The document discusses determining resectability in pancreatic cancer. It begins with an introduction to pancreatic cancer rates, stages, and classifications. It then discusses the National Comprehensive Cancer Network guidelines for classifying pancreatic cancers as resectable, borderline resectable, or unresectable based on tumor involvement of arteries and veins. The document outlines surgical procedures for pancreatic cancer and discusses how venous and arterial resection can increase resectability rates when performed by specialized surgeons, though they may increase morbidity.

1. DETERMINING RESECTABILITY
IN PANCREATIC CANCER
Moderator :
Dr. B. Srihari rao M.S
Dr. C. Srikanth Reddy M.S
Dr. K. Keerthinmayee M.S
Presenter:
Dr. Harish Y S

2. Discussed by
 INTRODUCTION
 CLASSIFICATION OF TUMORS
 STAGING OF TUMORS
 ANATOMY OF PANCREAS
 National Comprehensive Cancer Network (NCCN)
GUIDELINES
 INCREASING RESECTABILITY RATES
 VENOUS RESECTION
 ARTERIAL RESECTION.
 MANAGEMENT

3. INTRODUCTION
 It is the 13th most common cancer worldwide.
 5th MC cause of cancer-related mortality.
 Incidence rate is 9.7 per 100,000.
 Its peak incidence between the 7 & 8 decades and
 It is rare < 40yrs.
 Male to female ratio is 1:1
Parkin DM, Bray FI, Devesa SS. Cancer burden in the year 2000. The global
picture. Eur J Cancer. 2001;37 Suppl 8:S4-66

4. INTRODUCTION
 It has an overall survival of 0.4% to 4%.
 These patients presents late,
 At the time of diagnosis < 20% of patients are surgically
resectable disease
 Of the inoperable ones,
 1/3 rd. with distant metastases and
 Remaining 1/3 rd. with locally advanced disease.
 Defining resectability is therefore one of the most important and
crucial aspects in the management of pancreatic cancer.

5. WHO Classification of pancreatic exocrine tumors
Benign tumors:
 Serous cystadenoma
 Mucinous cystadenoma
 Intraductal papillary-mucinous adenoma
 Mature teratoma
 Borderline (uncertain malignant potential)
 Solid-pseudopapillary neoplasm
Most common

6. WHO Classification of pancreatic exocrine tumors
Malignant tumors:
 Ductal adenocarcinoma
 Mucinous noncystic carcinoma
 Signet ring cell carcinoma
 Adenosquamous carcinoma
 Undifferentiated (anaplastic) carcinoma
 Serous cystadenocarcinoma
 Mucinous cystadenocarcinoma
 intraductal papillary-mucinous carcinoma
 Acinar cell carcinoma
 Pancreatoblastoma
 Solid-pseudopapillary carcinoma

7. TNM STAGING:

8. The American joint committee on cancer stage

9. Arterial supply of pancreas

10. Venous drainage of pancreas

11. Lymphatic drainage of pancreas

12.  Historically pancreatic tumours have been classified
as either resectable or unresectable.
 It is primarily the relationship of the pancreatic
cancer to the vessels that defines resectability.
 Over the last two decades the terms “locally
advanced” and “borderline resectable” pancreatic
cancer have come in to use.

13. LOCALLY ADVANCED PANCREATIC CANCER
 Locally advanced pancreatic cancer is described as
 Tumor invaded locally adjacent structures such as major
blood vessels, lymph nodes, bowel or the bile duct,
without evidence of distant metastatic disease.
 Involvement of para-aortic LN considered as
metastasis and sugically contrindicated.
 Locally advanced pancreatic cancer may or may not
be resectable and would include T3 and T4,
whereas T1 and T2 are considered resectable
tumours.

14. BORDERLINE RESECTABLE PANCREATIC CANCER
 It is defined by two groups
 MD Anderson Cancer Center (MDACC)
 American HepatoPancreatoBiliary Association (AHPBA)/ Society
of Surgical Oncology (SSO)/Society for Surgery of the Alimentary
Tract (SSAT)
MDACC group describes any venous involvement as
resectable disease and only occlusion of the SMV or PV
(with the possibility of reconstruction) as borderline.
Cooper AB, Tzeng CW, Katz MH. Treatment of borderline resectable
pancreatic
cancer. Current treatment options in oncology. 2013;14(3):293-310.

