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Multimodality Therapy is Associated with Improved Cause-Specific Survival in Pancreatic Ductal Adenocarcinoma with Vascular Abutment
Olga Kantor*1, Mark S. Talamonti2, Waseem Lutfi2, Kristine M. Kuchta3, David J. Winchester2, Richard A. Prinz2, Marshall Baker2
1Surgery, University of Chicago, Chicago, IL; 2Surgery, NorthShore University HealthSystem, Evanston, IL; 3Center for Research Informatics, NorthShore University HealthSystem, Evanston, IL
Background: Optimal management strategies for patients presenting with what is considered borderline resectable adenocarcinoma (PDAC) in the pancreatic head continue to be defined.
Methods: The linked Surveillance, Epidemiology, and End-Results Program (SEER) and Medicare database was used to identify patients with stage II PDAC of the head of the pancreas with “vascular abutment” (defined as extension to major blood vessels). A combination of variables from SEER and Medicare were used to define treatment, perioperative complications, and cause-specific survival. Chi-square, independent t-tests, and Cox- proportional hazard modeling was used for analysis.
Results: From 2004-2012, 551 patients were treated for stage II PDAC of the pancreatic head with vascular abutment: 150 (27%) underwent resection with pancreaticoduodenectomy (PD) and 401 (73%) were treated with chemotherapy alone. Of patients that had PD, 108 (71%) underwent multimodality therapy (55 with PD and chemotherapy, 52 with PD and chemoradiation) and 43 (29%) underwent surgery alone. 58 patients (39%) required PD with vascular resection (PDVR) and 92 (61%) underwent PD alone. Patients >80yrs were less likely to undergo surgery than those ≤80yrs (17.2% vs 29.9%, p<0.01). There were no differences in race, gender, or comorbidities between patients undergoing chemotherapy alone and those undergoing surgery alone or multimodality therapy (p≥0.09). On Cox proportional hazards modeling adjusted for age, comorbities, and treatment, patients who were treated with multimodality therapy had significantly improved mean cause-specific survival (24.6mths) compared to those who underwent chemotherapy alone (12.3mths) and surgery alone (18.2mths), p≤0.03 [Figure]. Multimodality therapy significantly decreased the hazard of death from PDAC compared to chemotherapy (HR 0.72, CI 0.54-0.97) and compared to surgery alone (HR 0.37, CI 0.23-0.57). Radiation therapy as part of multimodality therapy did not significantly affect survival.
Of patients that underwent surgery, the overall rate of 30-day postoperative complications was 53.3%. When compared to patients undergoing PD, patients who had PDVR had significantly increased rates of portal vein thrombosis (9% vs 0%, p<0.01), septicemia (17% vs 5%, p=0.02) and readmission within 30 days (41% vs 24%, p=0.03) but had similar overall complication rates (55% vs 52%, p=0.72) and initial lengths of stay (12±7 vs 11±8, p=0.15). Adjusted cause-specific survival between patients undergoing PDVR and PD were statistically identical (mean survival 18.5mths vs 22.3mths, p=0.90).
Conclusion: Although surgical resection results in significant postoperative morbidity, multimodality therapy including resection and chemotherapy improves survival in patients with stage II PDAC of the head of the pancreas with vascular abutment compared to either therapeutic modality alone.
 Adjusted cause-specific survival probability of stage II PDAC with vascular abutment, stratified by treatment.
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