Skip to main content
SpringerLink
Log in

Significance of Cancer Cells at the Vein Edge in Patients with Pancreatic Adenocarcinoma Following Pancreatectomy with Vein Resection

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Background

Resection of the superior mesenteric and/or portal vein (SMV-PV) is increasingly performed with pancreatectomy for adenocarcinoma. We sought to analyze the impact of cancer at the transected edge(s) of the vein wall.

Methods

Patients who underwent pancreatectomy with vein resection between 2003 and 2015 at a single center were evaluated. R1 resection was defined per guidelines from the American Joint Commission on Cancer and the College of American Pathologists. Specimens were also evaluated for the presence (V+) or absence (V−) of cancer cells at the transected edge(s) and depth of vein invasion.

Results

Among 127 evaluated patients, 114 (90%) received preoperative therapy. R-status was categorized as margin-negative (R0)/V− (n = 72, 57%), R0/V+ (n = 19, 15%), margin-positive (R1)/V− (n = 24, 19%), and R1/V+ (n = 12, 9%). Patients with V− specimens had similar median durations of recurrence-free survival (RFS) (12 vs 9 months) and overall survival (OS) (30 vs 28 months) as did patients with V+ specimens (P > 0.05). In contrast, cancer invasion into the lumen was associated with RFS and OS (P < 0.05). Among patients who underwent R0 resection, V-status had no association with OS, RFS, or local control (P > 0.05).

Conclusion

Cancer invasion into the superior mesenteric and/or portal vein was adversely associated with survival, but cancer at the vein edge(s) was not. Transection of the SMV-PV through macroscopically normal vein may be performed to minimize resected vein length without fear of negatively affecting oncologic outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Fuhrman GM, Leach SD, Staley CA, Cusack JC, Charnsangavej C, Cleary KR et al. 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. 1996;223(2):154–62.

    CAS  Google Scholar 

  2. Tseng JF, Tamm EP, Lee JE, Pisters PW, Evans DB. Venous resection in pancreatic cancer surgery. Best Pract Res Clin Gastroenterol. 2006;20(2):349–64. doi:https://doi.org/10.1016/j.bpg.2005.11.003.

    Article  PubMed  Google Scholar 

  3. 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(2):300–9. doi:https://doi.org/10.1097/SLA.0b013e31815aab22.

    Article  PubMed  Google Scholar 

  4. Zhou Y, Zhang Z, Liu Y, Li B, Xu D. Pancreatectomy combined with superior mesenteric vein-portal vein resection for pancreatic cancer: a meta-analysis. World J Surg. 2012;36(4):884–91. doi:https://doi.org/10.1007/s00268-012-1461-z.

    Article  PubMed  Google Scholar 

  5. Ethun CG, Kooby DA. The importance of surgical margins in pancreatic cancer. Journal of surgical oncology. 2016;113(3):283–8. doi:https://doi.org/10.1002/jso.24092.

    Article  PubMed  Google Scholar 

  6. Amin MB, Edge SB, Greene FL, Compton CC, Gershenwald JE, Brookland RK et al. AJCC Cancer Staging Manual. 8th ed. New York: Springer; 2017.

    Book  Google Scholar 

  7. Kakar S, Shi C, Adsay NV, Fitzgibbons P, Frankel W, Klimstra DS et al. Protocol for the Examination of Specimens From Patients With Carcinoma of the Pancreas. Pancreas Exocrine. Version 4.0.0.1. 2017. http://www.cap.org/ShowProperty?nodePath=/UCMCon/Contribution%20Folders/WebContent/pdf/cp-pancreas-exocrine-17protocol-4001.pdf. Accessed 15 March 2018.

  8. Abel EJ, Carrasco A, Karam J, Tamboli P, Delacroix S, Vaporciyan AA et al. Positive vascular wall margins have minimal impact on cancer outcomes in patients with non-metastatic renal cell carcinoma (RCC) with tumour thrombus. BJU Int. 2014;114(5):667–73. doi:https://doi.org/10.1111/bju.12515.

    Article  PubMed  Google Scholar 

  9. Liu NW, Wren JD, Vertosick E, Lee JK, Power NE, Benfante NE et al. The Prognostic Impact of a Positive Vascular Margin on pT3 Clear Cell Renal Cell Carcinoma. J Urol. 2016;195(2):264–9. doi:https://doi.org/10.1016/j.juro.2015.08.099.

    Article  PubMed  Google Scholar 

  10. Trpkov K, Grignon DJ, Bonsib SM, Amin MB, Billis A, Lopez-Beltran A et al. Handling and staging of renal cell carcinoma: The International Society of Urological Pathology Consensus (ISUP) conference recommendations. American Journal of Surgical Pathology. 2013;37(10):1505–17. doi:https://doi.org/10.1097/PAS.0b013e31829a85d0.

