Surgical Resection Versus Palliative Chemoradiotherapy for the Management of Pancreatic Cancer with Local Venous Invasion: A Decision Analysis

  • Michael A. Abramson
  • Edward W. Swanson
  • Edward E. Whang
2008 ssat poster presentation



Benefit from pancreaticoduodenectomy (PD) combined with superior mesenteric-portal vein (SMV-PV) resection in the management of pancreatic adenocarcinoma with local venous invasion remains controversial.


Using formal decision analysis, we compared survival associated with PD plus SMV-PV resection when applied to patients with pancreatic adenocarcinoma with isolated local venous invasion (Group 1) versus that achieved with palliative chemoradiotherapy when applied to patients with locally advanced pancreatic cancer (Group 2). Individual studies were identified using Medline. A total of 1,324 and 709 patients were analyzed for Groups 1 and 2, respectively. Patients with distant metastases were excluded.


Overall decision analysis favored surgical resection (Group 1) over palliative chemoradiotherapy (Group 2). Sensitivity analyses indicated that this decision is sensitive to the perioperative mortality rate and the percentage of surgical resections with microscopic (R1) or macroscopic (R2) residual tumor at the resection margin. In contrast, sensitivity analysis revealed that the decision is not sensitive to the percentage of cases in which true venous invasion by cancer is documented histologically.


Surgical resection may confer a survival advantage over palliative chemoradiotherapy in select patients with pancreatic cancers with presumed local venous invasion.


