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. 1995 Jun;221(6):721–733. doi: 10.1097/00000658-199506000-00011

Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients.

C J Yeo 1, J L Cameron 1, K D Lillemoe 1, J V Sitzmann 1, R H Hruban 1, S N Goodman 1, W C Dooley 1, J Coleman 1, H A Pitt 1
PMCID: PMC1234702  PMID: 7794076

Abstract

OBJECTIVE: This single-institution study examined the outcome after pancreaticoduodenectomy in patients with adenocarcinoma of the head of the pancreas. SUMMARY OF BACKGROUND DATA: In recent years, pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas has been associated with decreased morbidity and mortality and, in some centers, 5-year survival rates in excess of 20%. METHODS: Two hundred one patients with pathologically verified adenocarcinoma of the head of the pancreas undergoing pancreaticoduodenectomy at The Johns Hopkins Hospital between 1970 and 1994 were analyzed (the last 100 resections were performed between March 1991 and April 1994). This is the largest single-institution experience reported to date. RESULTS: The overall postoperative in-hospital mortality rate was 5%, but has been 0.7% for the last 149 patients. The actuarial 5-year survival for all 201 patients was 21%, with a median survival of 15.5 months. There were 11 5-year survivors. Patients resected with negative margins (curative resections: n = 143) had an actuarial 5-year survival rate of 26%, with a median survival of 18 months, whereas those with positive margins (palliative resections; n = 58) fared significantly worse, with an actuarial 5-year survival rate of 8% and a median survival of 10 months (p < 0.0001). Survival has improved significantly from decade to decade (p < 0.002), with the 3-year actuarial survival of 14% in the 1970s, 21% in the 1980s, and 36% in the 1990s. Factors significantly favoring long-term survival by univariate analyses included tumor diameter < 3 cm, negative nodal status, diploid tumor DNA content, tumor S phase fraction < 18%, pylorus-preserving resection, < 800 mL intraoperative blood loss, < 2 units of blood transfused, negative resection margins, and use of postoperative adjuvant chemotherapy and radiation therapy. Multivariate analyses indicated the strongest predictors of long-term survival were diploid tumor DNA content, tumor diameter < 3 cm, negative nodal status, negative resection margins, and decade of resection. CONCLUSIONS: The survival of patients with pancreatic adenocarcinoma treated by pancreaticoduodenectomy is improving. Aspects of tumor biology, such as DNA content, tumor diameter, nodal status and margin status, are the strongest predictors of outcome.