    Article  PubMed  Google Scholar 

  11. Srigley JR, Zhou M, Allan R, Amin MB, Campbell SC, Chang A et al. Protocol for the examination of specimens from patients with invasive carcinoma of renal tubular origin, 4.0.0.0. 2017. http://www.cap.org/ShowProperty?nodePath=/UCMCon/Contribution%20Folders/WebContent/pdf/cp-kidney-17protocol-4000.pdf. Accessed 29 May 2018.

  12. Hwang RF, Wang H, Lara A, Gomez H, Chang T, Sieffert N et al. Development of an integrated biospecimen bank and multidisciplinary clinical database for pancreatic cancer. Ann Surg Oncol. 2008;15(5):1356–66. doi:https://doi.org/10.1245/s10434-008-9833-1.

    Article  PubMed  Google Scholar 

  13. Balachandran A, Bhosale PR, Charnsangavej C, Tamm EP. Imaging of pancreatic neoplasms. Surg Oncol Clin N Am. 2014;23(4):751–88. doi:https://doi.org/10.1016/j.soc.2014.07.002.

    Article  PubMed  Google Scholar 

  14. Piccirillo JF, Tierney RM, Costas I, Grove L, Spitznagel EL, Jr. Prognostic importance of comorbidity in a hospital-based cancer registry. JAMA. 2004;291(20):2441–7. doi:https://doi.org/10.1001/jama.291.20.2441.

    Article  CAS  Google Scholar 

  15. Evans DB LJ, Tamm E, Pisters PW. Pancreaticoduodenectomy (Whipple operation) and total pancreatectomy for cancer. In: Fischer JF, editor. Mastery of surgery. Philadelphia: Lippincott Williams & Wilkins; 2007. p. 1299–317.

    Google Scholar 

  16. Katz MH, Lee JE, Pisters PW, Skoracki R, Tamm E, Fleming JB. Retroperitoneal dissection in patients with borderline resectable pancreatic cancer: operative principles and techniques. J Am Coll Surg. 2012;215(2):e11–8. doi:https://doi.org/10.1016/j.jamcollsurg.2012.05.015.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Katz MH, Fleming JB, Pisters PW, Lee JE, Evans DB. Anatomy of the superior mesenteric vein with special reference to the surgical management of first-order branch involvement at pancreaticoduodenectomy. Ann Surg. 2008;248(6):1098–102. doi:https://doi.org/10.1097/SLA.0b013e31818730f0.

    Article  PubMed  Google Scholar 

  18. Liu L, Katz MH, Lee SM, Fischer LK, Prakash L, Parker N et al. Superior Mesenteric Artery Margin of Posttherapy Pancreaticoduodenectomy and Prognosis in Patients With Pancreatic Ductal Adenocarcinoma. Am J Surg Pathol. 2015;39(10):1395–403. doi:https://doi.org/10.1097/PAS.0000000000000491.

    Article  PubMed  Google Scholar 

  19. Wang J, Estrella JS, Peng L, Rashid A, Varadhachary GR, Wang H et al. Histologic tumor involvement of superior mesenteric vein/portal vein predicts poor prognosis in patients with stage II pancreatic adenocarcinoma treated with neoadjuvant chemoradiation. Cancer. 2012;118(15):3801–11. doi:https://doi.org/10.1002/cncr.26717.

    Article  PubMed  Google Scholar 

  20. Tzeng CW, Fleming JB, Lee JE, Wang X, Pisters PW, Vauthey JN et al. Yield of clinical and radiographic surveillance in patients with resected pancreatic adenocarcinoma following multimodal therapy. HPB (Oxford). 2012;14(6):365–72. doi:https://doi.org/10.1111/j.1477-2574.2012.00445.x.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations J Am Stat Assoc. 1958;53(282):457–81.

    Article  Google Scholar 

  22. Mantel N. Evaluation of survival data and two new rank order statistics arising in its consideration. Cancer Chemother Rep. 1966;50(3):163–70.

    CAS  PubMed  Google Scholar 

  23. Kaneoka Y, Yamaguchi A, Isogai M. Portal or superior mesenteric vein resection for pancreatic head adenocarcinoma: prognostic value of the length of venous resection. Surgery. 2009;145(4):417–25. doi:https://doi.org/10.1016/j.surg.2008.12.009.

    Article  PubMed  Google Scholar 

  24. Snyder RA, Prakash LR, Nogueras-Gonzalez GM, Kim MP, Aloia TA, Vauthey JN et al. Vein resection during pancreaticoduodenectomy for pancreatic adenocarcinoma: Patency rates and outcomes associated with thrombosis. Journal of surgical oncology. 2018. doi: https://doi.org/10.1002/jso.25067.

