This document provides details of a case of a 45-year-old male diagnosed with locally advanced distal pancreatic cancer who underwent neoadjuvant chemotherapy and radiation followed by radical antegrade modular pancreatosplenectomy (RAMPS). The summary discusses the patient's history, diagnostic workup, treatment course, surgical approach including RAMPS technique, histopathology results, and conclusions about RAMPS being a good approach for distal pancreatic tumors with benefits like better lymph node yield and margin negative resection rates compared to other approaches.

1. Locally advanced Distal Pancreatic Cancer
Dr. Kishore Abuji
Junior resident
PGIMER, Chandigarh.

2. Contents
• Case details
• Surgical details
• Discussion
• Surgical approach (RAMPS)
• Conclusion

3. DETAILS
Name - PM
Age - 45 Y/M
CR no - 20190XXXXXX
Adm no - 2019XXXX
DOA - 22/12/2019
DOSx - 31/12/2019
DOD - 08/01/2020
Diagnosis - Moderately differentiated adenocarcinoma of Distal pancreas Locally advanced S/P NACRT

4. HISTORY
o C/o Pain in abdomen x 3 month
o Epigastric region, dull aching ,insidious onset non radiating and non
progressive
o H/o loss of weight present
o No h/o Loss of appetite
o No h/o vomiting, jaundice, early satiety
o No h/o UGI/LGI bleed
o No h/o constipation/obstipation/abdominal distension

5. • Past History:
• K/C/O hypothyroidism on thyroxin 75mcg
• H/o lap cholecystectomy for symptomatic gall stone disease(7 year back)
• Personal History:
• Reformed smoker (20years 4-5 cigarette/day)
• Reformed alcoholic( had alcohol for 20 yr. 120-150ml/day)

6. EXAMINATION
• GPE:
• conscious and oriented
• Pallor absent, No icterus,
• Vitals :
• Pulse 80/min
• BP : 130/80 mmHg
• RR: 14/min
• BMI: 30.4
• ECOG 0
• P/A :
• soft ,no tenderness and no distension
• no lump palpable and no organomegaly
• scar marks of previous lap cholecystectomy +
• P/R : Normal
• CVS/RS - Normal

7. INVESTIGATIONS
Investigations Results
Hemogram 13.3/7100/163k
Coagulogram 13.6/0.91/100/27.3
SERFT 134/4.8/14/0.47
AST/ALT/ALP 29/20/95
CA 19 9 (pre-NACRT) 6340
CA 19 9 (Post-NACRT) 504
Hormonal workup (TFT, LH/FSH, Cortisol) Within normal limits

8. USG - Abdomen
• Hepatomegaly with grade 2 fatty liver
• Heterogeneous and bulky pancreatic body and tail

9. CECT ABDOMEN pre NACRT
opoorly enhancing lesion 51x32x30 mm - body of pancreas-
central hypo density/necrosis
oLoss of fat planes - proximal splenic artery
oSplenic vein distal to mass - thrombosed
oMPD mildly dilated 5 mm

10. oSoft tissue nodule 11x12mm – right adrenal gland
opancreatic mass with malignant adrenal nodule ?Metastasis
oFNAC from nodule s/o cellular and mesothelial cells - Benign
adrenal cells

11. Endoscopic Ultrasound
• Ill defined heterogeneous lesion present in body 28x 39 mm
• Fat planes loss - SMA
• Involving splenic artery

12. FNAC
Moderately differentiated adenocarcinoma

13. PET SCAN- PRE NACRT
oFDG avid soft tissue mass in body of pancreas (SUV max 13.5),
measuring 3.4 x5.1x3.3cm
oEncasing splenic vessels, with dilated MPD (7.8mm)
oMildly FDG avid subcentrimetric nodule noted in B/L adrenal
glands 1x0.9cm on right side

14. • Treatment History:
• Received NACRT: 3 gm capecitabine/day x 5 cycles
• Received: 45 Gy /25 fraction of EBRT for 5 weeks
completed on 28/11/2019

15. PET SCAN – POST NACRT
oFDG avid soft tissue mass noted in body of pancreas (SUV max
6.7), measuring 4.9x3.2x3.3cm
oLesion encasing splenic vessels, with mild dilated MPD distal
to it
oMildly FDG avid subcentrimetric nodule noted in B/L adrenal
glands, 1.1x0.9cm on right side (SUV max 2.2).

