Associations between pancreatectomy type, treatment sequence and textbook oncologic outcomes in patients with localized pancreatic adenocarcinoma

Background Prior studies have shown that achievement of textbook oncologic outcomes (TOO) after pancreatectomy for pancreatic adenocarcinoma (PDAC) is associated with better survival outcomes. However, the associations between TOO, procedure type, and treatment sequence has not been examined. Methods Patients with resected PDAC were identified within the National Cancer Database (2010–2018). We analyzed rates of TOO (defined as no 30-day readmission, no 90-day mortality, no prolonged length of stay, negative surgical margins, receipt of multi-agent chemotherapy, and nodal yield ≥12) stratified by procedure (pancreatoduodenectomy vs. distal pancreatectomy vs. total pancreatectomy) and treatment sequence (up-front surgery vs. neoadjuvant therapy). Results A total of 20,155 patients were identified. Patients who underwent distal pancreatectomy were less likely to have TOO compared to pancreatoduodenectomy (12.6% vs. 17.5%; OR=0.77, 95% CI: 0.68–0.88). There was no difference in TOO between patients who underwent total pancreatectomy compared to pancreatoduodenectomy (16.4% vs. 17.5%; OR=0.96, 95% CI: 0.84–1.11). Neoadjuvant chemotherapy was associated with a 5-fold increase in the odds of TOO (OR=5.07, 95% CI: 4.35–5.91). TOO was associated with improved OS regardless of surgical procedure (pancreatoduodenectomy: median OS: 33.7 vs. 20.5mo; HR=0.69, 95% CI: 0.65–0.73; distal pancreatectomy: median OS: 35.8 vs. 23.9mo; HR=0.73, 95% CI: 0.64–0.84; total pancreatectomy: median OS: 30.1 vs. 19.9mo; HR=0.69, 95% CI: 0.61–0.79). Conclusions The rate of TOO was lower for distal pancreatectomy as compared to pancreatoduodenectomy or total pancreatectomy. Neoadjuvant therapy was associated with higher likelihood of TOO. Regardless of pancreatectomy type, TOO was associated with improved OS.