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Selected References

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  1. Allison D. C., Bose K. K., Hruban R. H., Piantadosi S., Dooley W. C., Boitnott J. K., Cameron J. L. Pancreatic cancer cell DNA content correlates with long-term survival after pancreatoduodenectomy. Ann Surg. 1991 Dec;214(6):648–656. doi: 10.1097/00000658-199112000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Belli L., Riolo F., Romani F., Baticci F., Rossetti O., Puttini M. Pylorus preserving pancreatoduodenectomy versus Whipple procedure for adenocarcinoma of the head of the pancreas. HPB Surg. 1989 Oct;1(3):195–200. doi: 10.1155/1989/94691. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Bose K. K., Allison D. C., Hruban R. H., Piantadosi S., Zahurak M., Dooley W. C., Lin P., Cameron J. L. A comparison of flow cytometric and absorption cytometric DNA values as prognostic indicators for pancreatic carcinoma. Cancer. 1993 Feb 1;71(3):691–700. doi: 10.1002/1097-0142(19930201)71:3<691::aid-cncr2820710307>3.0.co;2-9. [DOI] [PubMed] [Google Scholar]
  4. Burrows L., Tartter P. Effect of blood transfusions on colonic malignancy recurrent rate. Lancet. 1982 Sep 18;2(8299):662–662. doi: 10.1016/s0140-6736(82)92764-7. [DOI] [PubMed] [Google Scholar]
  5. Böttger T. C., Störkel S., Wellek S., Stöckle M., Junginger T. Factors influencing survival after resection of pancreatic cancer. A DNA analysis and a histomorphologic study. Cancer. 1994 Jan 1;73(1):63–73. doi: 10.1002/1097-0142(19940101)73:1<63::aid-cncr2820730113>3.0.co;2-p. [DOI] [PubMed] [Google Scholar]
  6. Caldas C., Hahn S. A., Hruban R. H., Redston M. S., Yeo C. J., Kern S. E. Detection of K-ras mutations in the stool of patients with pancreatic adenocarcinoma and pancreatic ductal hyperplasia. Cancer Res. 1994 Jul 1;54(13):3568–3573. [PubMed] [Google Scholar]
  7. Caldas C., Hahn S. A., da Costa L. T., Redston M. S., Schutte M., Seymour A. B., Weinstein C. L., Hruban R. H., Yeo C. J., Kern S. E. Frequent somatic mutations and homozygous deletions of the p16 (MTS1) gene in pancreatic adenocarcinoma. Nat Genet. 1994 Sep;8(1):27–32. doi: 10.1038/ng0994-27. [DOI] [PubMed] [Google Scholar]
  8. Cameron J. L., Crist D. W., Sitzmann J. V., Hruban R. H., Boitnott J. K., Seidler A. J., Coleman J. Factors influencing survival after pancreaticoduodenectomy for pancreatic cancer. Am J Surg. 1991 Jan;161(1):120–125. doi: 10.1016/0002-9610(91)90371-j. [DOI] [PubMed] [Google Scholar]
  9. Cameron J. L., Pitt H. A., Yeo C. J., Lillemoe K. D., Kaufman H. S., Coleman J. One hundred and forty-five consecutive pancreaticoduodenectomies without mortality. Ann Surg. 1993 May;217(5):430–438. doi: 10.1097/00000658-199305010-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Crile G., Jr The advantages of bypass operations over radical pancreatoduodenectomy in the treatment of pancreatic carcinoma. Surg Gynecol Obstet. 1970 Jun;130(6):1049–1053. [PubMed] [Google Scholar]
  11. Crist D. W., Sitzmann J. V., Cameron J. L. Improved hospital morbidity, mortality, and survival after the Whipple procedure. Ann Surg. 1987 Sep;206(3):358–365. doi: 10.1097/00000658-198709000-00014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Crowe J. P., Gordon N. H., Fry D. E., Shuck J. M., Hubay C. A. Breast cancer survival and perioperative blood transfusion. Surgery. 1989 Nov;106(5):836–841. [PubMed] [Google Scholar]
  13. Cusack J. C., Jr, Fuhrman G. M., Lee J. E., Evans D. B. Managing unsuspected tumor invasion of the superior mesenteric-portal venous confluence during pancreaticoduodenectomy. Am J Surg. 1994 Oct;168(4):352–354. doi: 10.1016/s0002-9610(05)80164-3. [DOI] [PubMed] [Google Scholar]
