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

2. No disclosures

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”.

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?

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

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

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

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.

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

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

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

17. Locally Advanced (Stage III)
SMV
SMA

18. ? 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, pp

21. Intraoperative Assessment of Resectability
Not clinically informative.

27. SMA (Retroperitoneal/uncinate) Margin

28. Retroperitoneal
Margin

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

30. 5-year observed survival
Overall Survival
Stage of disease
5-year observed survival
SEER
Stage IA
14%
Stage IB
12%
Stage IIA 7%
Stage IIB 5%
Stage III 3%
Stage IV 1%

31. Survival Curves

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

33. Critical view Retroperitoneal margin Majority of surgery is done here
Majority of the blood loss

34. PV
SMA
SMV
673729

35. LRV
IVC
SMA
SMV

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

37. Pancreatic Adenocarcinoma PD with Vein resection vs
Pancreatic Adenocarcinoma PD with Vein resection vs. standard PD (univariate analysis)
Variable
No. patients
Median survival (mo)
95% CI
P value
Overall
291
24.9 --
Male
Female
175
116
23.1
27.0
.47
Standard PD
PD with VR
181
110
26.5
23.4
.18 T1 T2 T3 25 56
206
30.8
25.9
23.7
.22 N0 N1
146
145
31.9
21.1
.005 R0 R1
246 45
21.4
.14
Adjuvant therapy
No adjuvant therapy
209 29
25.1
18.5
.92
This table shows the results of the univariate analysis of predictors of decreased survival after pancreaticoduodenectomy for all patients with pancreatic adenocarcinoma.
Median survival for the entire cohort was 25 months.
As you can see, [click] patients who underwent vascular resection had a median survival of 23.4 months, which was not statistically different from the 26.5 month median survival of patients who underwent standard pancreaticoduodenectomy.
Lymph node status was a significant predictor of survival, however,
a positive margin resection, or R1 resection was not.
Tseng, J Gastroint Surg 2004;8:935.

38. Pancreatic Adenocarcinoma VR vs. standard PD (multivariate analysis)
Covariate HR
95% CI
P value
Female Gender
.925
.642
Age (per year)
1.008
.351
Reoperative PD
1.094
.671
Vascular resection
1.132
.499
Operative blood loss
1.0
.445
Tumor size
.953
.537
RP margin positive
1.164
.469
T stage (AJCC)
.730
Nodal metastasis
1.502
.01
Any adjuvant treatment
.962
.929
Neoadjuvant treatment
1.176
.623
Postop treatment
.946
.846
On multivariate analysis, the results were similar – the need for vascular resection had no impact on survival duration [click].
After adjusting for confounders, the only significant predictor of decreased survival was the presence of nodal metastases, with a HR of 1.5.
Since >90% of our patients received adjuvant therapy, we were unable to accurately assess the effect of such nonsurgical therapy on survival.
(Reoperative pancreaticoduodenectomy, blood loss, tumor size, T stage, the need for vascular resection, and an R1 resection had no effect on survival in this multivariable analysis).
Tseng, J Gastroint Surg 2004;8:935.

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

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

44. 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 PV
SMA IJ
SMA
SMV
SMV
553869

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

47. Tumor

48. Tumor

49. SMV
Jejunal branch
SMA
Branch of SMV
To ileum

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

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

53. A closer look at Borderline resectable

54. Borderline Resectable
Arterial abutment (< 180o): SMA, celiac
Short segment abutment/encasement of the CHA/PHA (typically at GDA origin)
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):
Katz MHG, et al. J Am Coll Surg. 2008;206(5):833-46

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

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)

57. 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
Maj Comp No
263 27
.01
Yes 93
R0 17 mo
R1 11 mo
ESPAC-1
Ann Surg 2001
Raut, Ann Surg 2007;246:52-60
Local Failure (All pts) 8%

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

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

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

61. SplV
SMV
SMA
SMV

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

64. Summary of questions

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

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.

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

68. THE END

69. Robotic Whipple Procedure