pancreatic cancer: surgical resection
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pancreatic cancer: surgical resection

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What would you recommend as first line therapy for a 68 y/o woman with local pancreatic cancer and no metastatic disease with ECOG-1? ...

What would you recommend as first line therapy for a 68 y/o woman with local pancreatic cancer and no metastatic disease with ECOG-1?
Chemoradiation: Rachna Shroff, MD
Surgical Resection: Yongyut Sirivatanauksorn, MD

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pancreatic cancer: surgical resection pancreatic cancer: surgical resection Presentation Transcript

  • Pancreatic Cancer • High incidence of regionally advanced and metastatic disease • Only 10-15% patients have resectable disease Head 60% Body/Tail 40%   20% resectable <5% resectable   20% 5-yr survival <15% 5-yr survival   <3% alive at 5 years
  • a 68 y/o woman with local pancreatic cancer and no metastatic disease with ECOG-1?
  • Resectable Pancreatic Cancer Only 10–20% are candidates for attempted curative resection  no distant metastases  no radiographic evidence of portal vein or superior mesenteric vein involvement.  clear fat planes around the superior mesenteric artery, hepatic artery, and celiac axis.
  • Borderline Resectable Pancreatic Cancer  no distant metastases  tumor abutment of the SMA does not exceed 180 degrees of the vessel wall circumference  any venous involvement of the SMV or portal vein allows for safe resection and reconstruction  gastroduodenal artery (GDA) encasement up to the hepatic artery with either direct abutment or short segment encasement of the hepatic artery without extension to the celiac axis
  • Borderline Resectable Pancreatic Cancer any venous involvement of the SMV or portal vein allows for safe resection and reconstruction
  • Borderline Resectable Pancreatic Cancer any venous involvement of the SMV or portal vein allows for safe resection and reconstruction
  • Unresectable Locally Advanced Pancreatic Cancer  unreconstructible encasement of the SMV/PV  any celiac involvement  encasement (≥180°) of the SMA  aortic involvement
  • Fewer Than 1/3 Of Resectable Patients Receive Surgery
  • Results following Pancreaticoduodenectomy Due to improved surgical skill and perioperative care  Mortality rate 20%-40% in earlier days  During the past decades, dramatically decreased and currently is between 0-4% in experience centers with experience.
  • Pancreatic Surgery Is Safe 1423 Pancreaticoduodenectomies for Pancreatic Cancer N Mortality Morbidity Overall 1175 2% 38% 1970’s 23 30% - 1980’s 65 5% 30% 1990’s 514 2% 31% 2000’s 573 1% 45% Winter JM, et al. J Gastrointest Surg 2006, 10:1199-1210
  • Complications of Pancreaticoduodenectomy Complication rate is still 30%-40% Delayed gastric emptying Pancreatic fistula Intra-abdominal abscess Hemorrhage Wound infection Metabolic (Diabetes, Pancreatic exocrine insufficiency)
  • One‐year postoperative survival for pancreatic‐cancer related pancreatectomy 1980s: 58% 1990s: 68% (P=0.02 vs. 1980s) 2000s: 68% (P=0.02 vs. 1980s). Winter et al., Annals of Surgical Oncology 2012
  • Pancreatic Surgery Is Safe At High-Volume Hospitals NEJM 2002;346(15):1128-37
  • Long-Term Survival Better At High-Volume Hospitals 1 0.5 0 0 500 1000 1500 2000 Days Survival High Volume Hospital Low Volume Hospital P=0.001 Fong, Ann Surg 2005; 242:540-7
  • Long-Term Survival Remains Poor Author Year N Median survival 5 year survival 10 year survival Predictors Ahmad 2001 116 16 mo 19% - Adj tx Cleary 2004 123 14 mo 15% 4% Stage, grade Winter 2006 1175 18 mo 18% 11% Size, LN, margin, grade Han 2006 123 15 mo 12% - Stage, margin Ferrone 2008 618 - 12% 5% Stage, Margin
  • Long‐term postoperative survival for pancreatic‐cancer related pancreatectomy among patients surviving to one year. 1980s, median=23.2 mths 1990s, median=25.6 mths 2000s, median=24.5 mths (P‐values compare the specified decade to the 1980s) Winter et al., Annals of Surgical Oncology 2012
  • Pre-Operative Therapy Selects Patients Better than Upfront Surgery ● Avoids surgery in patients with rapidly progressive disease (unfavorable tumor biology). ● Avoids surgery in patients unable to tolerate the stress of pre-operative therapy (those revealed to be unfit).
  • Paradigm Shift?  Neoadjuvant therapy for all patients  Potential benefits:  Avoid surgery in patients with widely micrometastatic disease  Down-size tumor to avoid vein resection  Examination of tumor biology  Opposition:  Resectable patients progress to unresectable  Complications of chemo prevent/delay surgery, increase complications
  • Pancreatic Cancer in 2014 • Surgery can be done safely • Venous resection acceptable for R0 resection. • Selection the ‘real’ candidate surgical patient. • Need better systemic therapy to impact long-term survival.
  • Faculty of Medicine Siriraj Hospital