More is More? Total Pancreatectomy for Periampullary Cancer as an Alternative in Patients with High-Risk Pancreatic Anastomosis: A Propensity Score-Matched Analysis

Abstract Background Postpancreatectomy morbidity remains significant even in high-volume centers and frequently results in delay or suspension of indicated adjuvant oncological treatment. This study investigated the short-term and long-term outcome after primary total pancreatectomy (PTP) and pylorus-preserving pancreaticoduodenectomy (PPPD) or Whipple procedure, with a special focus on administration of adjuvant therapy and oncological survival. Methods Patients who underwent PTP or PPPD/Whipple for periampullary cancer between January 2008 and December 2017 were retrospectively analyzed. Propensity score-matched analysis was performed to compare perioperative and oncological outcomes. Correspondingly, cases of rescue completion pancreatectomy (RCP) were analyzed. Results In total, 41 PTP and 343 PPPD/Whipple procedures were performed for periampullary cancer. After propensity score matching, morbidity (Clavien-Dindo classification (CDC) ≥ IIIa, 31.7% vs. 24.4%; p = 0.62) and mortality rates (7.3% vs. 2.4%, p = 0.36) were similar in PTP and PPPD/Whipple. Frequency of adjuvant treatment administration (76.5% vs. 78.4%; p = 0.87), overall survival (513 vs. 652 days; p = 0.47), and progression-free survival (456 vs. 454 days; p = 0.95) did not significantly differ. In turn, after RCP, morbidity (CDC ≥ IIIa, 85%) and mortality (40%) were high, and overall survival was poor (median 104 days). Indicated adjuvant therapy was not administered in 77%. Conclusions In periampullary cancers, PTP may provide surgical and oncological treatment outcomes comparable with pancreatic head resections and might save patients from RCP. Especially in selected cases with high-risk pancreatic anastomosis or preoperatively impaired glucose tolerance, PTP may provide a safe treatment alternative to pancreatic head resection.

Download Full-text

Neoadjuvant Therapy Followed by Resection Versus Upfront Resection for Resectable Pancreatic Cancer: A Propensity Score Matched Analysis

Journal of Clinical Oncology ◽

10.1200/jco.2016.68.5081 ◽

2017 ◽

Vol 35 (5) ◽

pp. 515-522 ◽

Cited By ~ 154

Author(s):

Ali A. Mokdad ◽

Rebecca M. Minter ◽

Hong Zhu ◽

Mathew M. Augustine ◽

Matthew R. Porembka ◽

...

Keyword(s):

Overall Survival ◽

Propensity Score ◽

Adjuvant Therapy ◽

Neoadjuvant Therapy ◽

Pancreatic Adenocarcinoma ◽

Early Stage ◽

Clinical Stage ◽

Pancreatic Head ◽

Hazard Ratio ◽

Stage I

Purpose To compare overall survival between patients who received neoadjuvant therapy (NAT) followed by resection and those who received upfront resection (UR)—as well as a subgroup of UR patients who also received adjuvant therapy—for early-stage resectable pancreatic adenocarcinoma. Patients and Methods Adult patients with resected, clinical stage I or II adenocarcinoma of the head of the pancreas were identified in the National Cancer Database from 2006 to 2012. Patients who underwent NAT followed by curative-intent resection were matched by propensity score with patients whose tumors were resected upfront. Overall survival was compared by using a Cox proportional hazards regression model. Early postoperative and oncologic outcomes were evaluated. Results We identified 15,237 patients with clinical stage I or II resected pancreatic head adenocarcinoma. From the NAT group, 2,005 patients (95%) were matched with 6,015 patients who underwent UR. The NAT group was associated with improved survival compared with UR (median survival, 26 months v 21 months, respectively; stratified log-rank P < .01; hazard ratio, 0.72; 95% CI, 0.68 to 0.78). Patients in the UR group had higher pathologic T stage (pT3 and T4: 86% v 73%; P < .01), higher positive lymph nodes (73% v 48%; P < .01), and higher positive resection margin (24% v 17%; P < .01). Compared with a subset of UR patients who received adjuvant therapy, NAT patients had a better survival (adjusted hazard ratio, 0.83; 95% CI, 0.73 to 0.89). Conclusion NAT followed by resection has a significant survival benefit compared with UR in early-stage, resected pancreatic head adenocarcinoma. These findings support the use of NAT, particularly as a patient selection tool, in the management of resectable pancreatic adenocarcinoma.

