Predictors for Survival in an International Cohort of Patients Undergoing Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma

Abstract

Background Surgical factors, including resection of Gerota’s fascia, R0-resection, and lymph node yield, may be associated with survival after distal pancreatectomy (DP) for pancreatic ductal adenocarcinoma (PDAC), but evidence from large multicenter studies is lacking. This study aimed to identify predictors for overall survival after DP for PDAC, especially those related to surgical technique. Patients and Methods Data from an international retrospective cohort including patients from 11 European countries and the USA who underwent DP for PDAC (2007–2015) were analyzed. Cox proportional hazard analyses were performed and included Gerota’s fascia resection, R0 resection, lymph node ratio, extended resection, and a minimally invasive approach. Results Overall, 1200 patients from 34 centers with median follow-up of 15 months [interquartile range (IQR) 5–31 months] and median survival period of 30 months [95% confidence interval (CI), 27–33 months] were included. Gerota’s fascia resection [hazard ratio (HR) 0.74; p = 0.019], R0 resection (HR 0.70; p = 0.006), and decreased lymph node ratio (HR 0.28; p < 0.001) were associated with improved overall survival, whereas extended resection (HR 1.75; p < 0.001) was associated with worse overall survival. A minimally invasive approach did not improve survival as compared with an open approach (HR 1.14; p = 0.350). Adjuvant chemotherapy (HR 0.67; p = 0.003) was also associated with improved overall survival. Conclusions This international cohort identified Gerota’s fascia resection, R0 resection, and decreased lymph node ratio as factors associated with improved overall survival during DP for PDAC. Surgeons should strive for R0 resection and adequate lymphadenectomy and could also consider Gerota’s fascia resection in their routine surgical approach. Electronic supplementary material The online version of this article (10.1245/s10434-020-08658-5) contains supplementary material, which is available to authorized users.

Prognostic Impact of Resection Margin Status in Distal Pancreatectomy for Ductal Adenocarcinoma

“…The prognostic roles of lymph node ratio, perineural invasion, and adjuvant chemotherapy in pancreatic body/tail cancer have been reported previously. 34 , 39 , 40 The dismal prognosis for patients undergoing extended DP for PDAC has been highlighted in our previous reports and in other studies. 34 , 40 – 43 In this study, resection margins were positive in 82% of patients undergoing extended resection.…”

“… 34 , 39 , 40 The dismal prognosis for patients undergoing extended DP for PDAC has been highlighted in our previous reports and in other studies. 34 , 40 – 43 In this study, resection margins were positive in 82% of patients undergoing extended resection. Considering that all extended resection specimens that were examined according to the standardized protocol in period 2 showed R 1, we believe that R 0 can hardly be expected in this group.…”

“…Recent studies based on the definitions of R 1 according to the Royal College of Pathologists (≤1 mm clearance; 0 mm clearance at the anterior surface) report on microscopic margin involvement in 40–45% of DP specimens, which is markedly lower than in our series. 32 , 34 , 35 However, the data are difficult to compare as the pathology examination protocols that were followed are hardly mentioned in these studies. Furthermore, since these were multicenter studies, the pathology examination methods may not have been uniform between the centers.…”

Prognostic impact of resection margin status in distal pancreatectomy for ductal adenocarcinoma

“…Recent studies based on the definitions of R1 according to the Royal College of Pathologists (B1 mm clearance; 0 mm clearance at the anterior surface) report on microscopic margin involvement in 40-45% of DP specimens, which is markedly lower than in our series. 32,34,35 However, the data are difficult to compare as the pathology examination protocols that were followed are hardly mentioned in these FIG. 1 Survival Following standard (R0/R1) and extended distal pancreatectomy in patients with non-metastatic ductal adenocarcinoma.…”

ASO Author Reflections: Surgical Predictors for Survival in Patients Undergoing Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma

“…This study provided evidence that several surgical factors are associated with improved survival after distal pancreatectomy for PDAC, allowing the opportunity to integrate these into standard surgical practice to optimize oncological outcomes. 5…”