1) Advances in the management of pancreatic cancers including improved preoperative assessment using CT, MRI, EUS and PET scans to determine resectability. 2) Surgical approaches to resectable pancreatic cancer including pylorus-preserving versus standard Whipple procedure and debates around extent of lymphadenectomy. 3) Outcomes have modestly improved with resection rates around 20%, operative mortality of 9% and 5 year survival of 12%, though pancreatic cancer prognosis remains poor.

1. ADVANCES IN THE MANAGEMENT OF
PANCREATIC CANCERS
by
Echebiri, Promise
Department of Surgery, National Hospital, Abuja
On 24th July, 2017
Supervisor: Dr Gwaram, U.

2. OUTLINE
Introduction
Risk factors
Preoperative assessment
Approach to resectable Pancreatic cancer
Complications of Pancreatic resection
Outcomes post resection
Palliation of advanced Pancreatic cancer
Future direction
Local experience
Conclusion
References

3. INTRODUCTION
Definition: Malignant neoplasms of the Pancreas.
Primary and Secondary origin
Parenchymal( Carcinomas) and Stromal (Sarcomas)
Exocrine (90% ductal adenocarcinomas) and Endocrine(physician)
tumours.
Epidemiology: About 44,000 new cases per year in the US, accounting for
3% of all new cancer diagnoses. However, ranks as fourth leading cause
of cancer-related deaths

4. RISK FACTORS
Male gender, Advancing age, African
American ethnicity, Cigarette smoking,
Family history of pancreatic cancer,
Western diet, Diabetes
Metformin

5. PREOPERATIVE ASSESSMENT
Exclusion of distant disease
Determination of resectability

6. PREOPERATIVE ASSESSMENT
ANGIOGRAPHY
• Diminishing role – superceded by helical Computerised tomography
• Venous phase of the arteriogram was used to exclude invasion of superior
mesenteric and portal veins

7. PREOPERATIVE ASSESSMENT

8. PREOPERATIVE ASSESSMENT

9. PREOPERATIVE ASSESSMENT
COMPUTERISED TOMOGRAPHY (CT)
• Standard in imaging of Pancreatic cancers
• Pancreatic protocol achieves high accuracy
• Helical CT preferred to conventional CT
• May miss subcentimetre hepatic deposits (<10mm) and peritoneal lesions
• Limited ability to differentiate benign from malignant lesions

10. PREOPERATIVE ASSESSMENT

11. PREOPERATIVE ASSESSMENT
MAGNETIC RESONANCE IMAGING (MRI/MRCP)
• Comparable to CT in assessing resectability
• Can differentiate inflammatory from malignant lesions – adenocarcinomas
are usually low signal intensity on T1 and T2
• Further improved by deployment of magnetic resonance endoscopy

12. PREOPERATIVE ASSESSMENT

13. PREOPERATIVE ASSESSMENT
LAPAROSCOPY AND LAPAROSCOPIC ULTRASOUND
• Better at detecting subcentimetre hepatic and peritoneal deposits and
lymph node involvement
• Laparoscopic ultrasound and peritoneal lavage cytology extends
diagnostic capability
• Limitations include retroperitoneal location of Pancreas and risk of port
site metastasis

14. PREOPERATIVE ASSESSMENT

15. PREOPERATIVE ASSESSMENT
ENDOSCOPIC ULTRASOUND (EUS)
• Superior to Conventional CT in assessing for vascular infiltration
• Combination with fine needle aspiration cytology improves diagnostic
yield to almost 80%
• Highly user-dependent
• Low sensitivity for nodal reactivity and micrometastases limits usefulness
in studying nodal involvement

16. PREOPERATIVE ASSESSMENT

17. PREOPERATIVE ASSESSMENT

18. PREOPERATIVE ASSESSMENT
POSITRON EMISSION TOMOGRAPHY
• Preferentially delineates malignant cells due to uptake of radiolabeled
fluorodeoxyglucose (FDG)
• Improves ability of conventional CT and EUS to detect hepatic deposits
and peritoneal lesions

19. PREOPERATIVE ASSESSMENT

20. PREOPERATIVE ASSESSMENT

21. SURGICAL APPROACH TO RESECTABLE CANCER
Determination of resectability:
• Resectable(I-IIA): Tumors localized, no distant metastasis, radiographic
evidence of clear fat planes around the major peri-pancreatic vessels
• Borderline resectable (IIB): no distant metastasis, venous involvement of
SMV or PV with suitable vessel proximal and distal allowing for safe
resection and replacement, limited Gastroduodenal or hepatic artery
encasement
• Unresectable(III-IV): distant metastasis, extensive vascular involvement

22. SURGICAL APPROACH TO RESECTABLE CANCER


23. SURGICAL APPROACH TO RESECTABLE CANCER
PREOPERATIVE BILIARY DRAINAGE
• Endoscopic or transhepatic route
• Controversial relationship with postoperative infective complications
• Beneficial when resection is delayed and in palliation of jaundice