Download Full-text

Total pancreatectomy and pancreatic fistula: friend or foe?

Updates in Surgery ◽

10.1007/s13304-021-01130-3 ◽

2021 ◽

Author(s):

Roberto Salvia ◽

Gabriella Lionetto ◽

Giampaolo Perri ◽

Giuseppe Malleo ◽

Giovanni Marchegiani

Keyword(s):

High Risk ◽

Pancreatic Fistula ◽

Total Pancreatectomy ◽

Postoperative Pancreatic Fistula ◽

Current Evidence ◽

Perioperative Outcomes ◽

Surgical Morbidity ◽

Pancreatic Anastomosis ◽

Promising Tool

AbstractPostoperative pancreatic fistula (POPF) still represents the major driver of surgical morbidity after pancreaticoduodenectomy. The purpose of this narrative review was to critically analyze current evidence supporting the use of total pancreatectomy (TP) to prevent the development of POPF in patients with high-risk pancreas, and to explore the role of completion total pancreatectomy (CP) in the management of severe POPF. Considering the encouraging perioperative outcomes, TP may represent a promising tool to avoid the morbidity related to an extremely high-risk pancreatic anastomosis in selected patients. Surgical management of severe POPF is only required in few critical scenarios. In this context, even if anecdotal, CP might play a role as last resort in expert hands.

Download Full-text

Could total pancreatectomy improve overall survival of pancreatic head adenocarcinoma patients? Preliminary results of prospective study with 110 cases

HPB ◽

10.1016/j.hpb.2020.04.411 ◽

2020 ◽

Vol 22 ◽

pp. S374-S375

Author(s):

F. Sánchez-Bueno ◽

PJ Gil Vazquez ◽

J. De la Peña ◽

E. Ortiz ◽

R Garcia Perez ◽

...

Keyword(s):

Overall Survival ◽

Prospective Study ◽

Total Pancreatectomy ◽

Pancreatic Head ◽

Preliminary Results

Download Full-text

Evaluation of conditional treatment effects of adjuvant treatments on patients with synovial sarcoma using Bayesian subgroup analysis

BMC Medical Informatics and Decision Making ◽

10.1186/s12911-020-01305-9 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Sung Wook Seo ◽

Jisoo Kim ◽

Jihye Son ◽

Sungbin Lim

Keyword(s):

Overall Survival ◽

Radiation Therapy ◽

High Risk ◽

Propensity Score ◽

Synovial Sarcoma ◽

Treatment Effects ◽

Spindle Cell ◽

Large Tumor ◽

Subgroup Analyses ◽

Risk Patients

Abstract Background The impact of adjuvant chemotherapy or radiation therapy on the survival of patients with synovial sarcoma (SS), which is a rare soft-tissue sarcoma, remains controversial. Bayesian statistical approaches and propensity score matching can be employed to infer treatment effects using observational data. Thus, this study aimed to identify the individual treatment effects of adjuvant therapies on the overall survival of SS patients and recognize subgroups of patients who can benefit from specific treatments using Bayesian subgroup analyses. Methods We analyzed data from patients with SS obtained from the surveillance, epidemiology, and end results (SEER) public database. These data were collected between 1984 and 2014. The treatment effects of chemotherapy and radiation therapy on overall survival were evaluated using propensity score matching. Subgroups that could benefit from radiation therapy or chemotherapy were identified using Bayesian subgroup analyses. Results Based on a stratified Kaplan–Meier curve, chemotherapy exhibited a positive average causal effect on survival in patients with SS, whereas radiation therapy did not. The optimal subgroup for chemotherapy includes the following covariates: older than 20 years, male, large tumor (longest diameter > 5 cm), advanced stage (SEER 3), extremity location, and spindle cell type. The optimal subgroup for radiation therapy includes the following covariates: older than 20 years, male, large tumor (longest diameter > 5 cm), early stage (SEER 1), extremity location, and biphasic type. Conclusion In this study, we identified high-risk patients whose variables include age (age > 20 years), gender, tumor size, tumor location, and poor prognosis without adjuvant treatment. Radiation therapy should be considered in the early stages for high-risk patients with biphasic types. Conversely, chemotherapy should be considered for late-stage high-risk SS patients with spindle cell types.

