Abstract
Purpose To investigate the oncological outcome and survival of patients following a conservative approach on the portal-mesenteric axis, in an intraoperative ultrasound-selected group of pancreatoduodenectomy (PD), performed on patients with primary resectable with vascular contact (prVC) pancreatic ductal adenocarcinoma (PDAC). Methods A consecutive series of patients who underwent PD for PDAC at our tertiary care center, between 2008 and 2017, were reviewed. A total of 156 PDs and 88 total pancreatectomies were performed during the study period, including 35 vascular resections. We identified a group of 40 (25.6%) patients with prVC-PDAC in whom after checking the feasibility with intraoperative ultrasound, we were able to perform PD by separation of the tumor from the portomesenteric axis avoiding vascular resection, without residual macroscopic disease (no vascular resection, nvrPD), and compared this group, using case-matched methodology, with the standard PD (sPD) group of primary resectable without vascular contact- (prwVC-) PDAC. Results The median follow-up was 28.5 ± 23.2 months in the sPD group and 23.8 ± 20.8 months in the nvrPD group (p = 0.35). Isolated local recurrence rate was 2/40 (5%) in both groups. Additionally, there were no statistical differences in the systemic progression of the disease (42.5% sPD vs. 45% nvrPD, p = 0.82) or local plus synchronous systemic disease rates (2.5% sPD vs. 7.5% nvrPD, p = 0.30). The median survival was 22 months for the sPD group and 23 months for the nvrPD group, p = 0.86. The overall survival was similar in the two groups (1 y: 76.3% sPD vs. 70.0% nvrPD; 3 y: 35.6% vs. 31.6%; and 5 y: 28.5% vs. 25.3%; p = 0.80). Conclusions. PD without vascular resection can be considered safe and oncologically acceptable in selected patients with preoperative diagnosis of prVC-PDAC. The poor prognosis of PDAC is related to the aggressive biology and systemic spread of the tumor, rather than the local control of the disease.
Highlights
Pancreatic ductal adenocarcinoma (PDAC) is one of the most biologically aggressive neoplasms characterized by poor prognosis with a mortality rate which currently ranks fifth in the list of cancer-related deaths
We identified a group of 40 patients with primary resectable disease with venous contact- PDAC, in whom, after checking the feasibility with intraoperative ultrasound (IOUS), the vein had been peeled off the tumor without leaving macroscopic residual disease, avoiding a vascular resection
The overall postoperative complication rate was similar in both groups, occurring in 16 patients (40.0%) in the standard PD (sPD) group and in 22 patients (55.0%) in the nvrPD group (p = 0 18)
Summary
Pancreatic ductal adenocarcinoma (PDAC) is one of the most biologically aggressive neoplasms characterized by poor prognosis with a mortality rate which currently ranks fifth in the list of cancer-related deaths. Surgical management remains the primary treatment, but resection is possible only in 15 to 20% of patients [1]. Patients with pancreatic head tumors may obtain improved survival from early diagnosis and treatment. In these cases, whenever possible, an R0 resection margin is associated with a 5-year survival rate of 20% in some reports. Because the pancreatic head is anatomically closely related to major arteries and veins, in 40% of patients, cancer involves one or more major vascular structures at the time of diagnosis [2]. The benefit in terms of improved disease-free survival by this aggressive major surgical resection remains unproven
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