Staging and Surgical Management
      of Pancreatic Cancer

          Justin Geoghegan
   St Vincent’s University Hospital
Walter Kausch (1867-1928)




                 Allen Oldfather Whipple (1881-1963)
Staging of Pancreas Cancer
                     CT

very good at predicting resectability

moderately good at predicting u...
Staging of Pancreas Cancer
            CT
Staging of Pancreas Cancer
Endoscopic ultrasound

diagnosis, especially of small
lesions

tumour size

staging of lymph no...
lymph node status

? selection for neo-adjuvant
treatment
Staging of Pancreas Cancer
  Laparoscopy and lap ultrasound
small volume peritoneal disease

metastatic liver disease

per...
Staging of Pancreas Cancer
     Laparoscopy and lap ultrasound
“always use it”
      changes management in 10-15%

     ?s...
Laparoscopy and peritoneal cytology

Author   Journal                    patient number   effect of positive cytology

Lea...
Staging of Pancreas Cancer
      Laparoscopy and lap ultrasound
“selective”
      larger tumours
      equivocal findings ...
Staging of Pancreas Cancer
      Laparoscopy and lap ultrasound
when to do it?
  separate anaesthetic or immediately prior...
When is biopsy required?
unresectable

imaging raises possibility of an alternative tissue type
  that may be amenable to ...
Unresectability
co-morbidity

distant metastases – liver, peritoneal

encasement of coeliac, hepatic or sup mesenteric art...
Pancreatic resection
balance between mortality/morbidity and benefit

mortality rate <5%

major complication rate 40%

hig...
Birkmeyer,2003
Technical Issues
neoadjuvant treatment

extended lymphadenectomy

portal vein resection

pylorus-preserving

pancreatic re...
Extended resections
total
pancreatectomy

extended
lympadenectomy

portal vein and
SMA resection




                     ...
Extended lymphadenectomy




               Michalski et al Br J Surg 2007
Extended lymphadenectomy




               Michalski et al Br J Surg 2007
Portal vein resection

does it affect survival?

does it affect morbidity and mortality?

does it have a role?
Koniaris, J Am Coll Surg 2003
Portal vein resection

portal vein resection does not affect survival

probably no effect on morbidity

portal vein invasi...
Pylorus preserving
pancreatectomy
Randomized trials of pylorus-
preserving vs classical Whipple
Pancreatic reconstruction

end-to end
pancreaticojejunostomy

end-to-side
pancreaticojejunostomy

pancreaticogastrostomy
Drains,Stents and Octreotide

drains – no benefit
                                Conlon, Ann Surg 2001



stents – no dif...
Quality of life after pancreatic
           resection




                     Schniewind et al
                     2006
Outcome of Whipple’s procedure depends on tumour type




       Schmidt, C. M. et al. Arch Surg 2004;139:718-727.
How to improve surgery?


earlier detection

screening

better staging

high-volume centres

neoadjuvant and adjuvant trea...
Staging and Surgical Management of Pancreatiic Cancer
Staging and Surgical Management of Pancreatiic Cancer
Staging and Surgical Management of Pancreatiic Cancer
Staging and Surgical Management of Pancreatiic Cancer
Staging and Surgical Management of Pancreatiic Cancer
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Staging and Surgical Management of Pancreatiic Cancer