16. National Comprehensive Cancer Network (NCCN)
Guidelines for pancreatic cancer treatment.
 Pancreatic cancers classified in to
 Resectable
 Borderline resectable and
 Unresectable.
Resectable
 Arterial: Clear fat planes around the coeliac axis (CA), SMA and HA.
 Venous: The SMV or PV abutment but no distortion of the vessels.

17. Borderline Resectable
Arterial :
Pancreatic head /uncinate process:
 Solid tumor contact with CHA without extension to celiac
axis or hepatic artery bifurcation.
 Solid tumor contact with the SMA of ≤180°
 Presence of variant arterial anatomy (ex: accessory right
hepatic artery, replaced right hepatic artery, replaced
CHA) and the presence and degree of tumor contact
should be noted if present as it may affect surgical
planning.

18. Borderline Resectable
Pancreatic body/tail:
 Solid tumor contact with the CA of ≤180°
 Solid tumor contact with the CA of ˃180° without
involvement of the aorta and with intact and
uninvolved gastroduodenal artery.
Venous: Venous involvement of the SMV or PV
with distortion or narrowing of the vein or occlusion
of the vein with suitable vessel proximal and distal,
allowing for safe resection and replacement.

19. Unresectable:
 Arterial (Head of Pancreas): Greater than 180° encasement
of the circumference of the SMA or any CA
abutment.
 Arterial (Body/Tail of Pancreas): SMA or CA encasement
>180°.
 Arterial (Any Part of the Pancreas): Aortic invasion or
encasement.
 Venous: Unreconstructable SMV and/or PV.
 Nodal Status: Metastases to lymph nodes beyond
the field of resection should be considered
unresectable.

20. Grading system proposed by Lu et al. for predicting vascular
invasion by tumor based on the degree of tumor contiguity with a
vessel
GRADE DESCRIPTION COMMENT
Grade 0 No contiguity of tumor with a vessel Vascular invasion in
0% of cases
Grade 1 Tumor is encasing <25% of the
circumference of a vessel
0%
Grade 2 25–50% of the circumference of a
vessel
57%
Grade 3 50–75% of the circumference of a
vessel
88%
Grade 4 >75% of the circumference of a
vessel or any vessel constriction
All cases

21. A fat plane is seen between the
tumor and the superior mesenteric
artery (SMA) and superior
mesenteric
vein. No evidence of vascular
invasion is seen.
The tumor is contiguous with < 90°
of the superior mesenteric vein
(Lu grade 1). There is no narrowing
or wall irregularity of the SMV
MDCT OF PANCREATIC CARCINOMA

22. The tumor is contiguous with
90°- 180 of the superior
mesenteric vein
(Lu grade 2). There is no
narrowing or wall irregularity of
the SMV.
The tumor (T) in the head
of
the pancreas eroding the
wall of the superior
mesenteric vein (SMV)
and penetrating it to form
a tumor thrombus

23. Grading system proposed by Loyer et al. for predicting vascular
invasion by tumor
GRADE DESCRIPTION COMMENT
Type A Fat plane separates the tumor and
the normal pancreatic parenchyma
from adjacent vessels
Overall resection rate:
100%.
Type B Normal parenchyma separates the
tumor
from adjacent vessels
Overall resection rate:
100%.
Type C Tumor is inseparable from adjacent
vessels, and the points of contact
form a convexity against the vessels
Overall resection rate:
89%.
Type D The points of contact form a concavity
against the vessels or partially
encircle the vessels
Overall resection rate:
47%.
Type E Tumor encircles adjacent vessels,
and no
fat plane is identified between the
tumor and the vessels
Overall resection rate:
0%.
Type F Tumor occludes the vessels Overall resection rate:

24. APPROCH TO A PATIENT
Clinical suspicion of pancreatic cancer or evidence of
dilated pancreatic duct.
MDCT angiography
Mass in
pancreas
No mass in pancreas
No metastasis
Multidisciplanary
review
• LFT
• EUS
• Chest
imaging
Metastasis
Biopsy
confirmation
No metastasis
• LFT
• EUS/FNA
• Chest
imaging
• MRCP/ERC
P
Metastasis
 Biopsy
confirmation
 EUS

25. APPROCH TO A PATIENT
No metastatic disease on physical examination and imaging
No jaundice jaundice
Symptoms of cholangitis or
fever
Short or self expanding metal
stents and antibiotic coverage
No symptoms of
cholangitis
Per operative CA-19-9
RESECTABLE
BORDERLINE
RESECTABLE
LOCALLY
ADVANCED ,
UNRESECTABLE

