Vein Wall Invasion Is a More Reliable Predictor of Oncological Outcomes than Vein-Related Margins after Pancreaticoduodenectomy for Early Stages of Pancreatic Ductal Adenocarcinoma
Abstract
:1. Introduction
2. Materials and Methods
Data Analysis
3. Results
3.1. Subsection Overall Survival (OS)
3.2. Disease-Free Survival (DFS)
3.3. Local Recurrence (LR)
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Complete Cohort (n = 372) | No Vein Resection (n = 267) | Vein Resection (n = 105) | p | |
---|---|---|---|---|
Age (median and range; years) | 69 (34–85) | 69 (34–85) | 71 (48–82) | 0.025 |
Sex (male:female) | 193:179 (52%:48%) | 148:119 (55%:45%) | 45:60 (43%:57%) | 0.038 |
Pre-operative stage on imaging | <0.001 | |||
Resectable | 279 (75%) | 248 (93%) | 31 (30%) | |
BR-V | 93 (25%) | 19 (7%) | 74 (70%) | |
Pre-operative CA19-9 (median and range) | 200 (2–36,000) | 193 (2–36,000) | 237 (2–10,000) | 0.929 |
Vein resection | - | |||
Yes | 105 (28%) | N/A | 105 (100%) | |
No | 267 (72%) | |||
Vein Reconstruction | - | |||
Primary | 85 (23%) | N/A | 85 (81%) | |
Interposition graft | 20 (5%) | 20 (19%) | ||
pT | 0.430 | |||
pT1 | 35 (9%) | 28 (10%) | 7 (7%) | |
pT2 | 308 (83%) | 218 (82%) | 90 (86%) | |
pT3 | 29 (8%) | 21 (8%) | 8 (7%) | |
pN | 0.172 | |||
pN0 | 44 (12%) | 38 (14%) | 6 (5%) | |
pN1 | 185 (39%) | 101 (38%) | 44 (42%) | |
pN2 | 183 (49%) | 128 (48%) | 56 (53%) | |
Peri-neural invasion (PNI) | 344 (93%) | 245 (92%) | 99 (94%) | 0.515 |
Intra-vascular invasion (VI) | 334 (90%) | 239 (90%) | 95 (91%) | 1.000 |
Surgical margin status | 0.818 | |||
Negative (R0) | 170 (46%) | 121 (45%) | 45 (46%) | |
Positive (R1) | 202 (54%) | 146 (55%) | 53 (54%) | |
Specific margin/surface positivity | ||||
Anterior | 21 (6%) | 17 (6%) | 4 (4%) | 0.457 |
Posterior | 31 (8%) | 27 (10%) | 4 (4%) | 0.059 |
Vein groove | 128 (34%) | 54 (24%) | 63 (60%) | <0.001 |
Vein transection | 17 (5%) | - | 17 (16%) | N/A |
SMA | 65 (18%) | 47 (18%) | 18 (17%) | 1.000 |
Pancreas | 53 (14%) | 31 (12%) | 22 (21%) | 0.022 |
BD | 11 (3%) | 9 (3%) | 2 (2%) | 0.527 |
Duodenum | 14 (4%) | 10 (4%) | 3 (3%) | 0.766 |
Vein wall invasion | 39 (11%) | N/A | 39 (37%) | - |
Post-operative complications | 154 (42%) | 108 (41%) | 46 (44%) | 0.640 |
Comprehensive Complications Index (median and range) | 0 (0–100) | 0 (0–100) | 0 (0–100) | 0.887 |
Length of stay (median and range; days) | 9 (2–200) | 9 (2–84) | 9 (4–200) | 0.032 |
Adjuvant chemotherapy | 267 (73%) | 193 (73%) | 74 (73%) | 1.000 |
Follow-up (median and range; months) | 18 (0–100) | 17 (0–100) | 18 (0–81) | 0.444 |
Disease recurrence | 226 (61%) | 159 (60%) | 67 (64%) | 0.639 |
Local | 84 (23%) | 60 (23%) | 24 (23%) | |
Distant | 107 (29%) | 70 (26%) | 37 (35%) | |
Both | 35 (9%) | 29 (11%) | 6 (6%) |
Univariable Analysis p; HR (95% CI) | |||
---|---|---|---|
Complete Cohort | No Vein Resection Subgroup | Vein Resection Subgroup | |
Age | 0.791; 1.002 (0.989–1.015) | 0.779; 1.002 (0.987–1.018) | 0.886; 0.998 (0.975–1.022) |