Download Full-text

Adjuvant therapy for high-risk stage II or stage III colon adenocarcinoma: A propensity score-matched, nationwide, population-based cohort study

Annals of Oncology ◽

10.1093/annonc/mdz421.013 ◽

2019 ◽

Vol 30 ◽

pp. ix33

Author(s):

C.-H. Chen ◽

S.-Y. Wu

Keyword(s):

Cohort Study ◽

High Risk ◽

Propensity Score ◽

Adjuvant Therapy ◽

Colon Adenocarcinoma ◽

Population Based ◽

Stage Ii ◽

Stage Iii

Download Full-text

Outcomes of neoadjuvant chemotherapy versus chemoradiation among patients with resected pancreatic head adenocarcinoma.

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.4_suppl.398 ◽

2016 ◽

Vol 34 (4_suppl) ◽

pp. 398-398

Author(s):

Jan Franko ◽

Harold W Hsu ◽

Pragatheeshwar Thirunavukarasu ◽

Daniela Frankova ◽

Charles David Goldman

Keyword(s):

Pancreatic Cancer ◽

Overall Survival ◽

Neoadjuvant Chemotherapy ◽

Household Income ◽

Pancreatic Head ◽

Insurance Status ◽

Long Term Outcome ◽

Facility Type ◽

Income Quartile ◽

Resection Volume

398 Background: Increasing use of neoadjuvant therapy in pancreatic cancer has been reported. We compared patterns of practice and outcomes of neoadjuvant chemotherapy (nCHT) versus chemoradiation (nCRT) among pancreatic cancer pts receiving pancreaticoduodenectomy. Methods: National Cancer Data Base pancreatic head adenocarcinoma patients (pts) diagnosed between 2003 and 2011 treated by nCHT or nCRT followed by pancreaticoduodenectomy. Backward elimination logistic and Cox regression models were used. Primary outcome measures were 30-day and 90-day postsurgical mortality and overall survival; adjusted odds (aOR) & hazard ratios (aHR) and 95% confidence intervals (CI) are reported. Results: In all 1,432 pts received neoadjuvant treatment with nCHT (n = 523) or nCRT (n = 909). Odds of 30-day mortality were influenced by age (aOR 1.03, CI 0.99-1.06,p = 0.077), average annual resection volume of facility (aOR 0.98, CI 0.97-1.00, p = 0.135), and household income quartile (aOR 1.94, CI 0.97-3.90, p = 0.060), but not by delivery of RT, comorbidities, gender, insurance status or facility type. Odds of 90-day mortality were influenced by age (aOR 1.03, 1.01-1.05,p = 0.004), household income quartile (aOR 1.37, CI 0.87-2.16, p = 0.171), and delivery of nCRT (aOR 1.69, CI 1.04-2.74, p = 0.032), but not by average annual resection volume of facility, comorbidity, gender, insurance status or facility type. Survival odds were influenced by age (aHR 1.01, CI 1.00-1.02, p = 0.001), margin status (aOR 1.50, CI 1.27-1.77, p < 0.001), ypN status (aHR 1.45, CI 1.26-1.68), p < 0.001), adjuvant CHT (aHR 0.81, CI 0.69-0.94, p = 0.006), and nCRT (aHR 1.21, CI 1.04-1.40, p = 0.012). On average pts with nCHT as compared to nCRT lived longer (median OS 26.4 vs. 24.2 months, p = 0.001; actuarial 3 yr 58% vs 49%, and 5 year survival 30% vs 14%). Conclusions: There is no detectable difference in early outcome (30-day postsurgical mortality) among pancreaticoduodenectomy pts treated with nCHT or nCRT. Trend toward a more favorable long-term outcome (30-day postsurgical mortality and overall survival) among those with nCHT without radiation is noted. Further studies with more detailed data sources are needed.

