Abstract
Background: Patients with pancreatic cancer (PC), which is not upfront resectable, but borderline, involving major peripancreatic vessels, have not been generally considered for surgery, considering that resection in such a setting may be futile.Materials and Methods: Retrospective analysis of prospectively collected data on patients with borderline pancreatic adenocarcinoma undergoing pancreatectomy en-block with portal and/or superior mesenteric vein resection in a tertiary referral center in Greece between January 2012 and February 2017. Follow-up was complete up to January 2018.Results: Twenty-four patients were included. Neoadjuvant therapy (NAT) was administered to only 38%, but more commonly in the second half of the group (58% vs. 17%, p = 0.035). It was associated with smaller tumor size (median: 2.5 vs. 4.2 cm, p < 0.001), fewer positive lymph nodes (LNs) in the resected specimen (median: 2 vs. 5, p = 0.04), and higher likelihood of adjuvant therapy (78% vs. 40%, p = 0.01), but not with survival. Resection was extensive: a median of 26 LNs were retrieved, R0 resection rate (≥1 mm) was 79%, and median length of vein segments was 4 cm, requiring interposition grafts in 58% (mostly polytetrafluoroethylene). Median intensive care unit stay was 0 days and length of hospital stay was 9 days. Post-operative mortality was 12.5%. Median overall survival was 24 months. Eastern Cooperative Oncology Group (ECOG) status was significantly associated with survival (p < 0.001) with ECOG-0: 33 months, ECOG-1: 12 months, and ECOG-2: 6 months.Conclusion: This first Greek national series of portomesenteric vein resection in borderline PC demonstrates that it results to 2 years of median survival, extending to 33 months in patients with good performance status, especially if NAT is uniformly administered.
Highlights
IntroductionManagement of pancreatic cancer (PC) with curative intent has made significant progress,[1] especially after the recognition that more patients with previously considered unresectable disease could be offered a curative operation following neoadjuvant therapy (NAT—chemotherapy/chemoradiation).[2,3,4,5] Surgical technique has advanced, so that tumors involving major peripancreatic vasculature, once considered unresectable, are safely removed in association with these major vessels in specialized centers.[3,6,7,8]Currently, ‘‘borderline resectable’’ tumors (NationalComprehensive Cancer Network [NCCN] criteria) are considered technically upfront resectable, but resection leads to improved outcome when preceded by Neoadjuvant therapy (NAT).[9]Departments of 1Surgery, 2Pathology, 3Cytology, 4Medical Oncology, and 5Anesthesiology, Mitera-Hygeia Hospitals, Marousi, Greece.a Gregory G
Total pancreatectomy was performed in all six patients with neck tumors, in two patients with large body tumors extending to the neck, in one patient with head tumor, and in three patients with uncinate tumors because of pre-existing insulindependent diabetes mellitus
The routine addition of neoadjuvant chemotherapy with or without chemoradiotherapy has led to even better results,[4,14,15] so that Neoadjuvant therapy (NAT) followed by surgery in borderline pancreatic cancer (PC) belongs to the guidelines of the International Study Group of Pancreatic Surgery[9] and is recommended by experts.[16,17]
Summary
Management of pancreatic cancer (PC) with curative intent has made significant progress,[1] especially after the recognition that more patients with previously considered unresectable disease could be offered a curative operation following neoadjuvant therapy (NAT—chemotherapy/chemoradiation).[2,3,4,5] Surgical technique has advanced, so that tumors involving major peripancreatic vasculature, once considered unresectable, are safely removed in association with these major vessels in specialized centers.[3,6,7,8]Currently, ‘‘borderline resectable’’ tumors (NationalComprehensive Cancer Network [NCCN] criteria) are considered technically upfront resectable, but resection leads to improved outcome when preceded by NAT.[9]Departments of 1Surgery, 2Pathology, 3Cytology, 4Medical Oncology, and 5Anesthesiology, Mitera-Hygeia Hospitals, Marousi, Greece.a Gregory G. Neoadjuvant therapy (NAT) was administered to only 38%, but more commonly in the second half of the group (58% vs 17%, p = 0.035) It was associated with smaller tumor size (median: 2.5 vs 4.2 cm, p < 0.001), fewer positive lymph nodes (LNs) in the resected specimen (median: 2 vs 5, p = 0.04), and higher likelihood of adjuvant therapy (78% vs 40%, p = 0.01), but not with survival. Conclusion: This first Greek national series of portomesenteric vein resection in borderline PC demonstrates that it results to 2 years of median survival, extending to 33 months in patients with good performance status, especially if NAT is uniformly administered
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