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.

Aorta to proper hepatic artery bypass with total pancreatectomy and celiac axis resection (TP-CAR) in a patient with locally advanced pancreas adenocarcinoma

“…Our division has a long-standing dedication to pancreatic surgery and performs >30 pancreas resections annually. We have been performing pancreatectomies with SMV-PV resection and reconstruction for several years [25] for borderline and locally advanced PC and we have moved on to major peripancreatic arterial resections [26] . The case presented is our first TP-CAR with aorto-PHA bypass (Mayo Clinic Class 2B) and, to the best of our knowledge, the first in Greece.…”

Distal pancreatectomy with celiac axis resection (DP-CAR): Optimal perioperative outcome in a patient with locally advanced pancreas adenocarcinoma

“…Our division (led by the first author) has a long-standing dedication to pancreatic surgery and performs more than 30 pancreas resections annually. We have been performing pancreatectomies with SMV-PV resection and reconstruction for several years [ 16 ] for borderline and locally advanced PC and we have moved on to major peripancreatic arterial resections. The case presented is our first DP-CAR and, to the best of our knowledge, the first in Greece.…”

Surgery After Response to Chemotherapy for Locally Advanced Pancreatic Ductal Adenocarcinoma: A Guide for Management

“…38,39 Moreover, as centers gathered more experience with the procedure, patients requiring venous resection and reconstruction had similar morbidity, mortality, and long-term survival when compared with those who did not require venous resection and reconstruction. [40][41][42][43] Management strategies surrounding tumors with arterial involvement are more complex and controversial. Certain groups have advocated for en bloc resection of the involved artery with reconstruction, reporting acceptable morbidity and mortality in a highly selected patient population.…”