Langenbeck's Archives of Surgery

, Volume 401, Issue 1, pp 63–69

Prognostic factors after pancreatoduodenectomy with en bloc portal venous resection for pancreatic cancer

  • Hryhoriy Lapshyn
  • Peter Bronsert
  • Louisa Bolm
  • Martin Werner
  • Ulrich T. Hopt
  • Frank Makowiec
  • Uwe A. Wittel
  • Tobias Keck
  • Ulrich F. Wellner
  • Dirk Bausch
ORIGINAL ARTICLE

Abstract

Purpose

Pancreatoduodenectomy (PD) with superior mesenteric/portal venous resection (PVR) for pancreatic ductal adenocarcinoma (PDAC) is performed routinely in case of tumor adhesion to the superior mesenteric or portal vein. True histopathological portal vein invasion (PVI) is found in a subgroup of patients. Even though this procedure has become routine in most centers for pancreatic surgery, data on prognostic factors in this situation is limited. The aim of this study was to identify prognostic factors after PD with PVR for PDAC.

Methods

Retrospective analysis was performed on the basis of a prospectively maintained database, and paraffin-embedded formalin-fixed tissue slides stained for hematoxylin-eosin were re-evaluated by two independent pathologists. Statistical analysis was conducted using MedCalc software.

Results

From 2001 to 2012, 86 cases of PD with PVR for PDAC with long-term follow-up and sufficient tissue for re-assessment were identified. Histopathological re-review disclosed PVI in 39 resection specimens and adhesion without infiltration in 47. Overall median survival in all patients was 22 months. Patients with PVI versus no PVI showed comparable baseline demographic and standard histopathological parameters; however, PVI was associated with microscopic hemangiosis (p = 0.001) and positive margin status (p = 0.001). Median survival in patients with PVI was 14 months versus 25 months in patients without PVI (p = 0.042). Only lymph node ratio and PVI were independent predictors of survival after resection.

Conclusion

The only independent factors influencing overall survival after PD with PVR for PDAC were lymph node ratio and PVI. PVI might indicate aggressive tumor biology, but the available data remains controversial.

Keywords

Pancreatic ductal adenocarcinoma Pancreatoduodenectomy Portal venous tumor infiltration Portal venous resection Median survival 