  1. 1. Staging and Surgical Management of Pancreatic Cancer Justin Geoghegan St Vincent’s University Hospital
  2. 2. Walter Kausch (1867-1928) Allen Oldfather Whipple (1881-1963)
  3. 3. Staging of Pancreas Cancer CT very good at predicting resectability moderately good at predicting unresectability cannot distinguish between reactive and malignant lymphadenopathy
  4. 4. Staging of Pancreas Cancer CT
  5. 5. Staging of Pancreas Cancer Endoscopic ultrasound diagnosis, especially of small lesions tumour size staging of lymph node status and assessment of vascular involvement biopsy
  6. 6. lymph node status ? selection for neo-adjuvant treatment
  7. 7. Staging of Pancreas Cancer Laparoscopy and lap ultrasound small volume peritoneal disease metastatic liver disease peritoneal cytology as CT improves, the pick-up rate from laparoscopy decreases selective vs invariable use
  8. 8. Staging of Pancreas Cancer Laparoscopy and lap ultrasound “always use it” changes management in 10-15% ?separate anaesthetic/procedure or immediately prior to laparotomy separate procedure needed if peritoneal cytology is considered important
  9. 9. Laparoscopy and peritoneal cytology Author Journal patient number effect of positive cytology Leach Surgery 1995 80 indicates advanced disease Merchant J Am Coll Surg 1999 228 assoc with advanced disease predicts unresectability Makary Arch Surg 1999 32 contraindicates resection Nakatsuka Internat J Surg Inves 1999 50 contraindicates resection Nakao Hepatogastroenterolgy 1999 74 no effect on survival Yachida Br J Surg 2002 134 doesn’t predict carcinomatosis doesn’t contraindicate resection Meszoely Am Surg 2004 168 should not preclude resection Ferrone J Gastrointest Surg 2006 462 same outcome as patients with stage IV disease Yamada Ann Surg 2007 233 no effect on survival
  10. 10. Staging of Pancreas Cancer Laparoscopy and lap ultrasound “selective” larger tumours equivocal findings on CT – ascites weight loss grossly elevated tumour markers changes management in 25%
  11. 11. Staging of Pancreas Cancer Laparoscopy and lap ultrasound when to do it? separate anaesthetic or immediately prior to laparotomy for resection decision needs to be individualised depending on - likelihood of positive finding - presence of jaundice - logistical factors
  12. 12. When is biopsy required? unresectable imaging raises possibility of an alternative tissue type that may be amenable to different treatment strategy patient request reasonable possibility of chronic pancreatitis mimicking cancer
  13. 13. Unresectability co-morbidity distant metastases – liver, peritoneal encasement of coeliac, hepatic or sup mesenteric arteries major encasement of portal vein-superior mesenteric vein lymph node status surgeon-dependent
  14. 14. Pancreatic resection balance between mortality/morbidity and benefit mortality rate <5% major complication rate 40% high rate of positive margins
  15. 15. Birkmeyer,2003
  16. 16. Technical Issues neoadjuvant treatment extended lymphadenectomy portal vein resection pylorus-preserving pancreatic reconstruction drains octreotide
  17. 17. Extended resections total pancreatectomy extended lympadenectomy portal vein and SMA resection Fortner, Cancer 1981
  18. 18. Extended lymphadenectomy Michalski et al Br J Surg 2007
  19. 19. Extended lymphadenectomy Michalski et al Br J Surg 2007
  20. 20. Portal vein resection does it affect survival? does it affect morbidity and mortality? does it have a role?
  21. 21. Koniaris, J Am Coll Surg 2003
  22. 22. Portal vein resection portal vein resection does not affect survival probably no effect on morbidity portal vein invasion is a function of tumour location rather than tumour biology
  23. 23. Pylorus preserving pancreatectomy
  24. 24. Randomized trials of pylorus- preserving vs classical Whipple
  25. 25. Pancreatic reconstruction end-to end pancreaticojejunostomy end-to-side pancreaticojejunostomy pancreaticogastrostomy
  26. 26. Drains,Stents and Octreotide drains – no benefit Conlon, Ann Surg 2001 stents – no difference Winter, J Gastrointest Surg 2006 octreotide – may be of value for high-risk pancreatic anastomosis Connor,Br J Surg 2005
  27. 27. Quality of life after pancreatic resection Schniewind et al 2006
  28. 28. Outcome of Whipple’s procedure depends on tumour type Schmidt, C. M. et al. Arch Surg 2004;139:718-727.
  29. 29. How to improve surgery? earlier detection screening better staging high-volume centres neoadjuvant and adjuvant treatment

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