ACOS Surgical Oncology In-Depth Review 2014 Douglas M. Iddings D.O., FACS FACOS Surgical Oncologist Pancreatic carcinoma Surgical management

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ACOS Surgical Oncology In-Depth Review 2014 Douglas M. Iddings D.O., FACS FACOS Surgical Oncologist Pancreatic carcinoma Surgical management Slide 2 No disclosures Slide 3 Objectives Review CT findings related to resectability. Brief review of Whipple and RAMP procedures. Reconstruction options for portal system. A closer look at borderline resectable. Slide 4 Questions What CT findings are consistent with locally advanced disease? According to the NCCN guidelines, what percentage of resections for body and tail lesions require an en bloc resection of an additional organ other than the spleen? What are some potential advantages in neo-adjuvant therapy in borderline resectable patients? Slide 5 Slide 6 Slide 7 Slide 8 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 MDACC Multidisciplinary Pancreatic Cancer Study Group Slide 9 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 Slide 10 Slide 11 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 Slide 12 Slide 13 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. Slide 14 Kitts 527268 Resectable tumor, RRHA SMV SMA T Resectable adenocarcinoma of the pancreatic head Slide 15 Resectable : Likely to require venous resection SMV SMA T Cava Slide 16 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 Slide 17 Locally Advanced (Stage III) SMV SMA Slide 18 ? Complete Resection R Status R DesignationGross ResectionMicroscopic Margin R0completenegative R1completepositive R2incompletepositive Exocrine Pancreas. In Greene FL, Page DL, Fleming ID, et al., eds. AJCC Cancer Staging Manual. Chicago, IL: Springer, 2002. pp. 157-164. Slide 19 Slide 20 Slide 21 Intraoperative Assessment of Resectability Not clinically informative. Slide 22 Slide 23 Slide 24 Slide 25 Slide 26 Slide 27 SMA (Retroperitoneal/uncinate) Margin Slide 28 Retroperitoneal Margin Slide 29 RP margin SMV SMA SMA (Retroperitoneal) Margin AJCC Cancer Staging Manual 7 th Edition Slide 30 Overall Survival Stage of disease5-year observed survival SEER 1992-1998 Stage IA14% Stage IB12% Stage IIA7% Stage IIB5% Stage III3% Stage IV1% Slide 31 Survival Curves Slide 32 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 Slide 33 Critical view Retroperitoneal margin Majority of surgery is done here Majority of the blood loss Slide 34 673729 SMV SMA PV Slide 35 SMA SMV IVC LRV Slide 36 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 Slide 37 VariableNo. patientsMedian survival (mo) 95% CIP value Overall 291 24.921.40-28.46-- 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. Slide 38 Pancreatic Adenocarcinoma VR vs. standard PD (multivariate analysis) CovariateHR95% CIP value Female Gender.925.665-1.286.642 Age (per year)1.008.991-1.026.351 Reoperative PD1.094.722-1.66.671 Vascular resection1.132.789-1.625.499 Operative blood loss1.01.0-1.0.445 Tumor size.953.818-1.11.537 RP margin positive1.164.772-1.755.469 T stage (AJCC).730 Nodal metastasis1.5021.10-2.05.01 Any adjuvant treatment.962.412-2.244.929 Neoadjuvant treatment1.176.615-2.248.623 Postop treatment.946.538-1.663.846 Tseng, J Gastroint Surg 2004;8:935. Slide 39 Resectable : Likely to require venous resection SMV SMA T Cava Slide 40 Slide 41 Slide 42 Slide 43 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 Slide 44 PV SMV IJ 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 Slide 45 Slide 46 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 Slide 47 Tumor Slide 48 Slide 49 SMV SMA Jejunal branch Branch of SMV To ileum Slide 50 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 Slide 51 Slide 52 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 Slide 53 A closer look at Borderline resectable Slide 54 Borderline Resectable 1.Arterial abutment (< 180 o ): 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 Slide 55 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 Slide 56 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) Slide 57 Accurate Pathology and Multimodality Therapy Pancreaticoduodenectomy: Ductal Adenocarcinoma M D Anderson (N = 360) VariableNo. PtsMed Surp value Overall36025 N017432.002 N118622 R030028.03 R16022 Maj Comp No26327.01 Yes9322 R017 mo R111 mo ESPAC-1 Ann Surg 2001 Raut, Ann Surg 2007;246:52-60 Local Failure (All pts) 8% Slide 58 Preoperative Therapy R1 Resection YES13% NO19% 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% Slide 59 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 Slide 60 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 Slide 61 SMV SplV SMA Slide 62 Body and tail lesions R.A.M.P. Radical anti-grade modular pancrectectomy Medical to lateral approach 40% of lesions require resection of another organ in addition to the spleen GU: Adrenal, kidney GI: Transverse colon, stomach or duodenum Slide 63 Slide 64 Summary of questions Slide 65 Question What CT findings are consistent with locally advanced disease? >180 degree encasement of the SMA Any celiac involvement/abutment Long segment of thrombosed portal vein Unreconstructable portal involvement Aortic or inferior vena cava invasion or involvement Slide 66 Question According to the NCCN guidelines, what percentage of resections for body and tail lesions require resection of an additional organ other than the spleen? An R0 for a distal pancrectomy mandates an en-bloc organ removal beyond that of the spleen alone in up to 40% of patients. Slide 67 Question What are some of the potential advantages in neo- adjuvant therapy in borderline resectable patients? Select those with favorable biology Treat radiographic occult/questionable M1 disease Enhance the chance of a complete (R0) resection Slide 68 THE END Slide 69 Robotic Whipple Procedure Slide 70