PANCREATIC NEUROENDOCRINE TUMOR: RATIONALE FOR REGIONALIZATION IN AN INTEGRATED HEALTH CARE SYSTEM
Diana Hsu*1, Sidney Le1, Alex Chang2, Austin L. Spitzer2, George Kazantsev2, Peter Peng2, Ck Chang2
1University of California System, Oakland, CA; 2Kaiser Permanente, Oakland, CA
Introduction: Pancreatic neuroendocrine tumors (PNET) of the pancreas are a heterogeneous group of tumors and represent about 1-2% of all pancreatic cancers. Though indolent, up to 60% of patients have metastatic disease at time of diagnosis. The biologic behaviors are unpredictable with high grade, nodal metastasis, or liver metastasis having an unfavorable prognosis. Previous data have shown that 5-year survival rates of PNETs was 80% for all stages. Surgery is the primary method of treatment for localized and metastatic disease, as debulking has been shown to improve survival. The complexity of surgical management and infrequency of PNETs may lend them to the benefits of regionalization of care.
Methods: A retrospective review was undertaken to identify patients with pancreatic neuroendocrine tumor treated in Northern California Kaiser Permanente (KP-NCAL) between February 2010 and December 2018. Univariate and multivariate analyses of factors were evaluated with the log-rank test and Cox regression. In addition, the Chi-square test of relevant clinicopathologic factors determined which factors were predictive for overall survival (OS). Four dedicated hepato-pancreato-biliary (HPB) centers of excellence (COE) were created from 21 hospitals throughout Northern California in 2015. All four centers are staffed with a team of fellowship-trained HPB surgeons, interventional radiologists, advanced gastroenterologists, medical and radiation oncologists, and nutrition specialists.
Results: Mean age was 61 years in our cohort of 354 patients, with 29% over the age of 70. Mean tumor size was 3.43 cm; 32% of the lesions were 2 cm or less. The pancreatic tail was the most common location (38%) followed by the head of the pancreas (24%). 51% of patients had localized disease and 32% of the patients presented with metastatic disease. On multivariate survival analysis, stage, location of the tumor, and surgical resection were statistically significant in terms of overall survival (OS) (p<.001). Mean OS for patients with localized disease was 93 months versus 37 months for patient with metastatic disease (p<.001). Surgery was utilized in 8.9% of patients with metastatic disease (p<.001). OS for patients of all stages treated at a non-COE versus COE was 60 months and 80 months, respectively (p<.001). Surgical interventions were more common for all stages at the COE versus non-COE at 70% and 40%, respectively (p<.001).
Conclusion: PNETs are indolent but have malignant potential at any size. Due to the frequency with which they metastasize, their management often requires complex surgeries. Our study showed that overall survival was statistically improved in patients treated at a center of excellence, where surgery was more frequently utilized for all stages of disease.
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