Pancreatic adenocarcinoma Pancreaticoduodenectomy Survival Decision analysis 


  1. 1.
    Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer statistics, 2007. CA Cancer J Clin 2007;57:43–66.PubMedGoogle Scholar
  2. 2.
    Detsky AS, Naglie G, Krahn MD, Naimark D, Redelmeier DA. Primer on medical decision analysis: Part 1—Getting started. Med Decis Mak 1997;17:123–125. doi:10.1177/0272989X9701700201.CrossRefGoogle Scholar
  3. 3.
    Detsky AS, Naglie G, Krahn MD, Redelmeier DA, Naimark D. Primer on medical decision analysis: Part 2—Building a tree. Med Decis Mak 1997;17:126–135. doi:10.1177/0272989X9701700202.CrossRefGoogle Scholar
  4. 4.
    Naglie G, Krahn MD, Naimark D, Redelmeier DA, Detsky AS. Primer on medical decision analysis: Part 3—Estimating probabilities and utilities. Med Decis Mak 1997;17:136–141. doi:10.1177/0272989X9701700203.CrossRefGoogle Scholar
  5. 5.
    Krahn MD, Naglie G, Naimark D, Redelmeier DA, Detsky AS. Primer on medical decision analysis: Part 4—Analyzing the model and interpreting the results. Med Decis Mak 1997;17:142–151. doi:10.1177/0272989X9701700204.CrossRefGoogle Scholar
  6. 6.
    Naimark D, Krahn MD, Naglie G, Redelmeier DA, Detsky AS. Primer on medical decision analysis: Part 5—Working with markov processes. Med Decis Mak 1997;17:152–159. doi:10.1177/0272989X9701700205.CrossRefGoogle Scholar
  7. 7.
    Greene FL, American Joint Committee on Cancer. American Cancer Society.: Ajcc cancer staging manual. 6th ed. New York: Springer, 2002.Google Scholar
  8. 8.
    Bilimoria KY, Bentrem DJ, Ko CY, Ritchey J, Stewart AK, Winchester DP et al. Validation of the 6th edition ajcc pancreatic cancer staging system: Report from the national cancer database. Cancer 2007;110:738–744. doi:10.1002/cncr.22852.PubMedCrossRefGoogle Scholar
  9. 9.
    Siriwardana HP, Siriwardena AK. Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer. Br J Surg 2006;93:662–673. doi:10.1002/bjs.5368.PubMedCrossRefGoogle Scholar
  10. 10.
    Yekebas EF, Bogoevski D, Cataldegirmen G, Kunze C, Marx A, Vashist YK et al. En bloc vascular resection for locally advanced pancreatic malignancies infiltrating major blood vessels: Perioperative outcome and long-term survival in 136 patients. Ann Surg 2008;247:300–309.PubMedCrossRefGoogle Scholar
  11. 11.
    Al-Haddad M, Martin JK, Nguyen J, Pungpapong S, Raimondo M, Woodward T et al. Vascular resection and reconstruction for pancreatic malignancy: A single center survival study. J Gastrointest Surg 2007;11:1168–1174. doi:10.1007/s11605-007-0216-x.PubMedCrossRefGoogle Scholar
  12. 12.
    Shimada K, Sano T, Sakamoto Y, Kosuge T. Clinical implications of combined portal vein resection as a palliative procedure in patients undergoing pancreaticoduodenectomy for pancreatic head carcinoma. Ann Surg Oncol 2006;13:1569–1578. doi:10.1245/s10434-006-9143-4.PubMedCrossRefGoogle Scholar
  13. 13.
    Carrere N, Sauvanet A, Goere D, Kianmanesh R, Vullierme MP, Couvelard A et al. Pancreaticoduodenectomy with mesentericoportal vein resection for adenocarcinoma of the pancreatic head. World J Surg 2006;30:1526–1535. doi:10.1007/s00268-005-0784-4.PubMedCrossRefGoogle Scholar
  14. 14.
    Nakao A, Takeda S, Inoue S, Nomoto S, Kanazumi N, Sugimoto H, Fujii T. Indications and techniques of extended resection for pancreatic cancer. World J Surg 2006;30(6):976–984.PubMedCrossRefGoogle Scholar
  15. 15.
    Riediger H, Makowiec F, Fischer E, Adam U, Hopt UT. Postoperative morbidity and long-term survival after pancreaticoduodenectomy with superior mesenterico-portal vein resection. J Gastrointest Surg 2006;10:1106–1115. doi:10.1016/j.gassur.2006.04.002.PubMedCrossRefGoogle Scholar
  16. 16.
    Zhou GW, Wu WD, Xiao WD, Li HW, Peng CH. Pancreatectomy combined with superior mesenteric-portal vein resection: Report of 32 cases. Hepatobiliary Pancreat Dis Int 2005;4:130–134.PubMedGoogle Scholar
  17. 17.
    Koniaris LG, Lillemoe KD, Yeo CJ, Abrams RA, Colemann J, Nakeeb A et al. Is there a role for surgical resection in the treatment of early-stage pancreatic lymphoma? J Am Coll Surg 2000;190:319–330. doi:10.1016/S1072-7515(99)00291-4.PubMedCrossRefGoogle Scholar
  18. 18.
