1. ΚΑΡΚΙΝΟΣ ΤΟΥ ΠΑΓΚΡΕΑΤΟΣ
ΧΕΙΡΟΥΡΓΙΚΗ ΑΝΤΙΜΕΤΩΠΙΣΗ
ΔΗΜΗΤΡΗΣ Π. ΚΟΡΚΟΛΗΣ
ΧΕΙΡΟΥΡΓΟΣ
ΔΙΔΑΚΤΩΡ ΠΑΝΕΠΙΣΤΗΜΙΟΥ ΑΘΗΝΩΝ
Α.Ο.Ν.Α. «Ο ΑΓΙΟΣ ΣΑΒΒΑΣ»

2. No disclosures

14. Stage-specific survival
Months From Dx
All patients 9.3
Stage I, II 15.4
resected 24.1
not resected 10.3
Stage III 9.9
borderline 17.6
Stage IV 6.1
MDACC: Pancreatic Cancer Program Database 1991-2007, N = 4,395
Katz MHG, Hwang RF, et al. TNM staging of pancreatic adenocarcinoma.
CA Cancer J Clin. 2008;58(2):111-25.

23. Imaging Template for Pancreatic Cancer
• Tumor size and location
• Tumor and veins relationship – SMV, portal vein
and splenic vein
• Tumor and arteries relationship – SMA, celiac
axis, common hepatic artery
• Presence or absence of distant metastases – liver,
lung, peritoneum
• CT scan: “Pancreatic Protocol”

24. Portal vein & SMV anatomy
PV
Splenic Vein
SMV
Ileal branch
of SMV Jejunal branch of SMV
IMV may enter spl vein or SMV
SMA
Vena
cava

26. Resectable defined
• Resectable: No extension into the celiac, CHA,
SMA stage I or II (cT1-3 +/- possible
lymphadenopathy)
• Borderline: The stuff in the middle
• Locally advanced means unresectable:
Involvement of the celiac, SMA encasement of
>180°, stage III (cT4), aortic or caval
involvement.

27. Kitts 527268
Resectable tumor, RRHA
SMV
SMA
T
Resectable adenocarcinoma of the pancreatic head

28. Resectable : Likely to require venous resection
SMV
SMA
T
Cava

29. SMA
Borderline Resectable
Varadhachary GR, et al. Ann Surg Oncol. 2006;13(8):1035-46
Katz MHG, et al. J Am Coll Surg. 2008;206(5):833-46
SMV

30. Locally Advanced (Stage III)
SMV
SMA

31. ? Complete Resection
R Status
R Designation Gross Resection Microscopic Margin
R0 complete negative
R1 complete positive
R2 incomplete positive
Exocrine Pancreas. In Greene FL, Page DL, Fleming ID, et al., eds.
AJCC Cancer Staging Manual. Chicago, IL: Springer, 2002. pp. 157-164.

35. Intraoperative Assessment of Resectability
Not clinically informative.

36. Intraoperative Assessment of Resectability
• Inaccurate
• Incomplete gross
resection provides no
survival benefit compared
to chemoradiation without
surgery

41. SMA
(Retroperitoneal/uncinate)
Margin

46. Retroperitoneal
Margin

47. RP margin
SMV
SMA
SMA (Retroperitoneal) Margin
AJCC Cancer Staging Manual 7th
Edition

50. Survival Curves
Resection Margins Lymph Nodes
Tumor Size Grade

51. Pancreatic Cancer
• 2,216 patients with panc adenocarcinoma
1990-2002
• 337 (15%) surgical resection (panc head/whipple)
4 periop deaths (1%); 5 additional pts lost to F/U
• 91 (28%) of 328 actual 5-year survivors
(4% of 2,216)
Matthew Katz, Jason Fleming, Rosa Hwang, SSO 2008