  14. Delcore R., Thomas J. H., Hermreck A. S. Pancreaticoduodenectomy for malignant pancreatic and periampullary neoplasms in elderly patients. Am J Surg. 1991 Dec;162(6):532–536. doi: 10.1016/0002-9610(91)90104-l. [DOI] [PubMed] [Google Scholar]
  15. Evans D. B., Termuhlen P. M., Byrd D. R., Ames F. C., Ochran T. G., Rich T. A. Intraoperative radiation therapy following pancreaticoduodenectomy. Ann Surg. 1993 Jul;218(1):54–60. doi: 10.1097/00000658-199307000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Fortner J. G. Regional pancreatectomy for cancer of the pancreas, ampulla, and other related sites. Tumor staging and results. Ann Surg. 1984 Apr;199(4):418–425. doi: 10.1097/00000658-198404000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Geer R. J., Brennan M. F. Prognostic indicators for survival after resection of pancreatic adenocarcinoma. Am J Surg. 1993 Jan;165(1):68–73. doi: 10.1016/s0002-9610(05)80406-4. [DOI] [PubMed] [Google Scholar]
  18. Gordon T. A., Burleyson G. P., Tielsch J. M., Cameron J. L. The effects of regionalization on cost and outcome for one general high-risk surgical procedure. Ann Surg. 1995 Jan;221(1):43–49. doi: 10.1097/00000658-199501000-00005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Grace P. A., Pitt H. A., Longmire W. P. Pylorus preserving pancreatoduodenectomy: an overview. Br J Surg. 1990 Sep;77(9):968–974. doi: 10.1002/bjs.1800770906. [DOI] [PubMed] [Google Scholar]
  20. Herrera M. F., van Heerden J. A., Katzmann J. A., Weiland L. H., Nagorney D. M., Ilstrup D. Evaluation of DNA nuclear pattern as a prognostic determinant in resected pancreatic ductal adenocarcinoma. Ann Surg. 1992 Feb;215(2):120–124. doi: 10.1097/00000658-199202000-00005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Ishikawa O., Ohigashi H., Imaoka S., Sasaki Y., Iwanaga T., Matayoshi Y., Inoue T. Is the long-term survival rate improved by preoperative irradiation prior to Whipple's procedure for adenocarcinoma of the pancreatic head? Arch Surg. 1994 Oct;129(10):1075–1080. doi: 10.1001/archsurg.1994.01420340089017. [DOI] [PubMed] [Google Scholar]
  22. Jessup J. M., Steele G., Jr, Mayer R. J., Posner M., Busse P., Cady B., Stone M., Jenkins R., Osteen R. Neoadjuvant therapy for unresectable pancreatic adenocarcinoma. Arch Surg. 1993 May;128(5):559–564. doi: 10.1001/archsurg.1993.01420170093014. [DOI] [PubMed] [Google Scholar]
  23. Kalser M. H., Ellenberg S. S. Pancreatic cancer. Adjuvant combined radiation and chemotherapy following curative resection. Arch Surg. 1985 Aug;120(8):899–903. doi: 10.1001/archsurg.1985.01390320023003. [DOI] [PubMed] [Google Scholar]
  24. Kellum J. M., Clark J., Miller H. H. Pancreatoduodenectomy for resectable malignant periampullary tumors. Surg Gynecol Obstet. 1983 Oct;157(4):362–366. [PubMed] [Google Scholar]
  25. Manabe T., Ohshio G., Baba N., Miyashita T., Asano N., Tamura K., Yamaki K., Nonaka A., Tobe T. Radical pancreatectomy for ductal cell carcinoma of the head of the pancreas. Cancer. 1989 Sep 1;64(5):1132–1137. doi: 10.1002/1097-0142(19890901)64:5<1132::aid-cncr2820640528>3.0.co;2-v. [DOI] [PubMed] [Google Scholar]
  26. Redston M. S., Caldas C., Seymour A. B., Hruban R. H., da Costa L., Yeo C. J., Kern S. E. p53 mutations in pancreatic carcinoma and evidence of common involvement of homocopolymer tracts in DNA microdeletions. Cancer Res. 1994 Jun 1;54(11):3025–3033. [PubMed] [Google Scholar]
  27. Roder J. D., Stein H. J., Hüttl W., Siewert J. R. Pylorus-preserving versus standard pancreatico-duodenectomy: an analysis of 110 pancreatic and periampullary carcinomas. Br J Surg. 1992 Feb;79(2):152–155. doi: 10.1002/bjs.1800790219. [DOI] [PubMed] [Google Scholar]
  28. Satake K., Nishiwaki H., Yokomatsu H., Kawazoe Y., Kim K., Haku A., Umeyama K., Miyazaki I. Surgical curability and prognosis for standard versus extended resection for T1 carcinoma of the pancreas. Surg Gynecol Obstet. 1992 Sep;175(3):259–265. [PubMed] [Google Scholar]
