Presentation on theme: "Borderline Resectable Pancreatic Carcinoma BY AHMED M. BASHA Senior Registirar Surgical Oncology Unit."— Presentation transcript:
Borderline Resectable Pancreatic Carcinoma BY AHMED M. BASHA Senior Registirar Surgical Oncology Unit
Background Complete surgical resection is the only potentially curative modality of treatment for pancreatic cancer. An initial assessment of resectability can usually be made based upon the preoperative triphasic contrast-enhanced CT scan of the pancreas.. Local unresectability is usually (but not always) due to vascular invasion, particularly of the superior mesenteric artery (SMA).
Intraoperative Assessment of Resectability Inaccurate Incomplete gross resection provides no survival benefit compared to chemoradiation without surgery
Consensus-based NCCN guidelines define the following characteristics as indicating unresectability: Head of pancreas lesions Greater than 180 degrees SMA encasement, any celiac abutment Unreconstructable SMV/portal vein occlusion Aortic invasion or encasement Body SMA or celiac encasement greater than 180 degrees Unreconstructable SMV/portal vein occlusion Aortic invasion Tail SMA or celiac encasement greater than 180 degrees For all sites Distant metastases Metastases to lymph nodes beyond the field of resection SMA SMV
Borderline resectable definition is variable consensus based definition NCCN, AHPBA, and cosponsored by the Society of Surgical Oncology and the Society for Surgery of the Alimentary tract include the following : No distant metastases. Venous involvement. Arterial involvement. SMA SMV
Borderline resectable Venous involvement of the SMV/portal vein demonstrating tumor abutment with or without narrowing of the lumen, encasement of the SMV/portal vein but without encasement of the nearby arteries, or short segment venous occlusion resulting from either tumor thrombus or encasement, but with suitable vessel proximal and distal to the area of vessel involvement, allowing for safe resection and reconstruction
Borderline resectable Arterial involvement GDA encasement up to the hepatic artery with either short segment encasement or direct tumor abutment of the hepatic artery, without extension to the celiac axis. Tumor abutment of the SMA not to exceed >180 degrees of the circumference of the vessel wall.
Treatment At some institutions, these patients are treated with upfront surgical exploration and resection, if technically feasible. However, at other centers, in an attempt to increase the likelihood of a margin-negative resection, such patients are treated initially with Neoadjuvant therapy (chemotherapy, chemoradiotherapy or both) followed by restaging and surgical reevaluation.
ALL the available data utilizing neoadjuvant therapy in patients with borderline resectable disease consist mainly of small single institution series and small phase II (uncontrolled) trials in which a mixture of patients with initially resectable, unresectable, and borderline resectable disease were enrolled
MD Anderson Trial 160 patients who were classified as borderline resectable 125 completed neoadjuvant therapy (induction chemotherapy in 82; chemoradiotherapy in 117) and were restaged
MD Anderson Trial 82 had potentially operative tumors, of whom 79 underwent an operation; 66 were resected, 62 with microscopically negative margins (38 % of the original cohort). At a median follow-up of 27 months Among the 66 patients who completed all therapy, the five-year survival was 36 %, and 27 patients remained free of disease progression at last follow-up.
SMV Spl A CHA Spl V saph vein patch divided bile duct PV Rev saph vein graft
A meta-analysis of phase II trials suggest that in some cases where resectability is borderline on the basis of vascular involvement, Neoadjuvant chemotherapy, chemoradiotherapy, or a combined approach is feasible and may contribute to complete resection and long-term survival. However, whether this approach is superior to upfront surgery followed by adjuvant therapy is not established. Furthermore, the best regimen to use for neoadjuvant therapy in this setting is not established.