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Outcomes of pancreatic resection for elderly patients with pancreatic cancer

BackgroundPancreatic ductal adenocarcinoma (PDAC) is a lethal disease with poor, albeit gradually improving, prognosis. We evaluated predictive clinicophysiological outcomes of elderly patients with PDAC.MethodsWe retrospectively examined 260 patients who underwent pancreatic resection classified into two groups: (A) those ≤ 80 (B) and those > 80 years. Operative characteristics, preoperative clinicophysiological parameters (body mass index, jaundice decompression, total bilirubin, albumin, creatinine, HbA1c, amylase, C-reactive protein, white blood cells, lymphocytes, hemoglobin, platelets, cancer antigen 19-9, carcinoembryonic antigen, neutrophil/lymphocyte ratio, prognostic nutritional index, platelet/lymphocyte ratio, and CRP/Alb ratio), disease-free survival (DFS), and overall survival (OS) were reported.ResultsThere were no differences noted in morbidity, mortality, and preoperative clinicophysiological parameters. Median DFS of groups A and B were 15.4 and 15.5 months respectively. One year and 3-year OS of groups A and B were 86.7/68% and 88.4/69.3%, respectively. There were no differences between the groups for DFS and OS.ConclusionCurative resection for PDAC can be safely performed in elderly and younger patients and elderly patients with PDAC can benefit from curative surgery without a significant decrease in survival rates.

O r i g i n a l A r t i c l e O u t c o m e s o f p a n c r e a t i c r e s e c t i o n f o r e l d e r l y p a t i e n t s w i t h p a n c r e a t i c c a n c e r R u n n i n g h e a d : e l d e r l y p a t i e n t s w i t h p a n c r e a t i c c a n c e r

Introduction
Treatment for patients with cancer has become a major public concern as the aging population continues to grow. This is especially true in Japan, where the aging population is growing more rapidly compared to the US and other European countries (1). From 2007 to 2011, the overall pancreatic ductal adenocarcinoma (PDAC) incidence rates were stable after slowly increasing for most of the past decade, and the death rate for PDAC increased slightly by 0.3% per year (2). As the population ages were older, more and more elderly patients were being diagnosed with PDAC and referred for treatment of their disease. In the Western population, two-thirds of patients with PDAC are older than 65 years (3). In Japan, the age-specific incidence of PDAC from age distribution in those <70 years old was 47.5% (<70/all ages number), and for those ≤80 years old, it was 17.9% (≤80/all ages number) based on data from 10 population-based cancer registries (4).
On the other hand, PDAC had a bad prognosis. In global surveillance of trends, agestandardized five-year net survival estimates were generally in the range 5-15% throughout 2000 to 2014 (5). The 5-year survival rate after curative resection of PDAC in

Statistical analysis
Continuous variables were compared using the Student's t-test and Chi-square test.
Kaplan-Meier survival curves were generated and compared using log-rank tests. Cox proportional hazard models were used to perform multivariate analyses. P-values of <0.05 were considered statistically significant. The SPSS statistical software package, version 22.0 (IBM Corp., Chicago, IL, USA) was used for statistical analyses. institutional research committee and with the 1964 Helsinki Declaration. This article does not contain any study performed on animals by any of the authors. The requirement for obtaining written informed consent from each patient was waived because of the study's retrospective design. We provided the patients with the opportunity to Opt-Out.

Results
The mean patient age was 68.15 years (range: 36-88 years), and the cohort included 160 men and 100 women. Surgical methods included primary distal pancreatectomy in 79 patients (including en bloc celiac axis resection in 10), PD in 172 patients (pyloruspreserving in 10, subtotal stomach-preserving in 149, and conventional in 13), and total pancreatectomy in nine patients. procedures in both groups (pancreaticoduodenectomy/ distal pancreatectomy/ total pancreatectomy) were 149/63/8 in group A and 23/16/1 in group B (p = 0.35). The stages in both groups (0/Ia/Ib/IIa/IIb/III/IV) were 7/5/48/154/0/5 in group A and 2/0/12/23/0/2 in group B (p = 0.444). The preoperative background in these groups did not differ in terms of location, biliary decompression, modified Glasgow Prognostic Score (mGPS), stage, and resectability (R). There were no differences in any of the preoperative clinicophysiological parameters, as shown in Table 2. Preoperative inflammation and immunological findings such as CRP, WB, NLR, PLR, CAR were not significantly different and nutritional findings such as albumin and PNI were not significantly different either. In this study, neoadjuvant therapies were administered in 39 cases (15%) as follows: 25 with radiation+gemcitabine+S-1, 8 with gemcitabine+S-1, 3 with gemcitabine+nab-paclitaxel, 2 with radiation+gemcitabine, and 1 with gemcitabine. Adjuvant chemotherapies were administered in 179 cases (68.8%) as follows: 97 cases with S-1, 75 with gemcitabine+S-1, 62 with gemcitabine, 4 with gemcitabine+cisplatin, 2 with gemcitabine+nab-paclitaxel, and in group B. As shown in Table 3 There were no differences between these groups in terms of DFS and OS.

Discussion
The safety of pancreatic resection has improved in recent years due to improvements in surgical techniques, perioperative care, and postoperative management. Resection has become a feasible procedure even for elderly patients (14-16). Contrary to previous studies that suggest that age is not an independent risk factor for patients undergoing PD (17,18), postoperative morbidity and mortality of elderly patients were significantly higher than that of younger patients in several previous reports ( (25). These researchers revealed that elderly patients had a higher risk of mortality, morbidity, and some complications than did younger patients, and therefore, an appropriate selection of elderly patients was important.
We investigated recent reports evaluating the outcomes in patients ≥80 years who underwent pancreatic resection after 2010 (Table 4) (10,16,21,22,(25)(26)(27)(28). The results of these 12 studies showed that the difference in morbidity between elderly patients and younger patients has gradually decreased over time, and that overall mortality rates of elderly patients undergoing this procedure have decreased.
An analysis of short-term outcomes revealed that elderly patients developed more postoperative anorexia and cachexia, thus compromising their nutritional and functional status more frequently than did younger patients (17).
There were no differences in postoperative complications such as pancreatic fistula and years or older than in younger patients (24). However, the incidences of cardiopulmonary complications, re-intervention rate, and re-admission rate in another meta-analysis were similar in these groups (22). In this study, there was no significant difference between variables, including hospital stay (p = 0.869), morbidity (p = 0.449), and mortality (p = 0.285). Sho reported that the postoperative prognosis in older patients was not as good as that in younger patients, possibly due to less frequent completion of adjuvant chemotherapy (10). As our report revealed, similar to younger patients, older patients could have received adjuvant chemotherapies; there were no differences between older and younger patients in terms of DFS and OS in our study. Our study also indicated no difference in complications between younger and elderly patients ( Table 4).
The 5-year survival rate after curative resection of PDAC in recent decades (2001 to 2007) has been reported to be 18.8% (5). The results in Table 3

Conclusions
Pancreatic curative resection for PDAC can be safely performed in both elderly and c o u n t r i e s . L a n c e t 2 0 1 8 M a r ; 3 9 1 ( 1 0 1 2 5 ) : 1 0 2 3 -1075.

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