TRIANGLE operation, combined with adequate adjuvant chemotherapy, can improve the prognosis of pancreatic head cancer: A retrospective study

doi:10.4251/wjgo.v16.i5.1773

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World Journal of Gastrointestinal Oncology

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Cohort Study

World J Gastrointest Oncol. May 15, 2024; 16(5): 1773-1786
Published online May 15, 2024. doi: 10.4251/wjgo.v16.i5.1773

Table 1 Demographic and clinicopathologic data

Variables	PD_TRIANGLE (n = 52)	PD_non-TRIANGLE (n = 55)	P value
Age, median (IQR; yr)	69 (60-74)	67 (61-74)	0.589
Sex			0.154
Male	26 (50.0)	35 (63.6)
Female	26 (50.0)	20 (36.4)
BMI (mean ± SD, kg/m²)	22.86 ± 3.19	22.15 ± 2.79	0.224
ASA score			0.387
1	10 (19.6)	15 (27.3)
2	37 (72.6)	33 (60.0)
3	4 (7.8)	7 (12.7)
Main pancreatic duct size (mm)			0.208
≤ 3	18 (34.6)	19 (34.5)
> 3	34 (65.4)	36 (65.5)
CA19-9, median (IQR; IU/mL)	94.4 (37.3-358.5)	108.0 (57.6-213.2)	0.711
CEA, median (IQR; ng/mL)	3.4 (2.1-6.5)	3.9 (2.3-5.7)	0.521
Albumin (mean ± SD, g/L)	39.7 ± 3.9	40.7 ± 4.5	0.227
Serum bilirubin, median (IQR; μmol/L)	29.3 (8.3-186.4)	18.8 (9.4-114.9)	0.660
AJCC stage (8^th ed)			0.291
I/IIa	28 (53.8)	24 (43.6)
IIb/III	24 (46.2)	31 (56.4)
Grading			0.385
1	2 (3.9)	0 (0.0)
2	39 (75.0)	45 (81.8)
3	11 (21.1)	10 (18.2)
PNI	44 (84.6)	44 (80.0)	0.532
PVI	28 (53.9)	27 (49.1)	0.623
Number of ELN, median (IQR)	20 (14-26)	14 (8-20)	0.001^a
Margin status			0.579
R0	42 (80.8)	42 (76.4)
R1	10 (19.2)	13 (23.6)

^aP < 0.01.

Values in parentheses are percentages unless indicated otherwise. PD: Pancreaticoduodenectomy; IQR: interquartile range; BMI: Body mass index; ASA: American Society of Anesthesiologists; CA19-9: Carbohydrate antigen 19-9; CEA: Carcinoembryonic antigen; AJCC: American Joint Committee on Cancer; PNI: Perineural invasion; PVI: Perivascular invasion; ELN: Examined lymph nodes.

Table 2 Surgical and recurrence data

Variables	PD_TRIANGLE (n = 52)	PD_non-TRIANGLE (n = 55)	P value
Operative time, median (IQR; min)	386 (324-423)	390 (345-425)	0.527
Intraoperative blood loss, median (IQR; mL)	300 (200-500)	300 (200-500)	0.863
LOS, median (IQR)	14 (11-19)	15 (12-22)	0.177
ICU stay ≥ 2 d	13 (25.0)	17 (30.9)	0.496
POPF (B/C)	9 (17.3)	13 (23.6)	0.418
Bile leakage (B/C)	0 (0.0)	3 (5.5)	0.262
Chyle leak (B/C)	0 (0.0)	2 (3.6)	0.496
DGE (B/C)	3 (5.8)	5 (9.1)	0.775
PPH (B/C)	0 (0.0)	2 (3.6)	0.496
Intra-abdominal infection	10 (19.2)	9 (16.4)	0.698
Diarrhea	14 (26.9)	9 (16.4)	0.184
Reoperation	1 (1.9)	3 (5.5)	0.651
90-d mortality	0 (0.0)	0 (0.0)	1.000
Adjuvant chemotherapy, ≥ 6 months	30 (57.7)	27 (49.1)	0.373
Chemotherapy regimens¹			0.887
Gemcitabine-based	24 (80.0)	22 (81.5)
5-fluorouracil-based	6 (20.0)	5 (18.5)
Recurrence			< 0.001^a
Yes	25 (48.1)	45 (81.8)
No	27 (51.9)	10 (18.2)

^aP < 0.001.