    Article  Google Scholar 

  25. Butler JR, Ahmad SA, Katz MH, Cioffi JL, Zyromski NJ. A systematic review of the role of periadventitial dissection of the superior mesenteric artery in affecting margin status after pancreatoduodenectomy for pancreatic adenocarcinoma. HPB (Oxford). 2016;18(4):305–11. doi:https://doi.org/10.1016/j.hpb.2015.11.009.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Roch AM, House MG, Cioffi J, Ceppa EP, Zyromski NJ, Nakeeb A et al. Significance of Portal Vein Invasion and Extent of Invasion in Patients Undergoing Pancreatoduodenectomy for Pancreatic Adenocarcinoma. J Gastrointest Surg. 2016;20(3):479–87; discussion 87. doi:https://doi.org/10.1007/s11605-015-3005-y.

    Article  PubMed  Google Scholar 

  27. Boggi U, Del Chiaro M, Croce C, Vistoli F, Signori S, Moretto C et al. Prognostic implications of tumor invasion or adhesion to peripancreatic vessels in resected pancreatic cancer. Surgery. 2009;146(5):869–81. doi:https://doi.org/10.1016/j.surg.2009.04.029.

    Article  PubMed  Google Scholar 

  28. Tran Cao HS, Balachandran A, Wang H, Nogueras-Gonzalez GM, Bailey CE, Lee JE et al. Radiographic tumor-vein interface as a predictor of intraoperative, pathologic, and oncologic outcomes in resectable and borderline resectable pancreatic cancer. J Gastrointest Surg. 2014;18(2):269–78; discussion 78. doi:https://doi.org/10.1007/s11605-013-2374-3.

    Article  PubMed  Google Scholar 

  29. Addeo P, Velten M, Averous G, Faitot F, Nguimpi-Tambou M, Nappo G et al. Prognostic value of venous invasion in resected T3 pancreatic adenocarcinoma: Depth of invasion matters. Surgery. 2017;162(2):264–74. doi:https://doi.org/10.1016/j.surg.2017.03.008.

    Article  PubMed  Google Scholar 

  30. Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A et al. Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2016;34(21):2541–56. doi:https://doi.org/10.1200/JCO.2016.67.5553.

    Article  PubMed  Google Scholar 

  31. Pingpank JF, Hoffman JP, Ross EA, Cooper HS, Meropol NJ, Freedman G et al. Effect of preoperative chemoradiotherapy on surgical margin status of resected adenocarcinoma of the head of the pancreas. J Gastrointest Surg. 2001;5(2):121–30.

    Article  CAS  Google Scholar 

  32. Raut CP, Tseng JF, Sun CC, Wang H, Wolff RA, Crane CH et al. Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma. Ann Surg. 2007;246(1):52–60. doi:https://doi.org/10.1097/01.sla.0000259391.84304.2b.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Katz MH, Merchant NB, Brower S, Branda M, Posner MC, William Traverso L et al. Standardization of surgical and pathologic variables is needed in multicenter trials of adjuvant therapy for pancreatic cancer: results from the ACOSOG Z5031 trial. Ann Surg Oncol. 2011;18(2):337–44. doi:https://doi.org/10.1245/s10434-010-1282-y.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors would like to thank Tamara K Locke and the department of scientific publications at the University of Texas MD Anderson Cancer Center for editorial support.

Funding

This study was supported by the NIH/NCI under award number P30CA016672.

Author information

Authors and Affiliations

  1. Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1484, Houston, TX, 77030, USA

    Laura R. Prakash, Jordan M. Cloyd, Ching-Wei D. Tzeng, Michael P. Kim, Jeffrey E. Lee & Matthew H. G. Katz

  2. Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Huamin Wang & Jun Zhao

  3. Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Graciela M. Nogueras-Gonzalez

Authors
  1. Laura R. Prakash
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Huamin Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jun Zhao
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Graciela M. Nogueras-Gonzalez
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jordan M. Cloyd
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ching-Wei D. Tzeng
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Michael P. Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jeffrey E. Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Matthew H. G. Katz
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors met all four requirements for authorship, including substantial contributions to the conception or design of the work or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be published; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Matthew H. G. Katz.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic Supplementary Material

Supplementary figure 1

The neoadjuvant therapy regimens in this study. Gy, gray; fr, fractions; FOLFIRINOX, fluorouracil, irinotecan, leucovorin and oxaliplatin; 5 –FU, fluorouracil (DOCX 58.4 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Prakash, L.R., Wang, H., Zhao, J. et al. Significance of Cancer Cells at the Vein Edge in Patients with Pancreatic Adenocarcinoma Following Pancreatectomy with Vein Resection. J Gastrointest Surg 24, 368–379 (2020). https://doi.org/10.1007/s11605-019-04126-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-019-04126-y

Keywords

Search

Navigation