Proximal versus distal resection in adenocarcinoma of the pancreatic neck: does it matter?

Abstract

Presenter: Shelby L Allen MD | Indiana University Background: Adenocarcinoma isolated to the neck of the pancreas is relatively uncommon, and tumors in this location present a unique challenge to the surgeon. Surgical resection can be done in the form of either a pancreatoduodenctomy or a distal pancreatectomy, depending on specific tumor and patient characteristics. The aim of this study was to explore current practices as well as evaluate surgical and oncologic outcomes for patients undergoing pancreatic resection for cancers of the pancreatic neck. Methods: This was a case series of patients treated at a single institution. NSQIP data was obtained on all patients undergoing pancreatic resection for malignant tumors of the pancreas at our institution from 2013 to 2020. Because a specific CPT code does not exist for neck-based tumors, chart review was utilized to identify cases of pancreatic ductal adenocarcinoma of the neck based on surgeon operative reports and surgical pathology reports. The pancreatic neck was defined as the parenchyma anterior to the superior mesenteric vessels, and between the gastroduodenal artery (GDA) and left border of the superior mesenteric artery. Tumors that involved the neck but that extended into the head or body of the pancreas, or that encased the GDA, were excluded from the analysis. Patients were then divided into groups based on type of resection (pancreatoduodenectomy vs. distal pancreatectomy) and outcomes were compared between the two groups. Data were analyzed using Fisher’s exact test, Mann-Whitney-U test and equality of medians as appropriate. Results: Of a total of 720 patients undergoing surgery for malignant neoplasm of the pancreas, 9 patients had ductal adenocarcinoma isolated to the neck of the pancreas. Four patients (44%) underwent pancreatoduodenectomy (PD) and 5 patients (56%) underwent distal pancreatectomy with splenectomy (DPS). All patients undergoing PD received some form of neoadjuvant chemotherapy, while only 2 patients undergoing DPS (40%) received neoadjuvant treatment. The mean lymph node harvest was 24 in the PD group vs 20 in the DPS group (p=0.556). The incidence of nodal metastases (N1 disease or higher) was similar between the two groups (50% in PD group vs 40% in DPS group, p=0.99). One patient in the PD group had invasive carcinoma at the final pancreatic margin, and two patients in the DPS group had positive pancreatic margins (25% vs. 40%, p=0.52). The mean overall survival (OS) was 14.9 months in the PD group vs 11.4 months in the DPS group (p=0.57). Conclusion: There is no significant difference in oncologic outcomes between pancreatoduodenectomy and distal pancreatectomy for patients with ductal adenocarcinoma of the pancreatic neck. The decision regarding type of resection to perform should be individualized based on patient factors, tumor characteristics and surgeon experience.