    Poon RT, Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK et al. Pancreaticoduodenectomy with en bloc portal vein resection for pancreatic carcinoma with suspected portal vein involvement. World J Surg 2004;28:602–608. doi:10.1007/s00268-004-7250-6.PubMedCrossRefGoogle Scholar
  19. 19.
    Tseng JF, Raut CP, Lee JE, Pisters PW, Vauthey JN, Abdalla EK et al. Pancreaticoduodenectomy with vascular resection: Margin status and survival duration. J Gastrointest Surg 2004;8:935–949. discussion 949–950 doi:10.1016/j.gassur.2004.09.046.PubMedCrossRefGoogle Scholar
  20. 20.
    Li B, Chen FZ, Ge XH, Cai MZ, Jiang JS, Li JP et al. Pancreatoduodenectomy with vascular reconstruction in treating carcinoma of the pancreatic head. Hepatobiliary Pancreat Dis Int 2004;3:612–615.PubMedGoogle Scholar
  21. 21.
    Howard TJ, Villanustre N, Moore SA, DeWitt J, LeBlanc J, Maglinte D et al. Efficacy of venous reconstruction in patients with adenocarcinoma of the pancreatic head. J Gastrointest Surg 2003;7:1089–1095. doi:10.1016/j.gassur.2003.07.010.PubMedCrossRefGoogle Scholar
  22. 22.
    Nakagohri T, Kinoshita T, Konishi M, Inoue K, Takahashi S. Survival benefits of portal vein resection for pancreatic cancer. Am J Surg 2003;186:149–513. doi:10.1016/S0002-9610(03)00173-9.PubMedCrossRefGoogle Scholar
  23. 23.
    Aramaki M, Matsumoto T, Etoh T, Ishio T, Himeno Y, Sasaki A et al. Clinical significance of combined pancreas and portal vein resection in surgery for pancreatic adenocarcinoma. Hepatogastroenterology 2003;50:263–266.PubMedGoogle Scholar
  24. 24.
    Kawada M, Kondo S, Okushiba S, Morikawa T, Katoh H. Reevaluation of the indications for radical pancreatectomy to treat pancreatic carcinoma: Is portal vein infiltration a contraindication? Surg Today 2002;32:598–601. doi:10.1007/s005950200108.PubMedCrossRefGoogle Scholar
  25. 25.
    Sasson AR, Hoffman JP, Ross EA, Kagan SA, Pingpank JF, Eisenberg BL. En bloc resection for locally advanced cancer of the pancreas: Is it worthwhile? J Gastrointest Surg 2002;6:147–157. discussion 157–148 doi:10.1016/S1091-255X(01)00063-4.PubMedCrossRefGoogle Scholar
  26. 26.
    Hartel M, Niedergethmann M, Farag-Soliman M, Sturm JW, Richter A, Trede M et al. Benefit of venous resection for ductal adenocarcinoma of the pancreatic head. Eur J Surg 2002;168:707–712. doi:10.1080/00000000000000007.PubMedCrossRefGoogle Scholar
  27. 27.
    Shibata C, Kobari M, Tsuchiya T, Arai K, Anzai R, Takahashi M et al. Pancreatectomy combined with superior mesenteric-portal vein resection for adenocarcinoma in pancreas. World J Surg 2001;25:1002–1005. doi:10.1007/s00268-001-0070-z.PubMedCrossRefGoogle Scholar
  28. 28.
    van Geenen RC, ten Kate FJ, de Wit LT, van Gulik TM, Obertop H, Gouma DJ. Segmental resection and wedge excision of the portal or superior mesenteric vein during pancreatoduodenectomy. Surgery 2001;129:158–163. doi:10.1067/msy.2001.110221.PubMedCrossRefGoogle Scholar
  29. 29.
    Bachellier P, Nakano H, Oussoultzoglou PD, Weber JC, Boudjema K, Wolf PD et al. Is pancreaticoduodenectomy with mesentericoportal venous resection safe and worthwhile? Am J Surg 2001;182:120–129. doi:10.1016/S0002-9610(01)00686-9.PubMedCrossRefGoogle Scholar
  30. 30.
    Park DI, Lee JK, Kim JE, Hyun JG, Shim SG, Lee KT et al. The analysis of resectability and survival in pancreatic cancer patients with vascular invasion. J Clin Gastroenterol 2001;32:231–234. doi:10.1097/00004836-200103000-00011.PubMedCrossRefGoogle Scholar
  31. 31.
    Kinoshita H, Hashimoto M, Hashino K, Tamae T, Nagashima J, Nishimura K et al. Evaluation of simultaneous excision of pancreatic cancer and the surrounding blood vessels. Kurume Med J 2001;48:21–24.PubMedGoogle Scholar
  32. 32.
    Launois B, Stasik C, Bardaxoglou E, Meunier B, Campion JP, Greco L et al. Who benefits from portal vein resection during pancreaticoduodenectomy for pancreatic cancer? World J Surg 1999;23:926–929. doi:10.1007/s002689900601.PubMedCrossRefGoogle Scholar
  33. 33.
    Civello IM, Frontera D, Viola G, Cina G, Sganga G, Crucitti F. Extensive resection in pancreatic cancer: Review of the literature and personal experience. Hepatogastroenterology 1998;45:1877–1883.PubMedGoogle Scholar
  34. 34.