52. Critical view
• Retroperitoneal margin
– Majority of surgery is done here
– Majority of the blood loss

53. 673729
SMV
SMA
PV

54. SMA
SMV
IVC
LRV

55. Portal system resection
• Important to obtain a negative margin
• Data supports resection
• Several reconstruction options
• Often is the SMV that requires resection
– Not portal vein

57. Variable No. patients Median
survival (mo)
95% CI P value
Overall 291 24.9 21.40-28.46 --
Male
Female
175
116
23.1
27.0
19.05-27.15
22.43-31.50
.47
Standard PD
PD with VR
181
110
26.5
23.4
21.1-31.89
19.50-27.37
.18
T1
T2
T3
25
56
206
30.8
25.9
23.7
16.61-44.92
20.2-31.46
19.94-27.46
.22
N0
N1
146
145
31.9
21.1
24.57-39.30
17.40-24.73
.005
R0
R1
246
45
26.5
21.4
22.29-30.71
17.05-25.68
.14
Adjuvant
therapy
No adjuvant
therapy
209
29
25.1
18.5
21.42-28.85
9.48-27.52
.92
Pancreatic Adenocarcinoma
PD with Vein resection vs. standard PD (univariate analysis)
Tseng, J Gastroint Surg 2004;8:935.

58. Pancreatic Adenocarcinoma
VR vs. standard PD (multivariate analysis)
Covariate HR 95% CI P value
Female Gender .925 .665-1.286 .642
Age (per year) 1.008 .991-1.026 .351
Reoperative PD 1.094 .722-1.66 .671
Vascular resection 1.132 .789-1.625 .499
Operative blood loss 1.0 1.0-1.0 .445
Tumor size .953 .818-1.11 .537
RP margin positive 1.164 .772-1.755 .469
T stage (AJCC) .730
Nodal metastasis 1.502 1.10-2.05 .01
Any adjuvant treatment .962 .412-2.244 .929
Neoadjuvant treatment 1.176 .615-2.248 .623
Postop treatment .946 .538-1.663 .846
Tseng, J Gastroint Surg 2004;8:935.

59. Resectable : Likely to require venous resection
SMV
SMA
T
Cava

63. 553869
SMV
SMA
PV
Division of the jejunal branch of the SMV which was
accessed by developing the plane of dissection
between the SMA and SMV

64. PV
SMV
IJ
SMA
SMA
553869
SMV
Jejunal branch of the SMV has been divided and the involved segment of the ileal branch is resected and
an IJ interposition graft used to reconstruct the SMV
PV
Spl V

65. 492495
SMV
Spl A
CHA
Spl V
saph vein
patch
divided
bile duct PV
Rev saph
vein graft
Final path:
R0
Lymph nodes: 0/24

66. Tumor

67. Tumor

68. SMV
SMA
Jejunal branch
Branch of SMV
To ileum

69. Final path:
R1: microscopic focus of adenocarcinoma at SMA margin
Lymph nodes: 0/22
SMA
SMV
Resection of the ileal branch without reconstruction as the jejunal branch is not involved
PV
Ileal branch of SMV
Branch of SMV
to jejunum

70. SMV
SMV
SplV
SMA

71. 606785
Final path:
R0
Lymph nodes: 0/20
IJ
graft
SMV
SMA
PV CHA
Replacement of
the SMV-PV
confluence with
an IJ interposition
graft (splenic vein
divided)Spl V

73. A closer look at
Borderline resectable

74. Borderline Resectable
1. Arterial abutment (< 180o
): SMA, celiac
2. Short segment abutment/encasement of the
CHA/PHA (typically at GDA origin)
3. Segmental venous occlusion with option for
reconstruction
(Many consider any aspect of venous invasion
as Borderline Resectable)
Varadhachary GR, et al. Ann Surg Oncol. 2006;13(8):1035-46
Katz MHG, et al. J Am Coll Surg. 2008;206(5):833-46

75. MDACC Classification System for
Borderline Resectable Disease
• Type A: Anatomically borderline resectable tumor
• Type B: Indeterminant extrapancreatic metastasis
• Type C: Patient of marginal performance status
Katz MHG, et al. J Am Coll Surg. 2008;206(5):833-46

