Outcomes of Tumor-Directed Surgery in Cancers of Head of Pancreas, Ampulla and Extrahepatic Bile Ducts: Influence of Patient Demographics, Disease Characteristics and Geographic Factors Público

Liu, Silu (2016)

Permanent URL: https://etd.library.emory.edu/concern/etds/xd07gs87r?locale=es
Published

Abstract

BACKGROUND: Despite shared anatomic location and similar surgical treatment, cancers of the periampullary region, which includes head of pancreas, ampulla, and extrahepatic bile ducts, have important differences with respect to histologic features, patient demographics, clinical manifestation and survival. The purpose of this analysis was to assess which patient-, disease- and treatment-related characteristics may act as determinants of survival among patients newly diagnosed with periampullary tumors.

METHODS: Patients with resectable adenocarcinoma of the head of pancreas, ampulla, and extrahepatic bile ducts who were reported to the US National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) program, from 2004 to 2012, were categorized by primary tumor site, surgery status, sex, marital status, race, age, grade, AJCC stage, tumor size, and residency. Post-diagnosis survival was examined using Cox regression models with results expressed as hazard ratios (HR) along with the corresponding 95% confidence intervals (95% CI).

RESULTS: A total of 10,383 eligible patients were identified in the SEER data. Surgery receipt was consistently associated with better prognosis for all three tumors with adjusted HRs (95% CI) of 0.41 (0.34 - 0.50), 0.21 (0.16 - 0.27), 0.35 (0.33 - 0.38) for extrahepatic bile ducts, ampulla and head of pancreas, respectively. Greater age and advanced grade were consistently associated with a significant worse prognosis for all three sites. Among patients in the surgical group, ampullary cancers were associated with better prognosis (HR, 0.56; 95% CI, 0.49 - 0.66) compared to cancers of the pancreatic head. Other significant predictors for worse prognosis in the surgically treated groups included male gender, black race, older age, greater tumor size, and more advanced tumor grade.

CONCLUSIONS: Our study identified substantial heterogeneity of factors that affect prognosis of patients diagnosed with tumors of the periampullary region. Additional research evaluating the roles of the interval between diagnosis and surgery, resection margins, preoperative laboratory values, perioperative complications, provider characteristics and individual patient-level lifestyle and socioeconomic factors is warranted.

Table of Contents

BACKGROUND. 1

MATERIALS AND METHODS. 4

RESULTS. 7

DISCUSSION. 10

CONCLUSIONS AND FUTURE DIRECTIONS. 13

REFERENCES. 14

TABLES. 18

Table 1. Patient demographics, disease characteristics and residency by primary site: Surveillance, Epidemiology, and End Results (SEER) program (2004 - 2012). 18

Table 2. Adjusted Cox proportional hazards model evaluating the association between surgery and disease-specific survival in patients with carcinomas in extrahepatic bile ducts, ampulla, and head of pancreas: Surveillance, Epidemiology, and End Results (SEER) program (2004 - 2012). 19

Table 3. Adjusted Cox proportional hazards model evaluating the association between tumor site and survival in patients with Whipple or Whipple-like surgery: Surveillance, Epidemiology, and End Results (SEER) program (2004 - 2012). 20

Table 4. Adjusted Cox proportional hazards model evaluating the association between tumor site and survival in patients with Whipple or Whipple-like surgery after excluding unknown tumor size: Surveillance, Epidemiology, and End Results (SEER) program (2004 - 2012). 21

FIGURES. 22

Figure 1. Kaplan-Meier survival curves by surgery receipt among patients with carcinoma of extrahepatic bile ducts (a), ampulla (b), head of pancreas (c) . 22

Figure 2. Kaplan-Meier survival curves by cancer site among surgical (a) and non-surgical (b) patients. 25

APPENDICES. 27

Supplemental Table 1. Median survival, one-year survival and five-year survival by surgery status for three primary tumor sites. 27

Supplemental Table 2. Hazard ratios for surgery according to different levels of the covariate that showed statistically significant (p<0.05) interactions. 28

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