References

  1. 1.
    Katz MHG, Marsh R, Herman JM et al (2013) Borderline resectable pancreatic cancer: need for standardization and methods for optimal clinical trial design. Ann Surg Oncol 20:2787–2795. doi:10.1245/s10434-013-2886-9 CrossRefPubMedGoogle Scholar
  2. 2.
    Chua TC, Saxena A (2010) Extended pancreaticoduodenectomy with vascular resection for pancreatic cancer: a systematic review. J Gastrointest Surg Off J Soc Surg Aliment Tract 14:1442–1452. doi:10.1007/s11605-009-1129-7 CrossRefGoogle Scholar
  3. 3.
    Delpero JR, Boher JM, Sauvanet A et al (2015) Pancreatic adenocarcinoma with venous involvement: is up-front synchronous portal-superior mesenteric vein resection still justified? A survey of the Association Française de Chirurgie. Ann Surg Oncol. doi:10.1245/s10434-014-4304-3 Google Scholar
  4. 4.
    Lopez NE, Prendergast C, Lowy AM (2014) Borderline resectable pancreatic cancer: definitions and management. World J Gastroenterol WJG 20:10740–10751. doi:10.3748/wjg.v20.i31.10740 CrossRefPubMedGoogle Scholar
  5. 5.
    Murakami Y, Satoi S, Motoi F et al (2015) Portal or superior mesenteric vein resection in pancreatoduodenectomy for pancreatic head carcinoma. Br J Surg 102:837–846. doi:10.1002/bjs.9799 CrossRefPubMedGoogle Scholar
  6. 6.
    Turrini O, Ewald J, Barbier L et al (2013) Should the portal vein be routinely resected during pancreaticoduodenectomy for adenocarcinoma? Ann Surg 257:726–730. doi:10.1097/SLA.0b013e318269d23c CrossRefPubMedGoogle Scholar
  7. 7.
    Castleberry AW, White RR, De La Fuente SG et al (2012) The impact of vascular resection on early postoperative outcomes after pancreaticoduodenectomy: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database. Ann Surg Oncol 19:4068–4077. doi:10.1245/s10434-012-2585-y CrossRefPubMedGoogle Scholar
  8. 8.
    Worni M, Castleberry AW, Clary BM et al (2013) Concomitant vascular reconstruction during pancreatectomy for malignant disease: a propensity score-adjusted, population-based trend analysis involving 10,206 patients. JAMA Surg 148:331–338. doi:10.1001/jamasurg.2013.1058 CrossRefPubMedGoogle Scholar
  9. 9.
    Bosman FT, Carneiro F, Hruban RH, Theise ND (2010) WHO classification of tumors of the digestive system, 4th edn. International Agency for Research in Cancer, Lyon, FranceGoogle Scholar
  10. 10.
    Fuhrman GM, Leach SD, Staley CA et al (1996) Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group. Ann Surg 223:154–162CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Leach SD, Lee JE, Charnsangavej C et al (1998) Survival following pancreaticoduodenectomy with resection of the superior mesenteric-portal vein confluence for adenocarcinoma of the pancreatic head. Br J Surg 85:611–7. doi:10.1046/j.1365-2168.1998.00641.x CrossRefPubMedGoogle Scholar
  12. 12.
    Bockhorn M, Uzunoglu FG, Adham M et al (2014) Borderline resectable pancreatic cancer: a consensus statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 155:977–988. doi:10.1016/j.surg.2014.02.001 CrossRefPubMedGoogle Scholar
  13. 13.
    Cao HST, Balachandran A, Wang H et al (2014) Radiographic tumor-vein interface as a predictor of intraoperative, pathologic and oncologic outcomes in resectable and borderline resectable pancreatic cancer. J Gastrointest Surg Off J Soc Surg Aliment Tract 18:269–278. doi:10.1007/s11605-013-2374-3 CrossRefGoogle Scholar
  14. 14.
    Gong Y, Zhang L, He T, et al. (2013) Pancreaticoduodenectomy combined with vascular resection and reconstruction for patients with locally advanced pancreatic cancer: a multicenter, retrospective analysis. PLoS ONE. doi: 10.1371/journal.pone.0070340Google Scholar
  15. 15.
    Müller SA, Hartel M, Mehrabi A et al (2009) Vascular resection in pancreatic cancer surgery: survival determinants. J Gastrointest Surg Off J Soc Surg Aliment Tract 13:784–792. doi:10.1007/s11605-008-0791-5 CrossRefGoogle Scholar
  16. 16.
    Nakao A, Kanzaki A, Fujii T et al (2012) Correlation between radiographic classification and pathological grade of portal vein wall invasion in pancreatic head cancer. Ann Surg 255:103–108. doi:10.1097/SLA.0b013e318237872e CrossRefPubMedGoogle Scholar
  17. 17.
    Shimada K, Sano T, Sakamoto Y, Kosuge T (2006) Clinical implications of combined portal vein resection as a palliative procedure in patients undergoing pancreaticoduodenectomy for pancreatic head carcinoma. Ann Surg Oncol 13:1569–1578. doi:10.1245/s10434-006-9143-4 CrossRefPubMedGoogle Scholar
  18. 18.
    Wang J, Estrella JS, Peng L et al (2012) Histologic tumor involvement of superior mesenteric vein/portal vein predicts poor prognosis in patients with stage II pancreatic adenocarcinoma treated with neoadjuvant chemoradiation. Cancer 118:3801–3811. doi:10.1002/cncr.26717 CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Yekebas EF, Bogoevski D, Cataldegirmen G et al (2008) En bloc vascular resection for locally advanced pancreatic malignancies infiltrating major blood vessels: perioperative outcome and long-term survival in 136 patients. Ann Surg 247:300–9. doi:10.1097/SLA.0b013e31815aab22 CrossRefPubMedGoogle Scholar
  20. 20.
    Zhou Y, Zhang Z, Liu Y et al (2012) Pancreatectomy combined with superior mesenteric vein-portal vein resection for pancreatic cancer: a meta-analysis. World J Surg 36:884–891. doi:10.1007/s00268-012-1461-z CrossRefPubMedGoogle Scholar
  21. 21.
    Kelly KJ, Winslow E, Kooby D et al (2013) Vein involvement during pancreaticoduodenectomy: is there a need for redefinition of “borderline resectable disease”? J Gastrointest Surg Off J Soc Surg Aliment Tract 17:1209–1217. doi:10.1007/s11605-013-2178-5, discussion 1217 CrossRefGoogle Scholar
  22. 22.
    Verbeke CS (2013) Resection margins in pancreatic cancer. Surg Clin North Am 93:647–662. doi:10.1016/j.suc.2013.02.008 CrossRefPubMedGoogle Scholar
  23. 23.
    Wang C, Wu H, Xiong J et al (2008) Pancreaticoduodenectomy with vascular resection for local advanced pancreatic head cancer: a single center retrospective study. J Gastrointest Surg Off J Soc Surg Aliment Tract 12:2183–2190. doi:10.1007/s11605-008-0621-9 CrossRefGoogle Scholar
  24. 24.
    Wang F, Gill AJ, Neale M et al (2014) Adverse tumor biology associated with mesenterico-portal vein resection influences survival in patients with pancreatic ductal adenocarcinoma. Ann Surg Oncol 21:1937–1947. doi:10.1245/s10434-014-3554-4 CrossRefPubMedGoogle Scholar
  25. 25.
    Rehders A, Stoecklein NH, Güray A et al (2012) Vascular invasion in pancreatic cancer: tumor biology or tumor topography? Surgery 152:S143–151. doi:10.1016/j.surg.2012.05.012 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Hryhoriy Lapshyn
    • 1
    • 2
  • Peter Bronsert
    • 3
    • 4
  • Louisa Bolm
    • 2
  • Martin Werner
    • 3
    • 4
    • 5
  • Ulrich T. Hopt
    • 1
    • 4
  • Frank Makowiec
    • 1
    • 4
  • Uwe A. Wittel
    • 1
    • 4
  • Tobias Keck
    • 2
  • Ulrich F. Wellner
    • 2
  • Dirk Bausch
    • 2
  1. 1.Clinic for General and Visceral SurgeryUniversity Medical Center FreiburgFreiburgGermany
  2. 2.Clinic for SurgeryUniversity Clinic Schleswig-Holstein, Campus LübeckLübeckGermany
  3. 3.Institute of Surgical PathologyUniversity Medical Center FreiburgFreiburgGermany
  4. 4.Comprehensive Cancer Center FreiburgUniversity Medical Center FreiburgFreiburgGermany
  5. 5.German Cancer Consortium (DKTK) and Cancer Research Center (DKFZ)HeidelbergGermany

Personalised recommendations