Sex | 0.579; 0.936 (0.740–1.183) | 0.539; 0.915 (0.690–1.214) | 0.735; 0.927 (0.598–1.437) |
Pre-operative CA19–9 | 0.948; 1.000 (1.000–1.000) | 0.915; 1.000 (1.000–1.000) | 0.946; 1.000 (1.000–1.000) |
Pre-operative stage | 0.075; 1.270 (0.976–1.654) | 0.745; 0.900 (0.476–1.701) | 0.054; 1.671 (0.990–2.818) |
Vein resection | 0.282; 1.151 (0.891–1.488) | - | - |
pT | 0.010; 1.473 (1.097–1.977) | 0.048; 1.389 (1.004–1.922) | 0.109; 1.808 (0.876–3.732) |
pN | <0.001; 1.679 (1.401–2.013) | <0.001; 1.715 (1.389–2.117) | 0.018; 1.558 (1.078–2.252) |
Surgical margin status | <0.001; 1.565 (1.234–1.983) | 0.009; 1454 (1.096–1.929) | 0.002; 2.041 (1.299–3.206) |
Anterior surface | 0.949; 1.017 (0.613–1.685) | 0.830; 1.064 (0.605–1.869) | 0.872; 0.980 (0.308–3.111) |
Posterior surface | 0.141; 1.342 (0.907–1.986) | 0.210; 1.315 (0.857–2.018) | 0.178; 2.003 (0.729–5.503) |
Vein groove | 0.002; 1.466 (1.148–1.872) | 0.049; 1.389 (1.001–1.928) | 0.050; 1.572 (1.000–2.471) |
Vein transection margin | 0.442; 0.949 (0.829–1.085) | N/A | 0.148; 1.535 (0.859–2.741) |
SMA margin | 0.002; 1.585 (1.181–2.128) | 0.004; 1.667 (1.175–2.365) | 0.232; 1.398 (0.807–2.421) |
Pancreas margin | 0.085; 1.366 (0.958–1.947) | 0.821; 1.058 (0.648–1729) | 0.011; 1.998 (1.169–3.415) |
BD margin | 0.061; 1.829 (0.971–3.444) | 0.046; 2.058 (1.012–4.185) | 0.678; 1.348 (0.329–5.518) |
Duodenal/gastric margin | 0.997; 1.001 (0.532–1.884) | 0.847; 0.928 (0.436–1.976) | 0.751; 1.205 (0.379–3.831) |
Vein wall invasion | 0.730; 0.975 (0.842–1.128) | N/A | 0.017; 1.728 (1.103–2.706) |
PNI | 0.844; 0.954 (0.598–1.521) | 0.698; 1.114 (0.646–1.920) | 0.024; 0.345 (0.137–0.868) |
VI | 0.414; 1.187 (0.787–1.791) | 0.626; 1.129 (0.694–1.835) | 0.389; 1.408 (0.646–3.065) |
Post-operative complications | 0.885; 1.018; (0.801–1.293) | 0.646; 0.935 (0.701–1.247) | 0.238; 1.296 (0.842–1.996) |
Comprehensive complications index | 0.001; 1.013 (1.005–1.020) | 0.005; 1.012 (1.003–1.020) | 0.032; 1.015 (1.001–1.030) |
Adjuvant chemotherapy | <0.001; 0.393 (0.304–0.509) | <0.001; 0.331 (0.243–0.451) | 0.030; 0.590 (0.366–0.951) |
(A) Multivariable models for total margin status p; HR (95% CI) | |||
Complete cohort | No vein resection subgroup | Vein resection subgroup | |
Pre-operative stage Resectable as reference | NS | Not included as p > 0.200 in univariable analysis | 0.063; 1.678 (0.972–2.897) |
pT pT1 as reference pT2 pT3 | 0.018 | NS | 0.009 |
0.921; 1.021 (0.673–1.550) | 0.881; 1.076 (0.413–2.802) | ||
0.030; 1.863 (1.061–3.270) | 0.029; 3.663 (1.145–11.723) | ||
pN pN0 as reference pN1 pN2 | <0.001 | <0.001 | 0.063 |
<0.001; 2.591 (1.595–4.209) | <0.001; 4.388 (2.465–7.811) | 0.911; 0.942 (0.330–2.688) | |
<0.001; 3.736 (2.318–6.019) | <0.001; 5.817 (3.339–10.137) | 0.340; 1.635 (0.595–4.494) | |
Surgical margin status R0 as reference | 0.015; 1.351 (1.059–1.723) | NS | 0.009; 1.942 (1.181–3.195) |
Vein wall invasion Negative as reference | Not included as p > 0.200 in univariable analysis | Not included as p > 0.200 in univariable analysis | 0.031; 1.708 (1.051–2.775) |
