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

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Presentation on theme: "ACOS Surgical Oncology In-Depth Review 2014 Douglas M. Iddings D.O., FACS FACOS Surgical Oncologist Pancreatic carcinoma Surgical management."— Presentation transcript:

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

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?

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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 PV Splenic Vein SMV Ileal branch of SMV Jejunal branch of SMV IMV may enter spl vein or SMV SMA Vena cava

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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

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

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

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

17 Locally Advanced (Stage III) SMV SMA

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, pp

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21 Intraoperative Assessment of Resectability Not clinically informative.

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27 SMA (Retroperitoneal/uncinate) Margin

28 Retroperitoneal Margin

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

30 Overall Survival Stage of disease5-year observed survival SEER Stage IA14% Stage IB12% Stage IIA7% Stage IIB5% Stage III3% Stage IV1%

31 Survival Curves

32 Pancreatic Cancer 2,216 patients with panc adenocarcinoma (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 SMV SMA PV

35 SMA SMV IVC LRV

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 VariableNo. patientsMedian survival (mo) 95% CIP value Overall Male Female Standard PD PD with VR T1 T2 T N0 N R0 R Adjuvant therapy No adjuvant therapy Pancreatic Adenocarcinoma PD with Vein resection vs. standard PD (univariate analysis) Tseng, J Gastroint Surg 2004;8:935.

38 Pancreatic Adenocarcinoma VR vs. standard PD (multivariate analysis) CovariateHR95% CIP value Female Gender Age (per year) Reoperative PD Vascular resection Operative blood loss Tumor size RP margin positive T stage (AJCC).730 Nodal metastasis Any adjuvant treatment Neoadjuvant treatment Postop treatment Tseng, J Gastroint Surg 2004;8:935.

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

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43 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

44 PV SMV IJ SMA 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

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

47 Tumor

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49 SMV SMA Jejunal branch Branch of SMV To ileum

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

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52 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

53 A closer look at Borderline resectable

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): 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) VariableNo. PtsMed Surp value Overall36025 N N R R16022 Maj Comp No Yes9322 R017 mo R111 mo ESPAC-1 Ann Surg 2001 Raut, Ann Surg 2007;246:52-60 Local Failure (All pts) 8%

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%

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

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

61 SMV SplV SMA

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

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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

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