    Naganuma T, Isaji S, Kawarada Y. Staging and extended resection for pancreatic cancer. Pancreas 1998;16:355–3562. doi:10.1097/00006676-199804000-00024.PubMedCrossRefGoogle Scholar
  35. 35.
    Harrison LE, Klimstra DS, Brennan MF. Isolated portal vein involvement in pancreatic adenocarcinoma. A contraindication for resection? Ann Surg 1996;224:342–347. discussion 347–349 doi:10.1097/00000658-199609000-00010.Google Scholar
  36. 36.
    Roder JD, Stein HJ, Siewert JR. Carcinoma of the periampullary region: Who benefits from portal vein resection? Am J Surg 1996;171:170–174. discussion 174–175 doi:10.1016/S0002-9610(99)80094-4.PubMedCrossRefGoogle Scholar
  37. 37.
    Klempnauer J, Ridder GJ, Bektas H, Pichlmayr R. Extended resections of ductal pancreatic cancer—Impact on operative risk and prognosis. Oncology 1996;53:47–53.PubMedGoogle Scholar
  38. 38.
    Yeo CJ, Cameron JL, Lillemoe KD, Sitzmann JV, Hruban RH, Goodman SN et al. Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients. Ann Surg 1995;221:721–731. discussion 731–723 doi:10.1097/00000658-199506000-00011.PubMedCrossRefGoogle Scholar
  39. 39.
    Allema JH, Reinders ME, van Gulik TM, van Leeuwen DJ, de Wit LT, Verbeek PC et al. Portal vein resection in patients undergoing pancreatoduodenectomy for carcinoma of the pancreatic head. Br J Surg 1994;81:1642–1646. doi:10.1002/bjs.1800811126.PubMedCrossRefGoogle Scholar
  40. 40.
    Takahashi S, Ogata Y, Tsuzuki T. Combined resection of the pancreas and portal vein for pancreatic cancer. Br J Surg 1994;81:1190–1193. doi:10.1002/bjs.1800810837.PubMedCrossRefGoogle Scholar
  41. 41.
    Ishikawa O, Ohigashi H, Imaoka S, Furukawa H, Sasaki Y, Fujita M et al. Preoperative indications for extended pancreatectomy for locally advanced pancreas cancer involving the portal vein. Ann Surg 1992;215:231–236. doi:10.1097/00000658-199203000-00006.PubMedCrossRefGoogle Scholar
  42. 42.
    Ikeda M, Okusaka T, Ito Y, Ueno H, Morizane C, Furuse J et al. A phase i trial of s-1 with concurrent radiotherapy for locally advanced pancreatic cancer. Br J Cancer 2007;96:1650–1655. doi:10.1038/sj.bjc.6603788.PubMedCrossRefGoogle Scholar
  43. 43.
    Haddock MG, Swaminathan R, Foster NR, Hauge MD, Martenson JA, Camoriano JK et al. Gemcitabine, cisplatin, and radiotherapy for patients with locally advanced pancreatic adenocarcinoma: Results of the north central cancer treatment group phase ii study n9942. J Clin Oncol 2007;25:2567–2572. doi:10.1200/JCO.2006.10.2111.PubMedCrossRefGoogle Scholar
  44. 44.
    Cohen SJ, Dobelbower R Jr, Lipsitz S, Catalano PJ, Sischy B, Smith TJ et al. A randomized phase iii study of radiotherapy alone or with 5-fluorouracil and mitomycin-c in patients with locally advanced adenocarcinoma of the pancreas: Eastern cooperative oncology group study e8282. Int J Radiat Oncol Biol Phys 2005;62:1345–1350. doi:10.1016/j.ijrobp.2004.12.074.PubMedGoogle Scholar
  45. 45.
    Mishra G, Butler J, Ho C, Melin S, Case LD, Ennever PR et al. Phase ii trial of induction gemcitabine/cpt-11 followed by a twice-weekly infusion of gemcitabine and concurrent external beam radiation for the treatment of locally advanced pancreatic cancer. Am J Clin Oncol 2005;28:345–350. doi:10.1097/01.coc.0000159559.42311.c5.PubMedCrossRefGoogle Scholar
  46. 46.
    Rich T, Harris J, Abrams R, Erickson B, Doherty M, Paradelo J et al. Phase ii study of external irradiation and weekly paclitaxel for nonmetastatic, unresectable pancreatic cancer: Rtog-98-12. Am J Clin Oncol 2004;27:51–56. doi:10.1097/01.coc.0000046300.88847.BF.PubMedCrossRefGoogle Scholar
  47. 47.
    Blackstock AW, Tepper JE, Niedwiecki D, Hollis DR, Mayer RJ, Tempero MA. Cancer and leukemia group b (calgb) 89805: Phase ii chemoradiation trial using gemcitabine in patients with locoregional adenocarcinoma of the pancreas. Int J Gastrointest Cancer 2003;34:107–116. doi:10.1385/IJGC:34:2-3:107.PubMedCrossRefGoogle Scholar
  48. 48.
    Martenson JA, Vigliotti AP, Pitot HC, Geeraerts LH, Sargent DJ, Haddock MG et al. A phase i study of radiation therapy and twice-weekly gemcitabine and cisplatin in patients with locally advanced pancreatic cancer. Int J Radiat Oncol Biol Phys 2003;55:1305–1310. doi:10.1016/S0360-3016(02)04399-7.PubMedGoogle Scholar
  49. 49.