PNI Negative as reference | Not included as p > 0.200 in univariable analysis | Not included as p > 0.200 in univariable analysis | 0.022; 0.318 (0.119–0.851) |
Adjuvant chemotherapy No chemotherapy as reference | <0.001; 2.909 (2.235–3.787) | <0.001; 4.571 (3.260–6.408) | NS |
(B) Multivariable models for individual surgical margins p; HR (95% CI) | |||
Complete cohort | No vein resection subgroup | Vein resection subgroup | |
pT pT1 as reference pT2 pT3 | 0.009 | NS | 0.002 |
0.813; 1.052 (0.691–1.601) | 0.390; 0.667 (0.265–1.680) | ||
0.015; 2.030 (1.145–3.599) | 0.084; 2.695 (0.874–8.308) | ||
pN pN0 as reference pN1 pN2 | <0.001 | <0.001 | NS |
<0.001; 2.505 (1.542–4.068) | <0.001; 4.384 (2.463–7.801) | ||
<0.001; 3.695 (2.298–5.941) | <0.001; 5.712 (3.274–9.966) | ||
PVG Negative as reference | 0.055; 1.280 (0.995–1.646) | NS | NS |
BD margin Negative as reference | NS | 0.048; 2.052 (1.005–4.189) | Not included as p > 0.200 in univariable analysis |
Pancreas margin Negative as reference | NS | Not included | 0.001; 2.465 (1.415–4.293) |
Vein wall invasion Negative as reference | Not included as p > 0.200 in univariable analysis | N/A | 0.005; 1.947 (1.228–3.089) |
Comprehensive complications index | 0.084; 1.007 (0.999–1.015) | NS | NS |
Adjuvant chemotherapy No chemotherapy as reference | <0.001; 2.672 (2.027–3.523) | <0.001; 4.639 (3.308–6.507) | NS |
Univariable Analysis p; HR (95% CI) | |||
---|---|---|---|
Complete Cohort | No Vein Resection Subgroup | Vein Resection Subgroup | |
Age | 0.449; 0.994 (0.980–1.009) | 0.773; 0.997 (0.980–1.015) | 0.189; 0.983 (0.957–1.009) |
Sex | 0.380; 0.889 (0.684–1.155) | 0.391; 0.871 (0.636–1.194) | 0.653; 0.895 (0.553–1.449) |
Pre-operative CA19–9 | 0.515; 1.000 (1.000–1.000) | 0.438; 1.000 (1.000–1.000) | 0.990; 1.000 (1.000–1.000) |
Pre-operative stage | 0.010; 1.467 (1.095–1.966) | 0.294; 1.390 (0.751–2.572) | 0.110; 1.600 (0.900–2.846) |
Vein resection | 0.130; 1.248 (0.937–1.661) | - | - |
pT | 0.007; 1.607 (1.142–2.262) | 0.003; 1.780 (1.215–2.608) | 0.965; 1.019 (0.447–2.323) |
pN | <0.001; 1.647 (1.348–2.012) | <0.001; 1.751 (1.389–2.208) | 0.227; 1.286 (0.855–1.933) |
Surgical margin status | <0.001; 1.813 (1.388–2.370) | <0.001; 1.807 (1.313–2.485) | 0.019; 1.805 (1.101–2.957) |
Anterior surface | 0.809; 0.931 (0.520–1.666) | 0.660; 0.860 (0.439–1.685) | 0.498; 1.497 (0.466–4.812) |
Posterior surface | 0.086; 1.470 (0.947–2.284) | 0.213; 1.366 (0.836–2.233) | 0.030; 3.127 (1.118–8.748) |
PVG | 0.008; 1.447 (1.101–1.903) | 0.270; 1.231 (0.850–1.783) | 0.036; 1.734 (1.037–2.901) |
Vein transection margin | 0.180; 0.903 (0.778–1.048) | N/A | 0.589; 1.216 (0.598–2.474) |
SMA margin | <0.001; 1.932 (1.397–2.674) | <0.001; 2.384 (1.633–3.480) | 0.656; 1.159 (0.605–2.219) |
Pancreas margin | 0.445; 1.168 (0.785–1.738) | 0.793; 1.074 (0.630–1.831) | 0.619; 1.168 (0.634–2.151) |
BD margin | 0.052; 2.023 (0.995–4.113) | 0.004; 3.047 (1.414–6.568) | 0.549; 0.546 (0.076–3.943) |
