Portal-Mesenteric Vein Resection in Borderline Pancreatic Cancer; 33 Month-Survival in Patients with Good Performance Status

Abstract

Background: Patients with pancreatic cancer (PC), which is not upfront resectable, but borderline, involving major peripancreatic vessels, have not been generally considered for surgery, considering that resection in such a setting may be futile. Materials and Methods: Retrospective analysis of prospectively collected data on patients with borderline pancreatic adenocarcinoma undergoing pancreatectomy en-block with portal and/or superior mesenteric vein resection in a tertiary referral center in Greece between January 2012 and February 2017. Follow-up was complete up to January 2018. Results: Twenty-four patients were included. Neoadjuvant therapy (NAT) was administered to only 38%, but more commonly in the second half of the group (58% vs. 17%, p = 0.035). It was associated with smaller tumor size (median: 2.5 vs. 4.2 cm, p < 0.001), fewer positive lymph nodes (LNs) in the resected specimen (median: 2 vs. 5, p = 0.04), and higher likelihood of adjuvant therapy (78% vs. 40%, p = 0.01), but not with survival. Resection was extensive: a median of 26 LNs were retrieved, R0 resection rate (≥1 mm) was 79%, and median length of vein segments was 4 cm, requiring interposition grafts in 58% (mostly polytetrafluoroethylene). Median intensive care unit stay was 0 days and length of hospital stay was 9 days. Post-operative mortality was 12.5%. Median overall survival was 24 months. Eastern Cooperative Oncology Group (ECOG) status was significantly associated with survival (p < 0.001) with ECOG-0: 33 months, ECOG-1: 12 months, and ECOG-2: 6 months. Conclusion: This first Greek national series of portomesenteric vein resection in borderline PC demonstrates that it results to 2 years of median survival, extending to 33 months in patients with good performance status, especially if NAT is uniformly administered.

Keywords: borderline pancreatic cancer; locally advanced pancreatic cancer; mesenteric vein resection; pancreaticoduodenectomy; portal vein resection.

FIG. 1.

Complete skeletonization of the SMV from its first tributaries deep within the mesentery, PV up to the liver hilum, and HA and SMA from their take off, the anterior wall of the A and the IVC. PTFE graft is placed at the resected portion of the SMV. A, aorta; HA, hepatic artery; IVC, inferior vena cava; PTFE, polytetrafluoroethylene; PV, portal vein; SMA, superior mesenteric arteries; SMV, superior mesenteric vein.

FIG. 2.

Kaplan–Meier OS curve of 24 patients who underwent pancreatic resection with vascular resection for a borderline resectable pancreatic cancer. OS is calculated from the time of diagnosis to death (event) or last follow-up (censored). (A) Complete cohort (n = 24). (B) Patients who died within 30 days of the procedure were excluded from this analysis (n = 21). IQR, interquartile range; OS, overall survival.

FIG. 3.

Kaplan–Meier OS curves of 24 patients who underwent pancreatic resection with vascular resection for a borderline resectable pancreatic adenocarcinoma, by ECOG category. OS is calculated from the time of diagnosis to death (event) or last follow-up (censored). ECOG, Eastern Cooperative Oncology Group.