Download Full-text

The Role of Neoadjuvant Versus Adjuvant Therapy for Duodenal Adenocarcinoma: A National Cancer Database Propensity Score Matched Analysis

The American Surgeon ◽

10.1177/0003134820954821 ◽

2020 ◽

pp. 000313482095482

Author(s):

Kimberly Linden ◽

Atlee Melillo ◽

John Gaughan ◽

Chioma Obinero ◽

Alec Kellish ◽

...

Keyword(s):

Overall Survival ◽

Propensity Score ◽

Adjuvant Therapy ◽

Neoadjuvant Therapy ◽

Surgical Resection ◽

Retrospective Review ◽

National Cancer Database ◽

Tumor Characteristics ◽

Duodenal Adenocarcinoma

Introduction Adjuvant therapy is recommended in duodenal adenocarcinoma (DA), but the role of neoadjuvant therapy remains undefined. We compared the effect of neoadjuvant therapy to adjuvant therapy on overall survival, 30-day, and 90-day mortality following the resection of DA. Methods A retrospective review of the National Cancer Database was performed on patients with DA who received either adjuvant or neoadjuvant therapy in addition to surgical resection. Propensity score matching was done for patient, socioeconomic, and tumor characteristics. Overall survival, 30-day, and 90-day mortality were compared. Results A total of 112 patients were identified; 55 received adjuvant therapy; 57 received neoadjuvant therapy. There was no difference in 30-day (0% vs. 1.75%; P = 1.00), 90-day mortality (1.82% vs. 7.02%; P = .36), nor overall survival (1 yr: 86% vs. 76; 3 yr: 49% vs. 46%; 5 yr: 42% vs. 39%; P = .28). Conclusions There was no difference in overall survival after propensity score matched analysis.

Download Full-text

Effect of adjuvant therapy on resected gallbladder adenocarcinoma: A propensity score matched analysis of national data.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.15_suppl.e15669 ◽

2017 ◽

Vol 35 (15_suppl) ◽

pp. e15669-e15669

Author(s):

Gyulnara G. Kasumova ◽

Omidreza Tabatabaie ◽

Rebecca A. Miksad ◽

Sing Chau Ng ◽

Manuel M. Hidalgo ◽

...

Keyword(s):

