‘Textbook Outcome’ in Patients Undergoing Resection of Pancreatic Neuroendocrine Tumors

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In a study reported in the Journal of Surgical Oncology, Timothy M. Pawlik, MD, MPH, PhD, and colleagues found that approximately half of patients undergoing resection of pancreatic neuroendocrine tumors (PNETs) had a “textbook outcome”—a result associated with significantly improved disease-free survival.

Timothy M. Pawlik, MD, MPH, PhD

Timothy M. Pawlik, MD, MPH, PhD

Study Details

The study included data on 821 patients who underwent curative-intent surgery for PNETs between 2000 and 2016 identified from the multi-institutional U.S. Neuroendocrine Tumor Study Group database, which incorporates information from eight major U.S. tertiary hepatobiliary centers. Patients with metastases at presentation, missing follow-up data, missing data on one or more of the individual textbook outcome parameters, grade 3 tumors, or who died within 30 days after surgery were excluded from the analysis.

Textbook outcome was defined as:

  • No postoperative severe complications (Clavien‐Dindo grade ≥ III)
  • No 90‐day mortality
  • No prolonged length‐of-hospital stay (ie, > 75th percentile)
  • No 90‐day readmission after discharge
  • R0 resection.

Key Findings

Patients had a median age of 58 years, and 50.3% were male. The median tumor size was 2.1 cm. Overall, 143 (17.4%) had a functional tumor. The most common surgery was distal pancreatectomy (n = 492, 59.9%), followed by pancreatoduodenectomy (n = 231, 28.1%) and enucleation (n = 98, 11.9%).

Textbook outcome was reported in 405 patients (49.3%). The frequencies of components of textbook outcome were no 90-day mortality in 99.0% of patients, R0 resection in 85.3%, no prolonged length of stay in 76.7%, no readmission in 79.9%, and no severe complications in 76.9%.  Rates of textbook outcome were 56.7% with distal pancreatectomy, 52.0% with enucleation, and 32.5% with pancreatoduodenectomy (overall, P < .001).

The most common factors associated with failure to achieve textbook outcome were (% failed to achieve): severe complications (70.1%) and prolonged length of stay (59.7%) with pancreatoduodenectomy; prolonged length of stay (73.5%) and lack of  R0 resection margin (73.5%) with enucleation; and severe complications (78.9%) and readmission (81.7%) with distal pancreatectomy. 

After a median follow-up of 29.3 months, 5-year disease-free survival was 80.7% among all patients, with rates of 78.2% in patients undergoing pancreatoduodenectomy, 82.1% in those undergoing distal pancreatectomy, and 81.9% among those undergoing enculeation (overall P = .66).

For patients with vs without textbook outcome, disease-free survival was 97.2% vs 93.0% at 1 year, 94.1% vs 87.8% at 2 years, and 91.7% vs 85.2% at 3 years (P < .001).

On multivariate analysis, textbook outcome was significantly associated with improved disease-free survival (hazard ratio [HR] = 0.49, P = .001). Other factors significantly associated with disease-free survival were tumor size > 2 cm (HR = 5.10, P < .001) and genetic syndrome (hazard ratio = 2.05, P = .002).

The investigators concluded, “Only one in two patients undergoing resection of a PNET achieved a textbook outcome, which varied markedly based on procedure type. Achievement of a textbook outcome was associated with improved [disease-free survival].”

Dr. Pawlik, The Urban Meyer III and Shelley Meyer Chair for Cancer Research at The Ohio State University, Wexner Medical Center, Columbus, is the corresponding author for the Journal of Surgical Oncology article.

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