Defining Venous Involvement in Borderline Resectable Pancreatic Cancer

Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
Annals of Surgical Oncology (Impact Factor: 3.93). 11/2010; 17(11):2832-8. DOI: 10.1245/s10434-010-1284-9
Source: PubMed


Pancreatic adenocarcinoma impinging the portal and/or superior mesenteric vein (PV-SMV) is classified as borderline resectable, and preoperative chemoradiation is recommended to increase the margin-negative resection rate. There is no consensus about what degree of venous impingement constitutes borderline resectability.
All patients undergoing potentially curative pancreatectomy for pancreatic adenocarcinoma were reviewed. Venous involvement was classified by preoperative computed tomography according to Ishikawa types: (I) normal, (II) smooth shift without narrowing, (III) unilateral narrowing, (IV) bilateral narrowing, (V) bilateral narrowing with collateral veins.
From 1990-2009, 109 patients underwent resection of pancreatic adenocarcinoma involving the PV-SMV. Seventy-four patients received preoperative chemoradiation, whereas 35 did not. Patients who received preoperative therapy had a significantly longer median overall survival rate of 23 months compared with 15 months for patients without preoperative therapy (P = 0.001). Preoperative chemoradiation was associated with higher R0 resection rate and negative lymph nodes (both P < 0.0001) but did not affect the need for vein resection. When stratified by Ishikawa types, preoperative therapy was associated with improved overall survival among patients with types II and III but not types IV and V. Similarly, the correlation between preoperative therapy and R0 resection rate was observed only among patients with Ishikawa types II and III.
Preoperative therapy for borderline resectable pancreatic adenocarcinoma is associated with higher margin-negative resection and survival rates in patients with Ishikawa type II and III tumors, defined as a smooth shift or unilateral narrowing of the PV-SMV. Patients with bilateral venous narrowing were less likely to benefit from preoperative treatment.

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    • "Accurate selection of the patients who are eligible for macroscopic (R0 or R1) resection with adjuvant chemotherapy is also vital, since median survival following incomplete macroscopic surgical resection (R2) of the primary tumour is comparable to that of patients with inoperable locally advanced disease treated with chemotherapy [34e38,40e42]. There is also a growing consensus on the radiological definitions of 'resectable', 'borderline resectable' and 'unresectable', and the National Comprehensive Cancer Network in the USA has endorsed a modified consensus from the Americas Hepato-Pancreato-Biliary Association, the Society of Surgical Oncology and the Society for Surgery of the Alimentary Tract [43] [44]. Current imaging modalities used for preoperative staging include abdominal ultrasound, computed tomography, magnetic resonance imaging and endoscopic ultrasonography. "
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    ABSTRACT: Pancreatic ductal adenocarcinoma (PDAC), which accounts for more than 90% of all pancreatic tumours, is a devastating malignancy with an extremely poor prognosis, as shown by a 1-year survival rate of around 18% for all stages of the disease. The low survival rates associated with PDAC primarily reflect the fact that tumours progress rapidly with few specific symptoms and are thus at an advanced stage at diagnosis in most patients. As a result, there is an urgent need to develop accurate markers of pre-invasive pancreatic neoplasms in order to facilitate prediction of cancer risk and to help diagnose the disease at an earlier stage. However, screening for early diagnosis of prostate cancer remains challenging and identifying a highly accurate, low-cost screening test for early PDAC for use in clinical practice remains an important unmet need. More effective therapies are also crucial in PDAC, since progress in identifying novel therapies has been hampered by the genetic complexity of the disease and treatment remains a major challenge. Presently, the greatest step towards improved treatment efficacy has been made in the field of palliative chemotherapy by introducing FOLFIRINOX (folinic acid, 5-fluorouracil, irinotecan and oxaliplatin) and gemcitabine/nab-paclitaxel. Strategies designed to raise the profile of PDAC in research and clinical practice are a further requirement in order to ensure the best treatment for patients. This article proposes a number of approaches that may help to accelerate progress in treating patients with PDAC, which, in turn, may be expected to improve the quality of life and survival for those suffering from this devastating disease.
    Full-text · Article · Oct 2014 · Pancreatology
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    • "In 2006, a new category of borderline resectable pancreatic cancer was proposed by Varadhachary based on the extent of artery involvement and technical capability of reconstructing the vein [20]. The Fox Chase Cancer Center also suggested that tumor-induced unilateral shift or narrowing of the SPMV confluence as one of criteria of borderline resectable [21]. In resectable pancreatic cancer, the reported positive margin rate (R1 + R2) ranged from 19% to 68% and the positive margin strongly predicts the short survival and early recurrence rate [20]. "
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    Full-text · Article · Sep 2014 · BMC Surgery
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    Full-text · Article · Nov 2010 · Annals of Surgical Oncology
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