Overall Survival ◽

Adjuvant Chemotherapy ◽

Propensity Score ◽

Adjuvant Therapy ◽

Median Overall Survival ◽

Resection Margins ◽

Adjuvant Radiation ◽

Cancer Data ◽

R1 Resection ◽

Gallbladder Adenocarcinoma

e15669 Background: There is a paucity of data and no consensus regarding administration of adjuvant therapy after resection of gallbladder cancer. In the absence of a completed clinical trial, we retrospectively reviewed US cancer data. Methods: National Cancer Data Base was queried for patients diagnosed with gallbladder adenocarcinoma between 2004-2014 who underwent definitive resection for non-metastatic disease (pT1b, pT2, pT3, pN0, pN1, pNX) and had R0 and R1 resection margins. One-to-one propensity score matching was used to account for potential selection bias in patient and tumor characteristics. Kaplan-Meier method was used to compare overall survival. Results: Of 4830 patients identified, 1489 (30.8%) received adjuvant chemotherapy. Patients who received adjuvant chemotherapy were more likely to be younger, have private insurance or Medicare, have no comorbidities, higher T stage, and moderately to poorly differentiated tumors (all p-values < 0.0001). The majority of patients who received adjuvant chemotherapy also received adjuvant radiation (58.0%). On unadjusted analysis, patients who received adjuvant chemotherapy had no difference in median overall survival compared to those who did not (25.8 vs 29.0 mo; p = 0.3060). After matching for sex, age, race, insurance, comorbidity, facility type, pT stage, lymph node status, resection margins (R0 vs R1), adjuvant radiation, and tumor grade no difference in median overall survival remained between patients who did (21.8 mo) and did not (22.6 mo) receive adjuvant chemo (p = 0.6843). However, after matching on the propensity to receive adjuvant radiation in addition to the above covariates, receipt of adjuvant radiation resulted in a persistently significant increase in median overall survival (27.8 vs 22.2 mo; p = 0.0005). Conclusions: After matching for potential confounders, there is no difference in overall survival for patients who did and did not receive adjuvant chemotherapy after R0/R1 resection for pT1b, pT2, and pT3 gallbladder adenocarcinoma; however, adjuvant radiation does appear to confer a survival advantage. These results support the current treatment guidelines until evidence from RCTs becomes available.

Download Full-text

Role of adjuvant chemotherapy in patients with pathological stage I NSCLC with high-risk features.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.9022 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. 9022-9022

Author(s):

Lubina Arjyal ◽

Dipesh Uprety ◽

Susan M Frankki ◽

Andrew J Borgert ◽

David E. Marinier

Keyword(s):

Overall Survival ◽

Survival Analysis ◽

High Risk ◽

Adjuvant Chemotherapy ◽

Propensity Score ◽

Tumor Size ◽

Stage I ◽

Median Income ◽

Pathological Stage ◽

Kaplan Meier

9022 Background: Lobectomy is the current standard of care for patients with stage I non-small cell lung cancer (NSCLC). There is a lack of prospective data on the benefit of adjuvant chemotherapy (CT) in patients with negative margins but with high-risk features: lympho-vascular invasion (LVI) or visceral pleural invasion (VPI). We aimed to investigate the benefit of adjuvant CT in patients with pathological stage I NSCLC with high-risk features. Methods: The 2016 National Cancer Database was queried to identify patients with pathological stage I NSCLC (8th edition AJCC staging) diagnosed from 2010-2015 who received lobectomy/pneumonectomy with clear surgical margins. Patients were stratified into high risk (tumor size ≥2 cm with LVI and/or VPI) or low risk group. Multivariate Cox proportional hazards regression and propensity score matched Kaplan-Meier survival analysis were used to compare overall survival between those who received adjuvant CT and those who did not. Results: 34,556 patients were identified with 1114 (3.2%) receiving adjuvant CT. On multivariate Cox regression analysis, high risk tumors (hazard ratio [95% confidence interval] = 1.31 [1.25-1.38]) and lack of adjuvant chemotherapy (1.25 [1.09-1.44]) were associated with worse overall survival (OS). Additionally, male sex, age ≥ 60 years, higher comorbidity burden, lack of insurance, low facility volume, low median income, non-squamous histology were associated with worse OS. After propensity score matching, Kaplan-Meier survival analysis of the high risk subgroup (n = 2923) showed a significant difference in overall survival (OS) between those who received adjuvant CT (n = 1032, 5 year OS, 74.7%; 95% CI, 70.9%-78.0%) and those who did not (n = 1891, 5 year OS, 66.9%; CI, 63.9%-69.6%; p = 0.0002). In patients with no high risk factors for recurrence (n = 384), OS was not significantly different between the patients who received adjuvant CT (n = 78, 5 year OS, 75.8%; CI, 61.3%-85.5%) and those who did not receive adjuvant CT (n = 306, 5 year OS, 77.1%; CI, 70.0%-82.7%; p = 0.3). Conclusions: Our study showed better survival with adjuvant CT in patients with pathological stage I NSCLC who have tumor size greater than 2 cm, LVI and/or VPI.

Download Full-text