Defining venous involvement in borderline resectable pancreatic cancer.
BACKGROUND
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.


METHODS
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.


RESULTS
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.


CONCLUSIONS
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.
Chun
Yun Shin
YS
Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA. yunshin.chun@fccc.edu
Milestone
Barton N
BN
Watson
James C
JC
Cohen
Steven J
SJ
Burtness
Barbara
B
Engstrom
Paul F
PF
Haluszka
Oleh
O
Tokar
Jeffrey L
JL
Hall
Michael J
MJ
Denlinger
Crystal S
CS
Astsaturov
Igor
I
Hoffman
John P
JP
D000230:Adenocarcinoma / Q000473:pathology* / Q000601:surgery / Q000628:therapy; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D008297:Male; D008642:Mesenteric Veins / Q000473:pathology / Q000601:surgery; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D010179:Pancreas / Q000098:blood supply* / Q000473:pathology; D010180:Pancreatectomy; D010190:Pancreatic Neoplasms / Q000473:pathology* / Q000601:surgery / Q000628:therapy; D011169:Portal Vein / Q000473:pathology / Q000601:surgery; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed