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Significance of Portal Vein Invasion and Extent of Invasion in Patients Undergoing Pancreaticoduodenectomy for Pancreatic Adenocarcinoma
Alexandra M. Roch*, Michael G. House, Jessica Cioffi, Eugene P. Ceppa, Nicholas J. Zyromski, Attila Nakeeb, C. Max Schmidt
Surgery, Indiana School of Medicine, Indianapolis, IN
Introduction: Several studies have confirmed the safety of pancreatoduodenectomy with portomesenteric vein resection and reconstruction in select patients. The effect of portal vein invasion and extent of invasion on survival is less clear. The purpose of this study was to examine the association between tumor invasion of the portomesenteric vein and long-term survival.
Methods: A retrospective review of a prospectively maintained database of patients who underwent pancreatoduodenectomy for pancreatic adenocarcinoma at a single academic medical center (2000-2014) was performed.Survival was compared with Kaplan-Meier method and log-rank test. P<0.05 was considered statistically significant.
Results: After non-pancreatic periampullary adenocarcinomas and patients with non-segmental (lateral wall only) resection of portal vein were excluded, there were 567 eligible patients. Of these, segmental portal vein resection was performed in 90 (16%) with end-to-end primary anastomosis in (67) or graft reconstruction (23). Histopathology of patients undergoing portal vein resection revealed a higher rate of perineural invasion (87% vs.74%, p=0.03). Portal vein resection, however, was not associated with differences in hospital stay, postoperative complications or operative mortality. Patients with portal vein resection showed no difference in recurrence rate and comparable overall, and 1-, 3- and 5-year survival rates. On final surgical histopathology, only 53 of 90 (59%) portal vein resections had adenocarcinoma involvement of the venous wall. Of these, invasion extent was at the level of adventitia (9), media/intima (31) and full thickness/intraluminal (10). Venous wall invasion (53) was associated with higher local recurrence but did not significantly influence overall survival (14 vs. 21 months, p=0.08). The extent of invasion did not impact recurrence, site of recurrence, or overall survival (p=0.08, 0.32, 0.58 and 0.5, respectively). Portal vein resection, histopathologic invasion or the extent of invasion were not independent predictors of overall survival in Cox regression analysis.
Conclusion: Portal vein resection is technically safe in select patients. Portomesenteric venous resection is not prognostic of overall survival. Direct tumor invasion into the portal vein wall on final surgical histopathology is associated with a higher rate of local recurrence, but did not affect overall survival even when stratified according to extent of venous wall invasion.
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