16. RESPONSE EVALUATION
• Stable disease (according to RECIST v 1.1)

17. RADICAL ANTEGRADE
MODULAR
PANCREATOSPLENECTOMY

18. INTRAOPERATIVE FINDINGS
Staging laparoscopy:
• No evidence of metastasis
On laparotomy:
• Omentum was densely adhered to GB fossa
• Hard mass of 4x5 cm in body of pancreas
• Multiple enlarged lymph LN - along CA, CHA and splenic
hilum
• Tumor densely adhered to celiac origin due to ?desmoplasia
?post radiotherapy changes
• Tumor separated from celiac axis

19. oReplaced left hepatic artery, arising from left gastric artery
oCommon hepatic artery and left gastric artery free
oRight gastric artery, short gastric artery and right gastroepiploic
vein, left gastric vein divided, IMV ligated at ligament of Treitz
oSMV and portal vein were free of tumor

21. oPancreas transacted at neck
oPancreatic duct closed with prolene 5-0
oPancreatic stump closed with 3-0 prolene interrupted
oSplenic artery at origin - ligated
oSplenic vein was ligated at splenoportal junction
oPlane of dissection was anterior to left adrenal and Gerota’s
fascia

22. .
SMA

24. Post operative course
 POD1: vitals stable, drain output 10ml, drain fluid
amylase 335
 POD2: Drain output 100 ml
 POD3: vitals stable, allowed orally tolerating, Drain
output 100 ,amylase 54
 POD5: drain o/p 100 ml , Amylase 8
 POD7: drain o/p 30ml, amylase 13
 POD 8: drain removed, discharged in stable condition

25. HISTOPATHOLOGICAL EXAMINATION
• Distal pancreatectomy
• Pancreas – Adenocarcinoma, moderately
differentiated
• Lymph nodes – free of tumor
•Celiac – 0/1
•Para-aortic – 0/4
•Common Hepatic Artery – 0/1
•Celiac Axis – 0/3

26. DISCUSSION
RADICAL ANTEGRADE MODULAR PANCREATO
SPLENECTOMY
(RAMPS)

27. Distal Pancreatic carcinoma (Body and Tail)
• One third of pancreatic neoplasm
• Locally advanced tumor at presentation
• 5-7% resectable
• Poor prognosis
• Absence of obstructive symptoms
• Late diagnosis
Barreto SG, Shukla PJ, Shrikhande SV. Tumors of Pancreatic Body and Tail. World J Oncol.
2010:1:52-65.

28. Symptoms
• Pain(90%)
• Weight Loss(54%)
• Nausea And Vomiting(16%)
• Recent Onset DM
• Anorexia
Barreto SG, Shukla PJ, Shrikhande SV. Tumors of Pancreatic Body and Tail. World J
Oncol. 2010:1:52-65.

29. Evaluation
• CECT abdomen with pancreatic protocol
• EUS with FNAC
• Tumor markers
• Blood workup

30. Borderline resectable:
1. Contact with celiac axis <180
2. Involvement of CA >180 but without involvement of aorta
and uninvolved GDA
3. Contact with <180 IVC
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology.
Pancreatic Adenocarcinoma Version 1.2020. 2019 Nov 26;National Comprehensive Cancer Network.
Available at https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf

31. Unresectability Criteria
1) Contact >180 with SMA or celiac axis
2) Contact with celiac axis and aortic involvement
3) Unreconstructable SMV & portal vein
4) Mets to lymph node beyond the field of resection
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Pancreatic Adenocarcinoma Version 1.2020. 2019 Nov 26;National
Comprehensive Cancer Network. Available at https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf

33. NACRT
• Locally advance tumors and borderline resectable tumors
• Advantages
o Downstage the disease
o Increase R0 resection rate
o Overall survival rate
o Disease free survival rate

34. Neoadjuvant regimens available are :
o Folfirinox ± subsequent chemo radiation
o Gemcitabine+paciltaxel ± subsequent chemo radiation
o Gemcitabine + cisplatin f/b chemo radiotherapy
o Oral capecitabine with coinciding radiotherapy
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in
Oncology. Pancreatic Adenocarcinoma Version 1.2020. 2019 Nov 26;National Comprehensive
Cancer Network. Available at
https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf

35. Hideyuki yoshitomi et al, feasibility and safety of distal pancreatectomy with en bloc DP-CAR combined with NAT for
borderline resectable and unresectable cancer; 2018
Group Cases included R0 resection Median survival
Neoadjuvant 31 23 39.5 months
Up front surgery 7 1 15.6 months

36. • FOLFIRINOX – 92% R0 resection (Ferrone et al; 2005)
• Gemcitabine f/b RT vs Gemcitabine and Cisplatin- 74% vs
58% R0 resection (Evans et al; 2008)
• Gemcitabine with wide irradiation area – 100% R0 resection
and acceptable prognosis (H. Kamachi et al; 2018)

