clinicopathological data and operative outcomes were analyzed.
Results: A total of 216 patients were evaluated, including 76 in era 1 and 140 in era 2. Overall operative mortality (30 d) was 1.4%, (1.3%, era 1, vs 1.4%, era 2, p=0.946). Patients in era 2 were at increased risk for a number of poorer pathological characteristics, although margin positivity decreased with the concomitant increased use of venous resection in era 2 (Table 1). There was no difference in median survival between era 1 and 2 on univariate analysis (18 mo., vs 21 mo., p=0.830). After adjusting for perineural invasion, lymphovascular invasion, margin status, EBL and venous resection, there was no association of improved survival in era 2 compared to era 1 (OR=1.036, p=0.848, CI=0.722 - 1.486).
Conclusion: Patients with more advanced and more aggressive tumors are undergoing definitive resection. After adjusting for clinicopathological features, there was no association of improved outcome over time. However, despite an increasing prevalence of anatomically advanced and histologically aggressive tumors, perioperative outcomes such as blood loss and margin negativity improved over time, with no increase in 30 day mortality. Strategies designed to improve systemic treatment of pancreas cancer are essential to improving outcome.
Table 1. Univariate Analysis of Factors Influencing Survival
| Factor | n (%) | p Value | | Era 1 | Era 2 | | Pathological Features: | | • Advanced Stage (IIB - III) | 35 (64) | 97 (71) | 0.333 | | • Perineural Invasion | 27 (40) | 95 (68) | <0.001 | | • Lymphovascular Invasion | 7 (10) | 42 (30) | 0.002 | | • Lymph Node Positivity | 45 (60) | 97 (70) | 0.148 | | • Mean Tumor Size (cm, mean ± SD) | 3.1±1.2 | 3.2±2.6 | 0.628 | | • Margin Positivity | 29 (39) | 25 (18) | 0.001 | | Operative Features: | | • Estimated Blood Loss (EBL in ml) (mean ± SD) | 990 ± 1599 | 640 ± 591 | 0.021 | | • Venous Resection | 9 (12) | 36 (26) | 0.018 | | Therapeutic Features: | | • Neoadjuvant Therapy | 8 (12) | 23 (16) | 0.376 | | • Adjuvant Therapy | 34 (50) | 79 (56) | 0.383 |
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