76. Rates of Resection, Path Response, Survival
160 Patients with Borderline Resectable PC
No. of Patients (%) Median Survival (Mos) p*
MDACC
Type Total Resected
Path Resp.
IIb, III, IV
All Pts Resected Unresected
A 84 (53) 32 (38) 19 (59) 21 40 15 0.001
B 44 (28) 22 (50) 13 (59) 16 29 12 0.001
C 32 (20) 12 (38) 5 (42) 15 39 13 0.009
Total 160 66 (41) 37 (56) 18 40 13 0.001
*p: comparison of median survival between resected and unresected patients of each type
Katz MHG, et al. J Am Coll Surg. 2008;206(5):833-46

77. Treatment of Borderline Resectable Pancreatic Cancer
Underlying hypothesis / assumption
1. Neoadjuvant treatment sequencing used to:
• select those with favorable biology
• treat radiographically occult M1 disease
• enhance the chance of a complete (R0,
R1) resection
2. Outcome for R1 different than R2 (ie, better)

78. Accurate Pathology and Multimodality Therapy
Pancreaticoduodenectomy: Ductal Adenocarcinoma
M D Anderson (N = 360)
Variable No. Pts Med Sur p value
Overall 360 25
N0 174 32 .002
N1 186 22
R0 300 28 .03
R1 60 22
Maj Comp
No 263 27 .01
Yes 93 22
R0 17 mo
R1 11 mo
ESPAC-1
Ann Surg 2001
Raut, Ann Surg 2007;246:52-60
Local Failure (All pts) 8%

79. Preoperative
Therapy
R1 Resection
YES 13%
NO 19%
The Importance of Neoadjuvant Therapy
Pancreaticoduodenectomy: Ductal Adenocarcinoma
M D Anderson (N = 360)
Raut, Ann Surg 2007;246:52-60
Local Failure (All pts) 8%

80. Treatment phase Break
~ 6 wks
CTX
gem combo
Staging CT
Restaging
Dropout
Borderline Resectable PC
MDACC Treatment Approach
Restaging
Dropout
Chemo-XRT
OR
Classification
as Borderline
Katz MHG, et al. J Am Coll Surg. 2008;206(5):833-46

83. Body and tail lesions
• R.A.M.P.
– Radical anti-grade modular pancreatectomy
– Lateral to Medial approach
– 40% of lesions require resection of another
organ in addition to the spleen
• GU: Adrenal, kidney
• GI: Transverse colon, stomach or duodenum

87. Distal Pancreatectomy - Splenectomy

89. Definitions: SSO/AHPBA CC
Resectable:
no extension to celiac, CHA, SMA, SMV-PV
confluence
stage I, II (T1-3, Nx, M0)
Borderline:
a) venous abutment or encasement (with
option for reconstruction)
b) arterial abutment (< 1800
)
Locally Advanced:
celiac, SMA encasement (> 1800
)
stage III (T4, Nx, M0)

90. Resectable
Borderline Resectable
Locally AdvancedCourtesy of R Wolff, MD

91. SMV SMA
Surrounding
perineural
plexus
NO YES
Resection
operative risk
Low High
If resect, is
the resection
complete
(R0)
Usually Usually
not

92. Kitts 527268
Resectable tumor, RRHA
SMV
SMA
T
Resectable adenocarcinoma of the pancreatic head

93. Resectable : likely to require venous resection
SMV
SMA

94. Resectable : likely to require venous resection

95. SMA
Borderline Resectable
Varadhachary GR, et al. Ann Surg Oncol. 2006;13(8):1035-46
Katz MHG, et al. J Am Coll Surg. 2008;206(5):833-46

96. Locally Advanced (Stage III)
SMV
SMA

97. Locally Advanced (Stage III)
Celiac encasement SMA encasement

129. - Aggressive Approach