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Vein Involvement During Pancreaticoduodenectomy: Is There a Need for Redefinition of “Borderline Resectable Disease”?

  • 2012 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Introduction

Current National Comprehensive Cancer Network guidelines recommend neoadjuvant therapy for borderline resectable pancreatic adenocarcinoma to increase the likelihood of achieving R0 resection. A consensus has not been reached on the degree of venous involvement that constitutes borderline resectability. This study compares the outcome of patients who underwent pancreaticoduodenectomy with or without vein resection without neoadjuvant therapy.

Methods

A multi-institutional database of patients who underwent pancreaticoduodenectomy was reviewed. Patients who required vein resection due to gross vein involvement by tumor were compared to those without evidence of vein involvement.

Results

Of 492 patients undergoing pancreaticoduodenectomy, 70 (14 %) had vein resection and 422 (86 %) did not. There was no difference in R0 resection (66 vs. 75 %, p = NS). On multivariate analysis, vein involvement was not predictive of disease-free or overall survival.

Conclusion

This is the largest modern series examining patients with or without isolated vein involvement by pancreas cancer, none of whom received neoadjuvant therapy. Oncological outcome was not different between the two groups. These data suggest that up-front surgical resection is an appropriate option and call into question the inclusion of isolated vein involvement in the definition of “borderline resectable disease.”

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Author information

Authors and Affiliations

  1. Department of Surgery, University of Wisconsin, Madison, WI, USA

    Kaitlyn J. Kelly, Emily Winslow, Clifford S. Cho & Sharon M. Weber

  2. Department of Surgery, Emory University, Atlanta, GA, USA

    David Kooby, Neha L. Lad & Shishir K. Maithel

  3. Department of Surgery, Vanderbilt University, Nashville, TN, USA

    Alexander A. Parikh & Nipun B. Merchant

  4. Department of Surgery, University of Louisville, Louisville, KY, USA

    Charles R. Scoggins & Robert C. Martin

  5. Department of Surgery, University of Cincinnati, Cincinnati, OH, USA

    Syed Ahmad

  6. Department of Surgery, University of North Carolina, Chapel Hill, NC, USA

    H. J. Kim

  7. University of Wisconsin Hospital and Clinics, 600 Highland Avenue BX7375 Clinical Science Center, Madison, WI, 53792-3284, USA

    Sharon M. Weber

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  1. Kaitlyn J. Kelly
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Additional information

Discussant

Dr. Sean P. Cleary (Toronto, ON, Canada): Dr. Kelly, thank you for that excellent presentation. You are to be congratulated for compiling a large multi-institutional experience in venous resection in pancreaticoduodenectomy. The issue of vascular resection and the use of perioperative chemotherapy and radiotherapy are certainly the dominant issues in the treatment of pancreatic cancer at present, and your series certainly makes an important contribution to the literature as a large series of patients who underwent vascular resection without pre-operative therapy.

My first question addresses patient selection in this series. Did patients undergo vascular resection based on intra-operative findings of adherence to the SMV or PV, or was this suspected in these patients on pre-operative imaging. These patients did not receive pre-operative therapy, however are patients ever treated at the participating centres with pre-operative therapy. If so, then how are patients selected to receive, or not receive, pre-operative therapy.

Secondly, I was wondering if you could provide us with some additional information regarding the extent and type of venous resections (sleeve/segmental vs tangential) and reconstructions in your series. I would be curious to know if the margin positivity rates, morbidity and outcomes are similar with these two types of resections.

Your multivariate analysis identifies intraoperative blood loss as a predictor of long-term outcome. Some of us may be skeptical that, outside of an immunologic effect, that intra-operative blood loss or transfusions would have little impact on perioperative events but such a strong influence on outcomes. I wonder if you could speculate as to whether you feel this is a true direct effect or a confounder of other patient or tumour factors.

Finally, as your series and others have eloquently shown, venous resection and reconstruction in pancreaticoduodenectomy can be performed safely with little impact on perioperative outcomes and possibly good long-term outcomes. This begs the question as to whether venous involvement is merely a technical consideration or does it represent a harbinger of more aggressive tumour biology. In other words, what role should venous involvement play in our definition of borderline resectability?

Closing Discussant

Dr. Kaitlyn J. Kelly: Dr. Cleary, thank you for your insightful critique. To address your first question, most patients in this study did undergo vascular resection based on intraoperative, rather than preoperative, evidence of vein involvement. Approximately 40 % of those patients who required vein resection had evidence of vein involvement on preoperative imaging studies. The institutions participating in this study tend to practice up-front surgery for pancreatic adenocarcinoma, however they do occasionally administer neoadjuvant therapy on clinical trial or when patients have evidence of locally unresectable disease at initial presentation. In this study, 16 patients were excluded for having received neoadjuvant therapy. Regarding your second question, we do not have data on the specific types of vein resections performed in this study, although tangential and segmental resections were included. Therefore, We do not know if there would be differences in margin positivity, morbidity, or outcome based on the type of vein resection performed.

Regarding your third question on the relevance of operative blood loss as a predictor of long-term outcome, we feel this is a true direct effect. This variable was an independent predictor of outcome on multivariate analysis. Also, it has been reported previously that operative blood loss predicts early recurrence and death in pancreatic adenocarcinoma (Nagai S, et al. Pancreas 2011; Raut CP et al. Annals of Surgery 2007; Sohn TA et al. J GI Surg 2000). We feel that vein involvement is more a feature of tumor location than it is a feature of more aggressive disease biology. In this study, as in many others, vein involvement was not associated with features of aggressive disease such as increasing tumor size, grade, or nodal involvement. Arterial involvement, on 24 Kelly et al.

The other hand, is associated with lymphatic and neural plexus invasion. That is why we propose that patients with vein involvement should be considered a different class than those with arterial involvement. Patients with isolated vein involvement should be offered a choice of up-front resection at a high volume center or neoadjuvant therapy.

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Kelly, K.J., Winslow, E., Kooby, D. et al. Vein Involvement During Pancreaticoduodenectomy: Is There a Need for Redefinition of “Borderline Resectable Disease”?. J Gastrointest Surg 17, 1209–1217 (2013). https://doi.org/10.1007/s11605-013-2178-5

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