26. RESECTABLE TUMOR
Consider staging laparoscopy in high risk patients
LAPAROTOMY
Surgical resection
Adjuvent treatment and
surveillance
Unresectable tumor
Biopsy confirmation, if not
performed previously
No jaundice
Gastrojujunostomy +
celiac plexus neurolysis (if
pain)
Jaundice
Self expanding metal
stents or biliary bypass
+Gastrojujunostomy +
celiac plexus neurolysis
(if pain)

27.  The goals of surgical extirpation of pancreatic
carcinoma focus on the achievement of an R0
resection
 a margin positive specimen is associated with poor
long-term survival
 Achievement of a margin negative dissection must
focus on meticulous perivascular dissection of the
lesion in resectional procedures, recognition of the
need for vascular resection and/or reconstruction

28. Surgical Procedures
 Tumors of the Body and
Tail
 Distal Pancreatectomy
 Removal of body & tail of
pancreas
 spleen

29. Surgical Procedures
 Head of the
pancreas: Whipple
Procedure
 Removal of:
 Distal stomach
 Duodenum and
proximal jejunem
 Head of pancreas
 Gallbladder and
common bile duct

31. Total pancreatectomy
 Indicated in tumor with multilocular or large tumors.
 It is combination of pancreaticoduodenectomy and
distal pancreatectomy with local lymphadenectomy.
 Complications are post operative exocrine and
endocrine insufficiency and associated with high
mortality rates.

32.  If the tumor is found to be unresectable during
surgery
 biopsy confirmation of adenocarcinoma can be done.
 If a patient with jaundice is found to be unresectable
at surgery stenting or biliary bypass can be done

33. BORDERLINE RESECTABLE, NO METASTASIS
Planned neoadjuvent therapy
Biopsy/ EUS+FNA / staging laparoscopy
Biopsy confirmed
Imaging: abdomen , chest and
pelvis
Consider staging laparoscopy
Surgical resection Unresectable
Cancer not confirmed
Repeat biopsy
Biopsy
confirmed
Biopsy not
confirmed
Planned
resection

34. INCREASING RESECTABILITY RATES
 Survival for pancreatic cancer has not changed in
the last 40 years. However, with advancement in
surgical technique and improvement in perioperative
care.
 In Specialised centres, postoperative mortality rates
of 2–3% have been reported.
 The increased resectability and improve in long-
term survival for patients with pancreatic cancer,
extensive surgical procedures have been developed,
mainly involving vascular reconstruction
techniques.

35. INCREASING RESECTABILITY RATES
 Birkmeyer et al. first reported aggressive surgery for
borderline resectable pancreatic cancer with the first
SMV resection and reconstruction in 1951.
 In 1973, Fortner first described the regional
pancreatectomy. This involved a total pancreatectomy,
radical lymph node clearance, combined PV resection
(type 1) and/or combined arterial resection and
reconstruction (type 2).

36. Venous Resection
 Venous involvement is not considered a contraindication
to surgical resection.
 Pancreatic resection requiring venous reconstruction is
technically challenging and may be associated with a
higher morbidity.
Ravikumar et al. published multicentre retrospective cohort study
comparing, PD with venous resection (PDVR) and surgical bypass for T3
adenocarcinoma of the head of the pancreas.
1.Morbidity was similar between the PDVR and PD groups,
2.Patients requiring blood transfusion being greater in the PDVR
group.
Ravikumar R, Sabin C, Abu Hilal M, et al. Portal vein resection in borderline
resectable pancreatic cancer: a United Kingdom multicenter study. J Am Coll Surg.
2014;218(3):401-11.

37. Venous Resection
In 2006, Siriwardana reported a large systematic review of 1646 patients
who had undergone portal-SMV resection during pancreatectomy for
cancer.
concluded that, with the high rate of nodal metastases and the
low five-year survival rates, once the PV is involved cure is unlikely
even
with radical surgery.
 Several studies have shown that PV resection in
patients with pancreatic cancer has comparable
survival compared to standard pancreatectomy and
 It is a safe procedure when performed in specialist
HPB Units
Siriwardana HP, Siriwardena AK. Systematic review of outcome of synchronous
portal-superior mesenteric vein resection during pancreatectomy for cancer. Br J
Surg. 2006;93(6):662-73

