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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?
Chemoradiation: Rachna Shroff, MD
Surgical Resection: Yongyut Sirivatanauksorn, MD

Published in: Health & Medicine
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pancreatic cancer: surgical resection

  1. 1. 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
  2. 2. a 68 y/o woman with local pancreatic cancer and no metastatic disease with ECOG-1?
  3. 3. 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.
  4. 4. 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
  5. 5. Borderline Resectable Pancreatic Cancer any venous involvement of the SMV or portal vein allows for safe resection and reconstruction
  6. 6. Borderline Resectable Pancreatic Cancer any venous involvement of the SMV or portal vein allows for safe resection and reconstruction
  7. 7. Unresectable Locally Advanced Pancreatic Cancer  unreconstructible encasement of the SMV/PV  any celiac involvement  encasement (≥180°) of the SMA  aortic involvement
  8. 8. Fewer Than 1/3 Of Resectable Patients Receive Surgery
  9. 9. 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.
  10. 10. 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
  11. 11. 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)
  12. 12. 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
  13. 13. Pancreatic Surgery Is Safe At High-Volume Hospitals NEJM 2002;346(15):1128-37
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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).
  18. 18. 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
  19. 19. 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.
  20. 20. Faculty of Medicine Siriraj Hospital

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