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Introduction: The consensus definition of borderline resectable pancreas cancer includes patients with any venous (SMV-PV) or limited arterial (SMA or GDA/CHA) involvement. Recent recommendations suggest that patients with borderline resectable pancreatic adenocarcinoma should receive neoadjuvant therapy to increase the likelihood of achieving R0 resection. It is established that a subset of patients with limited venous involvement can achieve R0 resection by utilizing vein resection. This study compares outcome of patients who underwent pancreaticoduodenectomy with (VR-PD) or without (PD) vein resection, and is unique because none received neoadjuvant therapy.
Methods: A large, multi-institutional database of patients who underwent PD without neoadjuvant therapy was reviewed. Patients who required vein resection due to SMV-PV involvement by tumor were compared to those who underwent PD without vein resection.
Results: Of 492 total patients, 70 (14%) underwent VR-PD and 422 (86%) underwent PD. There was no difference in R0 resection (66% VR-PD vs. 75% PD, p=0.11) or local recurrence rate (18% VR-PD vs. 14% PD, p=0.33), at a median follow up of 16 months (range 3.0 - 129.7). There was no difference in median DFS (10.1 months VR-PD vs. 15.2 months PD, p =NS, HR 1.24 (0.94 - 1.64)). Positive margin, increased EBL, advanced tumor grade, and lymph node involvement, but not vein involvement, were independent predictors of DFS. These same factors, as well as use of adjuvant therapy, predicted OS (Table).
Conclusion: This is the largest modern series examining patients with borderline resectable pancreas cancer due to SMV-PV involvement, none of whom received neoadjuvant therapy. This cohort of patients with vein involvement selected for up-front surgical resection demonstrates that oncologic outcomes, including R0 rate, local recurrence rate, and DFS, were not compromised when vein resection was required. These data suggest that up-front surgical resection is an appropriate option for patients with isolated vein involvement and calls into question the inclusion of all SMV-PV involvement within the definition of “borderline resectable disease.”

Multivariate analysis of demographic, pathologic, and operative factors for patients undergoing PD for adenocarcinoma that may influence disease free (DFS) and overall survival (OS)

Factor	DFS			OS
	HR	95% CI	P	HR	95% CI	P
Tumor Size (cm)	1.00	0.90-1.10	0.97	1.01	0.92-1.10	0.85
Tumor Grade			<0.05			<0.01
Well	1.66	1.07-2.57		1.93	1.33-2.81
Moderate	1.93	0.77-4.85		1.74	0.80-3.81
Poor	2.06	1.24-3.42		3.03	1.97-4.64
Positive Lymph Nodes	1.57	1.18-2.09	<0.01	1.56	1.22-1.99	0.01
Vein Involvement	1.15	0.78-1.68	0.83	1.20	0.87-1.63	0.26
R1 Margin	1.26	0.94-1.70	0.09	1.80	1.39-2.30	<0.01
Blood Loss (mL)	1.00	-	0.01	1.00	-	<0.01
Adjuvant Chemo	1.19	0.89-1.57	0.25	0.74	0.58-0.94	<0.01