    Epelbaum R, Rosenblatt E, Nasrallah S, Faraggi D, Gaitini D, Mizrahi S et al. Phase ii study of gemcitabine combined with radiation therapy in patients with localized, unresectable pancreatic cancer. J Surg Oncol 2002;81:138–143. doi:10.1002/jso.10159.PubMedCrossRefGoogle Scholar
  50. 50.
    Wolff RA, Evans DB, Gravel DM, Lenzi R, Pisters PW, Lee JE et al. Phase i trial of gemcitabine combined with radiation for the treatment of locally advanced pancreatic adenocarcinoma. Clin Cancer Res 2001;7:2246–2253.PubMedGoogle Scholar
  51. 51.
    Safran H, Moore T, Iannitti D, Dipetrillo T, Akerman P, Cioffi W et al. Paclitaxel and concurrent radiation for locally advanced pancreatic cancer. Int J Radiat Oncol Biol Phys 2001;49:1275–1279. doi:10.1016/S0360-3016(00)01527-3.PubMedGoogle Scholar
  52. 52.
    Talamonti MS, Catalano PJ, Vaughn DJ, Whittington R, Beauchamp RD, Berlin J et al. Eastern cooperative oncology group phase i trial of protracted venous infusion fluorouracil plus weekly gemcitabine with concurrent radiation therapy in patients with locally advanced pancreas cancer: A regimen with unexpected early toxicity. J Clin Oncol 2000;18:3384–3389.PubMedGoogle Scholar
  53. 53.
    Ishii H, Okada S, Tokuuye K, Nose H, Okusaka T, Yoshimori M et al. Protracted 5-fluorouracil infusion with concurrent radiotherapy as a treatment for locally advanced pancreatic carcinoma. Cancer 1997;79:1516–1520. doi:10.1002/(SICI)1097-0142(19970415)79:8<1516::AID-CNCR11>3.0.CO;2-0.PubMedCrossRefGoogle Scholar
  54. 54.
    Whittington R, Neuberg D, Tester WJ, Benson AB 3rd, Haller DG. Protracted intravenous fluorouracil infusion with radiation therapy in the management of localized pancreaticobiliary carcinoma: A phase i eastern cooperative oncology group trial. J Clin Oncol 1995;13:227–232.PubMedGoogle Scholar
  55. 55.
    Moertel CG, Frytak S, Hahn RG, O'Connell MJ, Reitemeier RJ, Rubin J et al. Therapy of locally unresectable pancreatic carcinoma: A randomized comparison of high dose (6000 rads) radiation alone, moderate dose radiation (4000 rads + 5-fluorouracil), and high dose radiation + 5-fluorouracil: The gastrointestinal tumor study group. Cancer 1981;48:1705–1710. doi:10.1002/1097-0142(19811015)48:8<1705::AID-CNCR2820480803>3.0.CO;2-4.PubMedCrossRefGoogle Scholar
  56. 56.
    Moertel CG, Childs DS Jr, Reitemeier RJ, Colby MY Jr, Holbrook MA. Combined 5-fluorouracil and supervoltage radiation therapy of locally unresectable gastrointestinal cancer. Lancet 1969;2:865–867. doi:10.1016/S0140-6736(69)92326-5.PubMedCrossRefGoogle Scholar
  57. 57.
    Louvet C, Labianca R, Hammel P, Lledo G, Zampino MG, Andre T et al. Gemcitabine in combination with oxaliplatin compared with gemcitabine alone in locally advanced or metastatic pancreatic cancer: Results of a gercor and giscad phase iii trial. J Clin Oncol 2005;23:3509–3516. doi:10.1200/JCO.2005.06.023.PubMedCrossRefGoogle Scholar
  58. 58.
    Rocha Lima CM, Green MR, Rotche R, Miller WH Jr, Jeffrey GM, Cisar LA et al. Irinotecan plus gemcitabine results in no survival advantage compared with gemcitabine monotherapy in patients with locally advanced or metastatic pancreatic cancer despite increased tumor response rate. J Clin Oncol 2004;22:3776–3783. doi:10.1200/JCO.2004.12.082.PubMedCrossRefGoogle Scholar
  59. 59.
    Bramhall SR, Schulz J, Nemunaitis J, Brown PD, Baillet M, Buckels JA. A double-blind placebo-controlled, randomised study comparing gemcitabine and marimastat with gemcitabine and placebo as first line therapy in patients with advanced pancreatic cancer. Br J Cancer 2002;87:161–167. doi:10.1038/sj.bjc.6600446.PubMedCrossRefGoogle Scholar
  60. 60.
    McGinn CJ, Zalupski MM, Shureiqi I, Robertson JM, Eckhauser FE, Smith DC et al. Phase i trial of radiation dose escalation with concurrent weekly full-dose gemcitabine in patients with advanced pancreatic cancer. J Clin Oncol 2001;19:4202–4208.PubMedGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2008

Authors and Affiliations

  • Michael A. Abramson
    • 1
  • Edward W. Swanson
    • 1
  • Edward E. Whang
    • 1
  1. 1.Department of SurgeryBrigham and Women’s Hospital, Harvard Medical SchoolBostonUSA

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