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? Surgical Resection

Yongyut Sirivatanauksorn MD MSc PhD

HPB & Transplant Surgery UnitFaculty of Medicine Siriraj Hospital

Pancreatic Cancer• High incidence of regionally advanced and

metastatic disease

• Only 10-15% patients have resectable

diseaseHead 60% Body/Tail 40%

20% resectable <5% resectable

20% 5-yr survival <15% 5-

yr survival

<3% alive at 5 years

a 68 y/o woman with local pancreatic cancer and no metastatic disease with ECOG-1?

Resectable Pancreatic CancerOnly 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.

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

any venous involvement of the SMV or portal vein allows for safe resection and reconstruction

Borderline Resectable Pancreatic Cancer

any venous involvement of the SMV or portal vein allows for safe resection and reconstruction

Borderline Resectable Pancreatic Cancer

Unresectable Locally Advanced Pancreatic Cancer

unreconstructible encasement of the SMV/PV

any celiac involvement

encasement (≥180°) of the SMA

aortic involvement

Fewer Than 1/3 Of Resectable Patients Receive Surgery

Results following Pancreaticoduodenect

omyDue 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.

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%

1423 Pancreaticoduodenectomies for Pancreatic Cancer

Winter JM, et al. J Gastrointest Surg 2006, 10:1199-1210

Pancreatic Surgery Is Safe

Complications of Pancreaticoduodenect

omy Complication rate is still 30%-40%

Delayed gastric emptying

Pancreatic fistula   

Intra-abdominal abscess   

Hemorrhage   

Wound infection

Metabolic (Diabetes, Pancreatic exocrine insufficiency)

1980s: 58%1990s: 68% (P=0.02 vs. 1980s)2000s: 68% (P=0.02 vs. 1980s).

Winter et al., Annals of Surgical Oncology 2012

One‐year postoperative survival for pancreatic‐cancer related pancreatectomy

NEJM 2002;346(15):1128-37

Pancreatic Surgery Is Safe At

High-Volume Hospitals

Long-Term Survival Better At

High-Volume Hospitals

0

0.5

1

0 500 1000 1500 2000

Days

Sur

viva

l High Volume Hospital

Low Volume Hospital

P=0.001

Fong, Ann Surg 2005; 242:540-7

Long-Term Survival Remains Poor

Author Year N Median survival

5 year surviv

al

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

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

Long‐term postoperative survival for pancreatic‐cancer related pancreatectomy

among patients surviving to one year.

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).

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

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.

Thank you

Faculty of Medicine Siriraj Hospital