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 QuestionsWhat 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 locationTumor and veins relationship – SMV, portal vein and splenic veinTumor and arteries relationship – SMA, celiac axis, common hepatic arteryPresence or absence of distant metastases – liver, lung, peritoneumMDACC Multidisciplinary Pancreatic Cancer Study Group
9 Portal vein & SMV anatomy Vena cavaPVSplenic VeinSMVIMV may enter spl vein or SMVSMAIleal branchof SMVJejunal branch of SMV
13 Resectable definedResectable: No extension into the celiac, CHA, SMA stage I or II (cT1-3 +/- possible lymphadenopathy)Borderline: The stuff in the middleLocally 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 KittsResectable tumor, RRHA
15 Resectable : Likely to require venous resection SMVSMATCava
16 Borderline Resectable SMVSMAVaradhachary GR, et al. Ann Surg Oncol. 2006;13(8):Katz MHG, et al. J Am Coll Surg. 2008;206(5):833-46
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/U91 (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
36 Portal system resection Important to obtain a negative marginData supports resectionSeveral reconstruction optionsOften is the SMV that requires resectionNot portal vein
37 Pancreatic Adenocarcinoma PD with Vein resection vs Pancreatic Adenocarcinoma PD with Vein resection vs. standard PD (univariate analysis)VariableNo. patientsMedian survival (mo)95% CIP valueOverall29124.9--MaleFemale175116188.8.131.52Standard PDPD with VR18111026.523.4.18T1T2T3255620630.825.923.7.22N0N114614531.921.1.005R0R12464521.4.14Adjuvant therapyNo adjuvant therapy20929184.108.40.206This 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) CovariateHR95% CIP valueFemale Gender.925.642Age (per year)1.008.351Reoperative PD1.094.671Vascular resection1.132.499Operative blood loss1.0.445Tumor size.953.537RP margin positive1.164.469T stage (AJCC).730Nodal metastasis1.502.01Any adjuvant treatment.962.929Neoadjuvant treatment1.176.623Postop treatment.946.846On 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 SMVSMATCava
50 R1: microscopic focus of adenocarcinoma at SMA margin Final path:R1: microscopic focus of adenocarcinoma at SMA marginLymph nodes: 0/22PVSMVBranch of SMVto jejunumSMAIleal branch of SMVResection of the ileal branch without reconstruction as the jejunal branch is not involved
54 Borderline Resectable Arterial abutment (< 180o): SMA, celiacShort 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 tumorType B: Indeterminant extrapancreatic metastasisType C: Patient of marginal performance statusKatz MHG, et al. J Am Coll Surg. 2008;206(5):833-46
56 Treatment of Borderline Resectable Pancreatic Cancer Underlying hypothesis / assumption1. Neoadjuvant treatment sequencing used to:select those with favorable biologytreat radiographically occult M1 diseaseenhance the chance of a complete (R0, R1) resection2. 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 valueOverall36025N017432.002N118622R030028.03R160Maj CompNo26327.01Yes93R0 17 moR1 11 moESPAC-1Ann Surg 2001Raut, Ann Surg 2007;246:52-60Local Failure (All pts) 8%
58 The Importance of Neoadjuvant Therapy Pancreaticoduodenectomy: Ductal Adenocarcinoma M D Anderson (N = 360)Preoperative TherapyR1 ResectionYES13%NO19%Raut, Ann Surg 2007;246:52-60Local Failure (All pts) 8%
59 Borderline Resectable PC MDACC Treatment Approach Break~ 6 wksTreatment phaseCTX gem comboChemo-XRTRestagingRestagingORClassification as BorderlineDropoutDropoutStaging CTKatz MHG, et al. J Am Coll Surg. 2008;206(5):833-46
62 Body and tail lesions R.A.M.P. Radical anti-grade modular pancrectectomyMedical to lateral approach40% of lesions require resection of another organ in addition to the spleenGU: Adrenal, kidneyGI: Transverse colon, stomach or duodenum
65 QuestionWhat CT findings are consistent with locally advanced disease?>180 degree encasement of the SMAAny celiac involvement/abutmentLong segment of thrombosed portal veinUnreconstructable portal involvementAortic or inferior vena cava invasion or involvement
66 QuestionAccording 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 QuestionWhat are some of the potential advantages in neo-adjuvant therapy in “borderline resectable” patients?Select those with favorable biologyTreat radiographic occult/questionable M1 diseaseEnhance the chance of a complete (R0) resection