DUODENO-PANCREATECTOMY WITHOUT VASCULAR RESECTION FOR ISHIKAWA TYPE B ADENOCARCINOMA: UNDERTREATMENT OR NOT?

BACKGROUND: Pancreatic cancer is an aggressive neoplasia characterized by poor prognosis. To achieve complete tumor clearance, en bloc portal/superior mesenteric vein resection has become routine in high volume hospitals, for locally advanced pancreatic head adenocarcinoma (PHA). However, it’s impact on survival still remain controversial. The aim of our study was to investigate the impact on local/distant recurrence rate and on patients survival of an Intraoperative Ultrasound (IU) guided conservative approach, on a selected group of patients, with preoperative radiological contact evidence of pancreatic head adenocarcinoma (Ishikawa type B group) with portal-mesenteric axis (PMA), in which we separate the neoplasia from the vein, without performing primary en bloc vascular resection (VR). METHODS: Retrospective data of a consecutive series of patients who underwent duodeno-pancreatectomy (DP) for PHA at our tertiary care center, between 2008 and 2016, were reviewed. All patients underwent pre-operative Computer Tomography and were grouped according to Ishikawa classification in five types based on the relationship of the tumor to the PMA. We identified a selected group of Ishikawa type B (contact tumor/PMA with smooth shift without narrowing) in which, after checking the feasibility with IU, we preserved the vein without macroscopic residual (no vascular resection, nvrDP), and we compared it with a Ishikawa type A (no direct contact tumor/PMA) standard DP (sDP) group, in order to evaluate differences in local/distant recurrence and oncologic outcomes. Survival was compared using the Kaplan–Meier method and log-rank test P<0.05 was considered statistically significant. RESULTS: A total of 136 DP were performed for PHA during the study period, of which 116 without VR and 20 with VR. The nvrDP group consisted in 34 (25%) cases whereas 82 (60%) patients were the sDP group. Isolated local recurrence rate in nrvDP cases, at the time of diagnosis disease recurrence, was not superior if compared with sDP group (12.5% vs 18.9%, p=0.56), as well as we didn’t find any statistically differences in systemic progression (38.5% in nvrDP group vs 44.3% in the sDP, p=0.38) or local plus synchronous systemic disease rate (4.9% in sDP group vs 11.5% in nvrDP group, p=0.26) at Chi-quadro test. Into the nrvDP group when desease recurrence was diagnosed, isolated local recurrence occurred only in the 13% vs 87% of cases in which a distant metastatic spread was found. There were no differences in terms of overall survival rate (1-year: 61% sDP vs 53% nvrDP; 3-year: 22% vs 18%; 5-years: 14% vs 17%; p=0.9) between the two groups. CONCLUSIONS: PD without VR is a surgical approach that could be considered safe and oncologically acceptable in the vast majority of pre-operative Ishikawa type B PHA, without any significant influence of oncologic outcomes respect to sDP. Poor prognosis of PHA is more related to the aggressive biology and systemic spread of the tumor, rather than the local control. “Principled” vascular resection could not be justified in all the Ishikawa B PHA, in absence of significant improvement of disease control and patient's survival.