24. SURGICAL APPROACH TO RESECTABLE CANCER

25. SURGICAL APPROACH TO RESECTABLE CANCER

26. SURGICAL APPROACH TO RESECTABLE CANCER
VASCULAR RESECTION
• Vessel involvement is a strong negative predictor of outcome
• Currently advocated when tumours appear macroscopically clear due to
findings of high rate of vascular involvement
• Diarrhoeal complications from extensive neurectomy

27. SURGICAL APPROACH TO RESECTABLE CANCER
PYLORUS-PRESERVING VERSUS STANDARD WHIPPLE
• Retains benefits of minimal stress ulceration and adequate oncological
clearance except in dorsal tumours aborting duodenum
• Disadvantage of higher incidence of delayed gastric emptying

28. SURGICAL APPROACH TO RESECTABLE CANCER

29. SURGICAL APPROACH TO RESECTABLE CANCER

30. SURGICAL APPROACH TO RESECTABLE CANCER

31. SURGICAL APPROACH TO RESECTABLE CANCER
EXTENT OF LYMPHADENECTOMY
• Node positivity is a strong negative predictor for survival; 5 year survival <
5 %
• Controversial as some studies showed survival benefit for extended
lymphadenectomy in node negative and positive patients with comparable
morbidity and mortality to standard nodal dissection
• Adjuvant therapy in addition to standard lymphadenectomy is now chosen
to improve survival

32. SURGICAL APPROACH TO RESECTABLE CANCER

33. COMPLICATIONS OF PANCREATIC RESECTION
Significant improvement in mortality demonstrated in high-volume
specialist pancreatic centres. However, high incidence of morbidity at 30-
40%
Complications that are common include: haemorrhage, delayed gastric
emptying, leakage of pancreatic anastomosis, abdominal abscess and
pancreatic fistulae.

34. COMPLICATIONS OF PANCREATIC RESECTION
Measures that were adopted involved stenting the pancreatic duct,
creation of separate roux loops for high risk cases.
Trend is for resection by experienced pancreatic specialist surgeons,
interventional imaging-guided drainage and inhibition of pancreatic
exocrine secretions using somatostatin analogues

35. SURVIVAL POST RESECTION
Resection rates for pancreatic cancers are approximately 20%, operative
mortality of 9% and 5 year survival rate of 12%
Extended resections increase resectability rates but do not improve
survival
Independent predictors of outcome are tumour aneuploidy, size, nodal
and resection margin status

36. SURVIVAL POST RESECTION
Adjuvant chemoradiotherapy after apparently curative resection for
survival advantage
Employment of neoadjuvant therapy to downstage locally invasive but
regional tumours followed by resection – better survival for patients
 Immunohistochemistry, commonly used for tumor markers like EGFR, to
guide treatment using targeted therapy agents including erlotinib,
sunnitinib

37. SURGICAL PALLIATION OF ADVANCED CANCER
Three key areas of intersest: Jaundice, duodenal obstruction and pain
Palliation of jaundice preferabbly via endoscopic drainage with metal
stents
Operative drainage is reserved for patients found to be inoperable at
surgery as well as failed stenting by via endoscpic and percutaneous
routes

38. SURGICAL PALLIATION OF ADVANCED CANCER
Choledochojejunostomy has superceded cholecystojejunostomy for
operative drainage as a result of longer patency rates
Gastric bypass now is reserved for patients with definite obstruction or
evidence of impending one due to associated morbidity of delayed gastric
emptying
Endoscopically-placed duodenal stents are in use for gastric bypass

39. SURGICAL PALLIATION OF ADVANCED CANCER
Coeliac plexus blockade has been used for pain palliation
Significant success has recently become possible with thoracoscopic
division of splanchnic nerves especially on the left. The approach may be
unilateral or bilateral

40. SURGICAL PALLIATION OF ADVANCED CANCER

41. SURGICAL PALLIATION OF ADVANCED CANCER

42. RESEARCH DIRECTIONS
Minimal access surgery for curative resection in order to improve recovery
time
Irreversible electroporation used in the NanoKnife system for precise
ablation of tumours in proximity to pancreatic vessels
Gemcitabine + Gastrin vaccine (G17 DT)

43. RESEARCH DIRECTIONS
Immunogenic telomerase peptides (TeloVac)
Lethally irradiated allogeneic pancreatic tumour cells transfected with GM-
CSF gene
Listeria carrying mesothelin peptide

44. LOCAL EXPERIENCE
12 patients with pancreatic cancer managed operatively in National
hospital over last 12 years
7 patients had bowel bypass procedures comprising double and triple
bypasses
5 patients had open biopsy

45. CONCLUSION
The management of pancreatic cancer continues to be difficult with poor
outcomes being common.
Small but remarkable recent improvements in survival of the disease.
Meanwhile, patients with pancreatic cancers should be managed by
multidisciplinary teams in specialist centres, if morbidity and mortality
associated with the management of this disease are to be minimized.

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