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Surgical Resection Versus Palliative Chemoradiotherapy for the Management of Pancreatic Cancer with Local Venous Invasion: A Decision Analysis

Michael A. Abramson, MD, Edward W. Swanson, BA, Edward E. Whang, MD
Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA


BACKGROUND:
Benefit from pancreaticoduodenectomy (PD) combined with superior mesenteric-portal vein (SMV-PV) resection in the management of pancreatic adenocarcinoma with local venous invasion remains controversial.

METHODS:
Using formal decision analysis, we compared survival associated with PD plus SMV-PV resection when applied to patients with pancreatic adenocarcinoma with isolated local venous invasion (Group I) versus that achieved with palliative chemoradiotherapy when applied to patients with locally advanced pancreatic cancer (Group II). Individual studies were identified using MEDLINE. A total of 1324 patients and 709 patients were analyzed for Groups 1 and 2, respectively. Patients with distant metastases were excluded.

RESULTS:
Overall decision analysis favored surgical resection (Group 1) over palliative chemoradiotherapy (Group 2). Sensitivity analyses indicated that this decision is sensitive to the perioperative mortality rate and the percentage of surgical resections with microscopic (R1) or macroscopic (R2) residual tumor at the resection margin. In contrast, sensitivity analysis revealed that the decision is not sensitive to the percentage of cases in which true venous invasion by cancer is documented histologically.

CONCLUSIONS:
Surgical resection may confer a survival advantage over palliative chemoradiotherapy in select patients with pancreatic cancers with presumed local venous invasion.

 

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