1. Alice C. Wei, MDCM, MSc, FRCSC, FACS
Resectability in pancreatic cancer The surgeon’s definition and view Debate session: What is the best strategy to increase rates of resectability in pancreatic cancer
Alice C. Wei, MDCM, MSc, FRCSC, FACS
Princess Margaret Cancer Centre
Assistant Professor of Surgery, University of Toronto, Canada
Great Debates & Updates in GI Malignancies
April 5-6, 2013

2. What is the best way to increase resectability rates in pancreas cancer?
    Pre-op chemotherapy alone
                        Jordan D. Berlin, MD
                        Pre-op chemoradiation
                        Chris Crane, MD

3. Role of surgery for pancreatic adenocarcinoma
Resection offers potential for long term survival
median OS ~ months 1, 2,3
Goals of surgery
relief of symptoms
complete tumor resection (R0) margin
adequate node retrieval
≥ 12 nodes
Multi-modality treatment recommended for all patients 4
Overall Survival following surgery (months)3
Lewis 424 pancreaticduodenectomies at 2 centres – U Pen and BI Deaconnes
Mayo – seer database study that goes up to 2005 – 2461 patients median survival 14 months (12 time period 1 vs. 16 time period 2)
Lewis R HPB (Oxford) Jan;15(1):49-60
Cleary SC, J Am Coll Surg May;198(5):722-31
Mayo SC, J Am Coll Surg January; 214(1): 33–45
Abrams RA, Ann Surg Oncol (2009) 16:1751–1756

4. Pancreatectomy has evolved2
Patient selection is better
staging is more sensitive
 CT/ MRI/ EUS
Pancreatectomy is safer
 peri-operative mortality 14%-<2%1,2
marked volume-outcome relationship
 volumes  better outcomes
surgeons are better oncologists
HPB sub-specialization
collaboration with cancer centers 3
 use of neo-adjuvant therapy 2
Van Heak, Ann Surg. 2005;242(6):781-8
Mayo SC, JACS, 2012; 214(1): 33–45
Nathan H,JACS, 2009; 208(4):

5. Technical advances allow bigger resections
Vascular resections
PV resection routine
arterial resections
increasing experience
Minimally invasive surgery
staging laparoscopy
laparoscopic/ robotic pancreatectomies
More complex resections
better margins
Better perioperative care
SMV and SMA resection with SFV graft
graft
SMV

6. Key principles of resectability
Localized disease
no evidence of metastatic disease
Technically resectable with R0 intent
Adequate performance status for major abdominal surgery

7. Resectable pancreatic cancer
No metastases
No superior mesenteric vein / portal vein distortion/ abutment/ encasement
Normal tissue planes preserved around the celiac axis, hepatic artery, and SMA
upfront resection recommended
case 565 CTIS
Callery MP, Ann Surg Oncol, :1727–1733
NCCN guidelines version , assessed March 18 13

8. Borderline resectable disease
technically resectable but high risk for margin-positivity
3 classification systems
differ in extent of venous involvement
AHPBA/ SSO/ SSAT Criteria (2009)1
NCCN Guidelines (2.2012) 2
MD Anderson Cancer Center 3
MD Anderson Classification 3
Type A: anatomic classification
Type B: potential metastatic disease
Type C: poor performance status
resected OS = 44 mo
unresected OS=13 mo
Katz and August 2006, 160 (7%) of 2,454 patients with PA were classified as
borderline resectable. Of these, 125 (78%) completed preoperative therapy and restaging, and
66 (41%) underwent pancreatectomy. Vascular resection was required in 18 (27%) of 66
patients, and 62 (94%) underwent a margin-negative pancreatectomy. A partial pathologic
response to induction therapy ( 50% viable tumor) was seen in 37 (56%) of 66 patients.
Median survival was 40 months for the 66 patients who completed all therapy and 13 months
for the 94 patients who did not undergo pancreatectomy (p ).
OS borderline resectable pancreas cancer resected vs. unresected patients 3
Callery MP, Ann Surg Oncol, :1727–1733
NCCN guidelines version , assessed March
Katz MH, J Am Coll Surg 2008;206:833–848.

9. NCCN (2012) criteria for borderline resectable1,2
No distant metastases
Venous involvement of SMV/ PV
tumor abutment with deformity or narrowing
encasement or short segment venous occlusion of SMV/PV
** venous vessels amenable to safe resection and reconstruction
GDA encasement up to hepatic artery +/- abutment or short-segment involvement of the hepatic artery
Abutment of the SMA < 180°
Figure 1. Tumor abutting SMA
Figure 2. Short segment involvement of hepatic artery at takeoff of GDA. From Katz et al JACS 2008
No distant metastases.
b. Venous involvement of the SMV/portal vein
demonstrating tumor abutment with or without
impingement and 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.
c. Gastro duodenal artery encasement up to the
hepatic artery with either short segment encasement
or direct abutment of the hepatic artery,
without extension to the celiac axis.
d. Tumor abutment of the SMA not to exceed[180
of the circumference of the vessel wall.
1. NCCN, guidelines version , assessed March
2. Callery MP, Ann Surg Oncol, :1727–1733

10. Borderline resectable: differences between classification systems1
1. Katz MH, Ann Surg Oncol, Feb 23 (online version)

11. NCCN criteria for unresectable disease1,2
metastases
tumor
Distant metastases
≥180 degrees SMA or celiac encasement
Non- reconstructible SMV/PV involvement
Aortic invasion or encasement
1. NCCN, guidelines version , assessed March
2. Callery MP, Ann Surg Oncol, :1727–1733

12. Conclusions Pancreatectomy Resectability depends on
essential for best results
Resectability depends on
anatomic features of tumor
cancer biology
patient physiology
Borderline resectable cancer
needs multimodality approach
vascular reconstruction often required
results are encouraging