¹Variables calculated on the total of patients who received adjuvant chemotherapy lasting longer than 6 months Values in parentheses are percentages unless indicated otherwise.

PD: Pancreaticoduodenectomy; IQR: Interquartile range; ICU: Intensive care unit; LOS: Length of stay; POPF: Postoperative pancreatic fistula; DGE: Delayed gastric emptying; PPH: Postpancreatectomy hemorrhage.

Table 3 Univariate and multivariate analyses of independent prognostic variables for different recurrence patterns

Variables	Total (n = 70)			Local (n = 21)			Distant (n = 34)			Local + distant (n = 15)
Variables	P₁	HR (95%CI)	P₂	P₁	HR (95%CI)	P₂	P₁	HR (95%CI)	P₂	P₁	HR (95%CI)	P₂
Age (yr), > 70/≤ 70	0.206	-		0.092	-		0.864	-		0.470	-
Sex, male/female	0.572	-		0.304	-		0.866	-		0.707	-
PD_TRIANGLE, +/-	< 0.001^c	0.424 (0.256-0.702)	0.001^b	0.002^b	0.175 (0.059-0.521)	0.002^b	0.649	-		0.011^a	0.188 (0.052-0.683)	0.011^a
Grading, 2-3/1
2	0.663	-		0.997	-		0.997	-		0.240	-
3	0.813	-		0.997	-		0.997	-		0.292	-
Margin status, R1/R0	0.031^a	2.255 (1.252-4.064)	0.007^b	0.249	-		0.346	-		0.066	-
AJCC stage (8^th ed), I-IIa/IIb-III	0.057	-		0.801	-		0.077	-		0.038^a	3.608 (1.057-12.308)	0.040^a
PNI, +/-	0.427	-		0.887	-		0.478	-		0.512	-
PVI, +/-	0.064	-		0.694	-		0.036^a	1.862 (0.940-3.691)	0.075	0.833
CA19-9, > 37.0/≤ 37.0	0.098	-		0.141	-		0.019^a	5.684 (1.354-23.868)	0.018^a	0.152	-
CEA, > 5.0/≤ 5.0	0.823	-		0.068	-		0.289	-		0.612	-
Adjuvant chemotherapy, ≥ 6 months/< 6 months	0.001^b	0.370 (0.222-0.618)	< 0.001^c	0.527	-		0.002^b	0.332 (0.164-0.672)	0.002^b	0.127	-

^aP < 0.05.

^bP < 0.01.

^cP < 0.001.

P₁: Univariate P value; P₂: Multivariate P value; PD: Pancreaticoduodenectomy; CA19-9: Carbohydrate antigen 19-9; CEA: Carcinoembryonic antigen; AJCC: American Joint Committee on Cancer; PNI: Perineural invasion; PVI: Perivascular invasion.

Table 4 P values for survival comparisons between the four groups

Group comparison	P value of mRFS	P value of mOS
Group 1 vs group 2	0.002^b	< 0.001^c
Group 1 vs group 3	0.013^a	0.488
Group 1 vs group 4	< 0.001^c	< 0.001^c
Group 2 vs group 3	0.663	0.031^a
Group 2 vs group 4	0.027^a	0.040^a
Group 3 vs group 4	0.147	< 0.001^c

^aP < 0.05.

^bP < 0.01.

^cP < 0.001.

Group 1: No clearance of the Heidelberg triangle and not receiving ≥ 6 months of adjuvant chemotherapy; Group 2: No clearance of the Heidelberg triangle but receiving ≥ 6 months of adjuvant chemotherapy; Group 3: Clearance of the Heidelberg triangle but not receiving ≥ 6 months of adjuvant chemotherapy; Group 4: Clearance of the Heidelberg triangle and receiving ≥ 6 months of adjuvant chemotherapy;mRFS: Median recurrence-free survival; mOS: Median overall survival.

Citation: Chen JH, Zhu LY, Cai ZW, Hu X, Ahmed AA, Ge JQ, Tang XY, Li CJ, Pu YL, Jiang CY. TRIANGLE operation, combined with adequate adjuvant chemotherapy, can improve the prognosis of pancreatic head cancer: A retrospective study. World J Gastrointest Oncol 2024; 16(5): 1773-1786
URL: https://www.wjgnet.com/1948-5204/full/v16/i5/1773.htm
DOI: https://dx.doi.org/10.4251/wjgo.v16.i5.1773