Duodenal/gastric margin | 0.378; 1.330 (0.705–2.508) | 0.670; 1.179 (0.552–2.518) | 0.288; 1.883 (0.586–6.049) |
Vein wall invasion | 0.597; 0.957 (0.813–1.126) | N/A | 0.006; 2.019 (1.219–3.345) |
PNI | 0.101; 1.700 (0.901–3.207) | 0.106; 1.799 (0.882–3.667) | 0.921; 1.074 (0.262–4.399) |
VI | 0.063; 1.563 (0.976–2.503) | 0.236; 1.394 (0.805–2.415) | 0.125; 2.051 (0.820–5.130) |
Post-operative complications | 0.152; 0.820 (0.624–1.076) | 0.280; 0.836 (0.604–1.157) | 0.269; 0.754 (0.458–1.244) |
Comprehensive complications index | 0.145; 0.993 (0.983–1.002) | 0.245; 0.993 (0.982–1.005) | 0.300; 0.991 (0.974–1.008) |
Adjuvant chemotherapy | 0.003; 0.613 (0.445–0.846) | 0.012; 0.604 (0.408–0.894) | 0.130; 0.646 (0.367–1.138) |
(A) Multivariable models for total margin status p; HR (95% CI) | |||
Complete cohort | No vein resection subgroup | Vein resection subgroup | |
Pre-operative stage Resectable as reference | 0.027; 1.398 (1.039–1.883) | Not included as p > 0.200 on univariable analysis | NS |
pT pT1 as reference pT2 pT3 | 0.014 | 0.015 | Not included as p > 0.200 on univariable analysis |
0.925; 0.977 (0.598–1.595) | 0.648; 1.144 (0.642–2.038) | ||
0.040; 1.966 (1.030–3.753) | 0.019; 2.444 (1.160–5.146) | ||
pN pN0 as reference pN1 pN2 | <0.001 | <0.001 | Not included as p > 0.200 in univariable analysis |
<0.001; 2.964 (1.708–5.144) | <0.001; 3.450 (1.860–6.399) | ||
<0.001; 3.970 (2.289–6.885) | <0.001; 4.536 (2.459–8.367) | ||
Surgical margin status R0 as reference | <0.001; 1.734 (1.321–2.276) | 0.002; 1.693 (1.218–2.352) | 0.044; 1.684 (1.013–2.799) |
Vein wall invasion Negative as reference | Not included as p > 0.200 on univariable analysis | N/A | 0.016; 1.894 (1.127–3.182) |
Post-operative complications Negative as reference | 0.015; 0.703 (0.530–0.933) | Not included as p > 0.200 in univariable analysis | Not included as p > 0.200 in univariable analysis |
Adjuvant chemotherapy No chemotherapy as reference | <0.001; 2.167 (1.532–3.065) | <0.001; 2.653 (1.728–4.075) | NS |
(B) Multivariable models for individual surgical margins p; HR (95% CI) | |||
Complete cohort | No vein resection subgroup | Vein resection subgroup | |
Pre-operative stage Resectable as reference | 0.011; 1.476 (1.092–1.993) | Not included as p < 0.200 in univariable analysis | NS |
pT pT0 as reference pT1 pT2 | 0.038 | 0.038 | Not included as p > 0.200 in univariable analysis |
0.680; 0.901 (0.550–1.476) | 0.776; 1.088 (0.608–1.949) | ||
0.126; 1.672 (0.865–3.234) | 0.047; 2.145 (1.009–4.558) | ||
pN pN0 as reference pN1 pN2 | <0.001 | <0.001 | Not included as p > 0.200 in univariable analysis |
<0.001; 2.887 (1.665–5.006) | <0.001; 3.339 (1.795–6.209) | ||
<0.001; 3.898 (2.248–6.760) | <0.001; 4.371 (2.346–8.144) | ||
Posterior margin Negative as reference | 0.051; 1.585 (0.998–2.516) | Not included as p > 0.200 in univariable analysis | 0.024; 3.295 (1.173–9.254) |
SMA margin Negative as reference | 0.002; 1.688 (1.208–2.357) | <0.001; 2.197 (1.480–3.262) | Not included as p > 0.200 in univariable analysis |