37. SURGICAL APPROACH
• Retrograde distal pancreatectomy
• Radical antegrade modular pancreatosplenectomy (RAMPS)
• Anterior RAMPS
• Posterior RAMPS
• Modified Appleby Procedure

38. Lymphatic Drainage of Body & Tail of Pancreas
• First group of LN
A) superior and inferior left of the body - splenic and
gastrosplenic LN
B) superior and inferior right of the body - gastroduodenal
and infra pancreatic LN
• Second group in relation to celiac and SMA
• Both are considered to be N1 only
O’Morchoe CC.Lymphatic system of the pancreas. Microsc Res Tech. 1997;7:456–477

40. • Disadvantage of Retrograde distal pancreatectomy
o Poor visibility of retroperitoneum
o Positive tangential margin rates are high
o N1 lymph nodes are left behind low node resection rates
common

41. Radical antegrade modular pancreatosplenectomy
o Described in 2003 by Strasberg
o Dissection: right  left
o Early vascular control (splenic vessel)
o Early division of neck of pancreas
o Visibility is good
o Posterior margin anterior to renal fascia
o Anterior RAMPS: anterior to adrenal
o Posterior RAMPS: posterior to adrenal
Strasberg SM, Drebin JA, Linehan D.Radical antegrade modular pancreatosplenectomy. Surgery. 2003;133:521–527

42. Procedure
• Staging laparoscopy
• left subcostal or midline
• Division of neck of pancreas
• Dissection of celiac lymph node
• Posterior extent of dissection
anterior RAMPS
posterior RAMPS

44. Advantage over retrograde approach
oNegative tangential margins in 89%
oMean number of lymph node removed 18
oNegative margins achieved in 81%
o5 years overall survival was 26%
Strasberg SM, Fields R. Left-sided pancreatic cancer: distal pancreatectomy and its variants: radical
antegrade modular pancreatosplenectomy and distal pancreatectomy with celiac axis resection. Cancer J.
2012;18(6):562–70

45. Pathological examination shows statistically significant differences between
RAMPS and DP in the Ro resection rate
LN extraction
Overall 5 years survival rate (35% vs 26%)
Zhou Q, Gao F, Gong J, Xie Q, Wang Q, Lei Z. Assessement of postoperative long-term
survival quality and complications associated with radical antegrade modular
pancreatosplenectomy and distal pancreatectomy: a meta-analysis and systematic
review. BMC Surg. 2019;19:12

46. • In a study done in 2016 on 78 patient:
• Negative tangential margins were 94 %
• R0 resection rate was 85%
• Lymph node count was 20
• Median survival was 24.6%
• 5 year survival was 25.1%
Grossman JG, Field RC, Hawkins WG, Strassberg SM. Single institution results of radical antegrade
modular pancreatosplenectomy for adenocarcinoma of the body and tail of pancreas in 78 patients. J
Hepatobiliary Pancreat Sci. 2016;23:432-41.

47. Modified Appleby procedure
• Surgery involves resection of celiac axis & complete celiac lymph node
clearance
• 1st performed by Lyon applebay for gastric adenocarcinoma
• Liver maintained arterial blood supply with retrograde flow from GDA
• Results:
• 91% patient had R0 resection
• median survival 21 months
• 5-year survival was 42%
Hirano S, Kondo S, Hara T, et al. Distal pancreatectomy with en bloc celiac axis resection for
advanced pancreatic body cancer: long term results. Ann Surg. 2007;246:46-51.

49. Compare DP with DP and celiac axis resection.
Compare CA/CHA (-) and CA/CHA (+).
Hirano S, Kondo S, Hara T, et al. Distal pancreatectomy with en bloc celiac axis resection for advanced
pancreatic body cancer: long term results. Ann Surg. 2007;246:46-51.
Surgery 1year 3years Median survival
DP only 61.3% 36.7% 19.2months
DP with celiac axis
resection
31.3% 12.5% 8.7months
Surgery 1year 3year Median survival
CA/CHA (-) 71.4% 28.6% 14.3months
CA/CHA (+) 0% 0% 8.2months

50. Recurrence and surveillance
• Follow up every 3-6 months for 2 years
• Every 6-12 months for as clinically indicated

51. CONCLUSION
• RAMPS – Good approach for distal pancreatic tumors
• Better LN yield
• More R0 resection
• Early vascular control
• NAT – R0 resection improved
• NAT improve overall survival compare to up front surgery
group

52. THANK YOU