Date Published: May 24, 2019
Publisher: Public Library of Science
Author(s): Zhenjiang Zheng, Chunlu Tan, Yonghua Chen, Jie Ping, Mojin Wang, Jason S. Gold.
The only curative treatment for pancreatic adenocarcinoma is radical surgical resection. Because of the special anatomic features of pancreatic neck, the selection of optimal surgical procedure for treatment of adenocarcinoma of pancreatic neck has always been a dilemma for surgeons. In this paper, we aim to investigate whether different surgical procedures can affect prognosis in the patient with adenocarcinoma of pancreatic neck.
We used the surveillance, epidemiology, and end results database to review patients with adenocarcinoma of pancreatic neck diagnosed between 1998 and 2015. We calculated overall survival (OS) and cancer-specific survival (CSS) of these patients using Kaplan-Meier analysis and Cox regression model.
Overall, 1443 patients were included in the study, with 12.5% treated with surgical resection. Among them, 30 (18.8%) patients underwent distal pancreatectomy (DP), 105 (65.6%) patients underwent pancreatoduodenectomy (PD), and 25 (15.6%) patients underwent total pancreatectomy (TP). Patients underwent DP were older than these underwent TP (70.5±10.7 vs. 62.2±14.1, P = 0.027). Patients underwent TP had higher percentages of nodal metastasis (N1 stage) than these underwent DP (68.0% vs. 34.5%, P = 0.014). The surgical procedures did not significantly affect either OS times (P = 0.924) or CSS times (P = 0.786) in Kaplan-Meier analysis, even if in any subgroup of AJCC stage. The multivariate Cox regression model showed that types of surgery were not associated with OS and CSS. Higher tumor grade and AJCC stage are independent prognostic factors for OS and CSS. No radiotherapy was associated with a worse CSS (HR 1.610, 95% CI 1.016–2.554, P = 0.043).
Different surgical procedures did not affect prognosis in the patients with adenocarcinoma of pancreatic neck. TP should be performed in carefully selective patients in high-volume pancreatic centers.
Pancreatic adenocarcinoma is one of most lethal disease with 8% overall 5-year survival. The only curative treatment for pancreatic adenocarcinoma is radical surgical resection. Conventional surgical procedures for pancreatic adenocarcinoma are basically represented by pancreatoduodenectomy (PD) and distal pancreatectomy (DP), according to the tumor’s location. Advances in surgical skills have allowed for evolution in pancreatic adenocarcinoma surgery. Thus, total pancreatectomy (TP) has become an alternative surgical procedure in high-volume pancreatic centers to achieve complete tumor resection with negative margins. Pancreatic neck located in a short segment (approximately 2 cm) between pancreatic head and body, anterior to the portal vein (PV), on the left side of the gastroduodenal artery (GDA), and below the common hepatic artery (CHA). These anatomic features resulted in different clinicopathologic characteristics of pancreatic neck cancer, as compared to cancer located in the head or in the body and/or tail of the pancreas. For the treatment of benign diseases or low-grade malignancies in pancreatic neck, central pancreatectomy is appropriate, to preserve more pancreatic parenchyma and function.[5,6] However, this technique is improper in the setting of invasive tumor as parenchyma-sparing may lead to tumor lesion residual. Because of the special anatomic features of pancreatic neck, the selection of optimal surgical procedure for invasive tumor has always been a dilemma for surgeons. Few discussions on pancreatic adenocarcinoma has been focused on the pancreatic neck, due to these cases are often classified as pancreatic head or body cancer. Furthermore, no studies to date have compared the impact of different surgical procedures on survival of adenocarcinoma of pancreatic neck.
The surgical management remains the only curative treatment for pancreatic adenocarcinoma. PD, DP, and TP are regarded as standard procedures in the treatment of pancreatic duct adenocarcinoma and should be performed according to tumor location. Much debate has focused on the selection of optimal surgical procedures.[3,8] In this population-based study, we analysed the treatment practices for patients with adenocarcinoma of pancreatic neck and assessed the prognostic factors. This study showed that only 12.5% patients had undergone surgical resection with better OS and CSS compared to those with no surgery. The Kaplan-Meier analysis demonstrated that the OS and CSS in the DP, PD and TP groups did not differ significantly. Even if in subgroups of AJCC stage, similar results were found. Considering the factors on survival, the multivariate analysis showed that types of surgery were not associated with prognosis. On the contrary, higher AJCC stage and grade were independent prognostic factors for poor OS and CSS. In addition, no radiotherapy was another factor associated with poor CSS. Some population-based data have evaluated the association between surgical procedures and prognosis based on tumor location, with the exception of pancreatic neck. Nathan el at. found, by using SEER database, that long-term survival was similar following TP versus partial pancreatectomy (e.g. PD and DP) for pancreatic adenocarcinoma in different tumor location (HR 1.06, P = 0.49 for head; HR 0.84, P = 0.51 for body/tail; HR 1.06, P = 0.79 for unspecified locations). Also using SEER database, Govindarajan et al. found that there had been no significant difference in survival between TP, PD and pylorus-preserving pancreaticoduodenectomy for cancer of pancreatic head.