  29. Seymour A. B., Hruban R. H., Redston M., Caldas C., Powell S. M., Kinzler K. W., Yeo C. J., Kern S. E. Allelotype of pancreatic adenocarcinoma. Cancer Res. 1994 May 15;54(10):2761–2764. [PubMed] [Google Scholar]
  30. Shapiro T. M. Adenocarcinoma of the pancreas: a statistical analysis of biliary bypass vs Whipple resection in good risk patients. Ann Surg. 1975 Dec;182(6):715–721. doi: 10.1097/00000658-197512000-00010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Sharp K. W., Ross C. B., Halter S. A., Morrison J. G., Richards W. O., Williams L. F., Sawyers J. L. Pancreatoduodenectomy with pyloric preservation for carcinoma of the pancreas: a cautionary note. Surgery. 1989 May;105(5):645–653. [PubMed] [Google Scholar]
  32. Sindelar W. F. Clinical experience with regional pancreatectomy for adenocarcinoma of the pancreas. Arch Surg. 1989 Jan;124(1):127–132. doi: 10.1001/archsurg.1989.01410010137027. [DOI] [PubMed] [Google Scholar]
  33. Steele G. D., Jr, Osteen R. T., Winchester D. P., Murphy G. P., Menck H. R. Clinical highlights from the National Cancer Data Base: 1994. CA Cancer J Clin. 1994 Mar-Apr;44(2):71–80. doi: 10.3322/canjclin.44.2.71. [DOI] [PubMed] [Google Scholar]
  34. Takada T., Yasuda H., Shikata J., Watanabe S., Shiratori K., Takeuchi T. Postprandial plasma gastrin and secretin concentrations after a pancreatoduodenectomy. A comparison between a pylorus-preserving pancreatoduodenectomy and the Whipple procedure. Ann Surg. 1989 Jul;210(1):47–51. doi: 10.1097/00000658-198907000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Tashiro S., Uchino R., Hiraoka T., Tsuji T., Kawamoto S., Saitoh N., Yamasaki K., Miyauchi Y. Surgical indication and significance of portal vein resection in biliary and pancreatic cancer. Surgery. 1991 Apr;109(4):481–487. [PubMed] [Google Scholar]
  36. Trede M., Schwall G., Saeger H. D. Survival after pancreatoduodenectomy. 118 consecutive resections without an operative mortality. Ann Surg. 1990 Apr;211(4):447–458. doi: 10.1097/00000658-199004000-00011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Trede M. The surgical treatment of pancreatic carcinoma. Surgery. 1985 Jan;97(1):28–35. [PubMed] [Google Scholar]
  38. Tsuchiya R., Noda T., Harada N., Miyamoto T., Tomioka T., Yamamoto K., Yamaguchi T., Izawa K., Tsunoda T., Yoshino R. Collective review of small carcinomas of the pancreas. Ann Surg. 1986 Jan;203(1):77–81. doi: 10.1097/00000658-198601000-00013. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Willett C. G., Lewandrowski K., Warshaw A. L., Efird J., Compton C. C. Resection margins in carcinoma of the head of the pancreas. Implications for radiation therapy. Ann Surg. 1993 Feb;217(2):144–148. doi: 10.1097/00000658-199302000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Williamson R. C., Bliouras N., Cooper M. J., Davies E. R. Gastric emptying and enterogastric reflux after conservative and conventional pancreatoduodenectomy. Surgery. 1993 Jul;114(1):82–86. [PubMed] [Google Scholar]
  41. Wu H. S., Little A. G. Perioperative blood transfusions and cancer recurrence. J Clin Oncol. 1988 Aug;6(8):1348–1354. doi: 10.1200/JCO.1988.6.8.1348. [DOI] [PubMed] [Google Scholar]
  42. Yeo C. J., Cameron J. L. Arguments against radical (extended) resection for adenocarcinoma of the pancreas. Adv Surg. 1994;27:273–284. [PubMed] [Google Scholar]
  43. Yeung R. S., Weese J. L., Hoffman J. P., Solin L. J., Paul A. R., Engstrom P. F., Litwin S., Kowalyshyn M. J., Eisenberg B. L. Neoadjuvant chemoradiation in pancreatic and duodenal carcinoma. A Phase II Study. Cancer. 1993 Oct 1;72(7):2124–2133. doi: 10.1002/1097-0142(19931001)72:7<2124::aid-cncr2820720711>3.0.co;2-c. [DOI] [PubMed] [Google Scholar]

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