BD margin Negative as reference | NS | 0.002; 3.441 (1.580–7.494) | Not included as p > 0.200 in univariable analysis |
Vein wall invasion Negative as reference | Not included as p > 0.200 in univariable analysis | N/A | 0.003; 2.169 (1.306–3.602) |
Post-operative complications Negative as reference | 0.009; 0.682 (0.513–0.907) | Not included as p > 0.200 in univariable analysis | Not included as p > 0.200 in univariable analysis |
Adjuvant chemotherapy No chemotherapy as reference | <0.001; 2.127 (1.508–3.001) | <0.001; 2.827 (1.841–4.340) | NS |
Univariable Analysis p; HR (95% CI) | |||
---|---|---|---|
Complete Cohort | No Vein Resection Subgroup | Vein Resection Subgroup | |
Age | 0.844; 1.002 (0.981–1.023) | 0.966; 1.001 (0.976–1.025) | 0.800; 1.006 (0.963–1.050) |
Sex | 0.668; 1.083 (0.751–1.562) | 0.525; 1.147 (0.751–1.752) | 0.875; 0.943 (0.453–1.963) |
Pre-operative CA19–9 | 0.243; 1.000 (1.000–1.000) | 0.322; 1.000 (1.000–1.000) | 0.705; 1.000 (1.000–1.000) |
Pre-operative stage | 0.266; 1.276 (0.831–1.958) | 0.668; 1.219 (0.492–3.021) | 0.206; 1.787 (0.726–4.399) |
Vein resection | 0.914; 1.024 (0.671–1.562) | N/A | N/A |
pT | 0.016; 1.820 (1.121–2.957) | 0.023; 1.839 (1.088–3.108) | 0.337; 1.871 (0.521–6.716) |
pN | 0.000; 1.673 (1.269–2.206) | <0.001; 1.856 (1.357–2.540) | 0.739; 1.108 (0.607–2.022) |
Surgical margin status | <0.001; 2.135 (1.464–3.115) | 0.002; 1.997 (1.294–3.083) | 0.022; 2.452 (1.140–5.273) |
Anterior surface | 0.705; 1.159 (0.540–2.492) | 0.743; 1.149 (0.501–2.636) | 0.810; 1.279 (0.171–9.557) |
Posterior surface | 0.064; 1.762 (0.968–3.207) | 0.090; 1.731 (0.918–3.261) | 0.445; 2.201 (0.290–16.702) |
PVG | 0.028; 1.538 (1.048–2.257) | 0.079; 1.540 (0.952–2.492) | 0.199; 1.659 (0.767–3.591) |
Vein transection margin | 0.978; 1.003 (0.805–1.250) | N/A | 0.603; 1.328 (0.456–3.872) |
SMA margin | 0.004; 1.997 (1.248–3.197) | 0.001; 2.432 (1.413–4.185) | 0.646; 1.255 (0.476–3.314) |
Pancreas margin | 0.203; 1.412 (0.830–2.404) | 0.305; 1.414 (0.729–2.741) | 0.529; 1.339 (0.539–3.326) |
BD margin | 0.003; 3.588 (1.561–8.248) | 0.001; 5.117 (2.028–12.913) | 0.798; 1.298 (0.176–9.605) |
Duodenal/gastric margin | 0.281; 1.571 (0.690–3.576) | 0.693; 1.224 (0.448–3.342) | 0.111; 3.277 (0.762–14.094) |
Vein wall invasion | 0.552; 1.076 (0.845–1.371) | N/A | 0.030; 2.365 (1.089–5.133) |
PNI | 0.030; 4.697 (1.160–19.030) | 0.043; 4.246 (1.043–17.292) | 0.517; 21.287 (0.002–222017.1) |
VI | 0.101; 1.769 (0.895–3.497) | 0.260; 1.560 (0.720–3.383) | 0.223; 2.454 (0.579–10.403) |
Post-operative complications | 0.173; 0.766 (0.523–1.124) | 0.259; 0.775 (0.497–1.207) | 0.356; 0.697 (0.324–1.500) |
Comprehensive complications index | 0.056; 0.986 (0.971–1.000) | 0.075; 0.984 (0.967–1.002) | 0.390; 0.988 (0.962–1.015) |
Adjuvant chemotherapy | 0.388; 1.244 (0.758–2.040) | 0.706; 0.889 (0.481–1.642) | 0.324; 1.538 (0.654–3.618) |
(A) Multivariable models for total margin status p; HR (95% CI) | |||