38. Venous Resection
Lygidakis et al. compared en bloc splenopancreatic and
venous resection versus palliative gastrobiliary bypass
and reported two-year survival rates of 81.8% and 0%,
respectively.
Randomised controlled trial by Doi et al. in 2008 was
closed early when interim analysis showed a clear
survival benefit for PDVR with chemoradiotherapy
compared with chemoradiotherapy with or without a
surgical bypass
Lygidakis NJ, Singh G, Bardaxoglou E, et al. Mono-bloc total spleno-
pancreaticoduodenectomy
for pancreatic head carcinoma with portal-mesenteric venous invasion. A prospective randomized
study. Hepatogastroenterology. 2004;51(56):427-33.
Doi R, Imamura M, Hosotani R, et al. Surgery versus radiochemotherapy for
resectable locally invasive pancreatic cancer: final results of a randomized multi-institutional trial.
Surg Today. 2008;38(11):1021-8.

39. Arterial Resection
 In 2007, Hirano et al. reported their long-term follow-up
for patients undergoing distal pancreatectomy with en
bloc CA resection (DP-CAR)
 They reported 1yr and 5yr survival rates of 71% and
42%, respectively, and
 concluded that DP-CAR offers a high resectability rate
and may potentially achieve complete local control in
selected patients.
Hirano S, Kondo S, Hara T, et al. Distal pancreatectomy with en bloc celiac axis resection
for locally advanced pancreatic body cancer: long-term results. Ann Surg. 2007;246(1):46-
51.

40. Arterial Resection
 Bachellier et al., in 2011, matched a group of patients undergoing
pancreatectomy with arterial resection to conventional
pancreatectomy and demonstrated similar three-year survival
rates.
 Bockhorn et al. reported one of the largest series on
pancreatectomy with simultaneous arterial resection (n = 29)
and
 concluded that there was no overall difference in disease-
specific survival for patients who underwent arterial
reconstruction versus those patients who underwent
pancreatectomy alone
Bachellier P, Rosso E, Lucescu I, et al. Is the need for an arterial resection a
contraindication to pancreatic resection for locally advanced pancreatic
adenocarcinoma? A case-matched controlled study. J Surg Oncol. 2011;103(1):75-84.
Bockhorn M, Burdelski C, Bogoevski D, et al. Arterial en bloc resection for
pancreatic carcinoma. Br J Surg. 2011;98(1):86-92.

41. Arterial Resection
 Mollberg et al. in 2011, systematic review and meta-
analysis. This report included 26 studies, a total of 2609
patients,
 366, out of the 2609 patients underwent an arterial
resection and reconstruction in conjunction with a
pancreatectomy.
Results:
 Significantly increased perioperative morbidity and a mortality rate
compared with standard pancreatectomy .
 Significantly poorer survival outcomes at
 one year (49.1%),
 three years (8.3%) and
 five years (0%) were demonstrated in this study

42. LOCALLY ADVANCED UNRESECTABLE TUMOR
Biopsy ,if not previously performed
Adenocarcinoma
confirmed
If jaundice,
placement of
self expanding
metal stents.
CHEMOTHERAP
Y
Cancer not confirmed
Repeat biopsy
Others cancers
Treat as appropriate

43. LOCALLY ADVANCED UNRESECTABLE TUMOR
 FOLFIRINOX or
 Gemcitabine or
 Gemcitabine + albumine
bound paclitaxel. or
 Capecitabine + continuous IV
5-FU or
 Fluropyrimidine + oxaliplatine
or
 Clinical trial preferred.
 Fluropyrimidine based
therapy if previously
treated with
Gemcitabine based
therapy
 Gemcitabine based
therapy if previously
treated with
Fluropyrimidine based
therapy
PALLIATIVE AND BEST
SUPPORTIVE CARE

44. METASTATIC DISEASE
If jaundice, placement of self expanding metal stents.
Good performance
CHEMOTHERAPY
Poor performance
Palliative and supportive
care.

45. SURVIVAL
 5-year survival rate of
 R0 resection - 24.2%
 R1 and R2 resection - 4.3%
 Median survival in R0 resected patients, the was
 28 months with pancreaticoduodenectomy and
 26 months with PPPD.
 R1 resected patients - 15 months
 R2 resected patients - 9.8 months
Wagner M, Redaelli C, Lietz M, Seiler CA, Friess H, Buchler MW. Curative resection is
the single most important factor determining outcome in patients with pancreatic
adenocarcinoma. Br J Surg 2004;91:58694

46. THANK YOU