1. Has Survival following Pancreaticoduodenectomy for Pancreas Adenocarcinoma
Improved over Time?
Ahmed I. Salem, MD, Mina Alfi, Emily Winslow, MD, FACS, Clifford S. Cho, MD, FACS, Sharon M. Weber, MD, FACS
Section of Surgical Oncology – Division of General Surgery – University of Wisconsin School of Medicine and Public Health
Introduction:
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=0.83). 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 (HR=1.036, p=0.848, CI=0.722 – 1.486).
Conclusions:
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
ValueEra 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
Kaplan-Maier survival analysis for Era 1 and Era 2
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