Complete cohort | No vein resection subgroup | Vein resection subgroup | |
pT pT1 as reference pT2 pT3 | 0.005 | 0.027 | Not included as p > 0.200 in univariable analysis |
0.993; 1.003 (0.518–1.941) | 0.719; 1.146 (0.547–2.399) | ||
0.020; 2.756 (1.174–6.473) | 0.028; 2.949 (1.121–7.755) | ||
pN pN0 as reference pN1 pN2 | 0.014 | 0.003 | Not included as p > 0.200 in univariable analysis |
0.112; 1.728 (0.880–3.391) | 0.114; 1.794 (0.8168–3.707) | ||
0.007; 2.516 (1.288–4.916) | 0.002; 3.082 (1.517–6.259) | ||
Surgical margin statusR0 as reference | <0.001; 2.041 (1.391–2.996) | 0.007; 1.845 (1.183–2.877) | 0.022; 2.452 (1.140–5.273) |
(B) Multivariable models for individual surgical margins p; HR (95% CI) | |||
Complete cohort | No vein resection subgroup | Vein resection subgroup | |
pT pT1 as reference pT2 pT3 | 0.010 | NS | Not included as p > 0.200 in univariable analysis |
0.826; 0.928 (0.476–1.809) | |||
0.045; 2.398 (1.020–5.638) | |||
pN pN0 as reference pN1 pN2 | 0.014 | 0.004 | Not included as p > 0.200 in univariable analysis |
0.133; 1.684 (0.853–3.326) | 0.134; 1.741 (0.843–3.597) | ||
0.008; 2.498 (1.269–4.917) | 0.003; 2.981 (1.466–6.060) | ||
SMA margin Negative as reference | 0.012; 1.854 (1.145–3.001) | 0.006; 2.172 (1.245–3.788) | Not included as p > 0.200 in univariable analysis |
BD margin Negative as reference | 0.005; 3.342 (1.431–7.808) | 0.001; 5.276 (2.067–13.468) | Not included as p > 0.200 in univariable analysis |
PNI Negative as reference | 0.99; 3.277 (0.799–13.441) | NS | Not included as p > 0.200 in univariable analysis |
Vein wall invasion Negative as reference | Not included as p > 0.200 in univariable analysis | N/A | 0.030; 2.365 (1.089–5.133) |
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Ahuja, M.; Pandé, R.; Chugtai, S.; Brown, R.M.; Cain, O.; Bartlett, D.C.; Dasari, B.V.M.; Marudanayagam, R.; Roberts, K.J.; Isaac, J.; et al. Vein Wall Invasion Is a More Reliable Predictor of Oncological Outcomes than Vein-Related Margins after Pancreaticoduodenectomy for Early Stages of Pancreatic Ductal Adenocarcinoma. Diagnostics 2023, 13, 3465. https://0-doi-org.brum.beds.ac.uk/10.3390/diagnostics13223465
Ahuja M, Pandé R, Chugtai S, Brown RM, Cain O, Bartlett DC, Dasari BVM, Marudanayagam R, Roberts KJ, Isaac J, et al. Vein Wall Invasion Is a More Reliable Predictor of Oncological Outcomes than Vein-Related Margins after Pancreaticoduodenectomy for Early Stages of Pancreatic Ductal Adenocarcinoma. Diagnostics. 2023; 13(22):3465. https://0-doi-org.brum.beds.ac.uk/10.3390/diagnostics13223465
Chicago/Turabian StyleAhuja, Manish, Rupaly Pandé, Shafiq Chugtai, Rachel M. Brown, Owen Cain, David C. Bartlett, Bobby V. M. Dasari, Ravi Marudanayagam, Keith J. Roberts, John Isaac, and et al. 2023. "Vein Wall Invasion Is a More Reliable Predictor of Oncological Outcomes than Vein-Related Margins after Pancreaticoduodenectomy for Early Stages of Pancreatic Ductal Adenocarcinoma" Diagnostics 13, no. 22: 3465. https://0-doi-org.brum.beds.ac.uk/10.3390/diagnostics13223465