What would you recommend as first line therapy for a 68 y/o woman with local pancreatic cancer and no metastatic disease with ECOG-1? Chemoradiation: Rachna Shroff, MD Surgical Resection: Yongyut Sirivatanauksorn, MD

2. Pancreatic Cancer
• High incidence of regionally advanced and
metastatic disease
• Only 10-15% patients have resectable disease
Head 60% Body/Tail 40%
 
20% resectable <5% resectable
 
20% 5-yr survival <15% 5-yr survival
 
<3% alive at 5 years

3. a 68 y/o woman with local pancreatic cancer
and no metastatic disease with ECOG-1?

7. Resectable Pancreatic Cancer
Only 10–20% are candidates for attempted curative resection
 no distant metastases
 no radiographic evidence
of portal vein or superior
mesenteric vein
involvement.
 clear fat planes around
the superior mesenteric
artery, hepatic artery,
and celiac axis.

8. Borderline Resectable Pancreatic Cancer
 no distant metastases
 tumor abutment of the SMA does not exceed 180
degrees of the vessel wall circumference
 any venous involvement of the SMV or portal vein
allows for safe resection and reconstruction
 gastroduodenal artery (GDA) encasement up to
the hepatic artery with either direct abutment or
short segment encasement of the hepatic artery
without extension to the celiac axis

9. Borderline Resectable Pancreatic Cancer
any venous involvement of the
SMV or portal vein allows for safe
resection and reconstruction

10. Borderline Resectable Pancreatic Cancer
any venous involvement of the
SMV or portal vein allows for safe
resection and reconstruction

11. Unresectable Locally Advanced
Pancreatic Cancer
 unreconstructible encasement of the SMV/PV
 any celiac involvement
 encasement (≥180°) of the SMA
 aortic involvement

12. Fewer Than 1/3 Of Resectable Patients
Receive Surgery

13. Results following
Pancreaticoduodenectomy
Due to improved surgical skill and perioperative
care
 Mortality rate 20%-40% in earlier days
 During the past decades, dramatically
decreased and currently is between 0-4% in
experience centers with experience.

14. Pancreatic Surgery Is Safe
1423 Pancreaticoduodenectomies for Pancreatic Cancer
N Mortality Morbidity
Overall 1175 2% 38%
1970’s 23 30% -
1980’s 65 5% 30%
1990’s 514 2% 31%
2000’s 573 1% 45%
Winter JM, et al. J Gastrointest Surg 2006, 10:1199-1210

15. Complications of
Pancreaticoduodenectomy
Complication rate is still 30%-40%
Delayed gastric emptying
Pancreatic fistula
Intra-abdominal abscess
Hemorrhage
Wound infection
Metabolic (Diabetes, Pancreatic exocrine insufficiency)

16. One‐year postoperative survival for
pancreatic‐cancer related pancreatectomy
1980s: 58%
1990s: 68%
(P=0.02 vs. 1980s)
2000s: 68%
(P=0.02 vs. 1980s).
Winter et al., Annals of
Surgical Oncology 2012

17. Pancreatic Surgery Is Safe At
High-Volume Hospitals
NEJM 2002;346(15):1128-37

18. Long-Term Survival Better At
High-Volume Hospitals
1
0.5
0
0 500 1000 1500 2000
Days
Survival
High Volume Hospital
Low Volume Hospital
P=0.001
Fong, Ann Surg 2005; 242:540-7

19. Long-Term Survival
Remains Poor
Author Year N Median
survival
5 year
survival
10 year
survival
Predictors
Ahmad 2001 116 16 mo 19% - Adj tx
Cleary 2004 123 14 mo 15% 4% Stage, grade
Winter 2006 1175 18 mo 18% 11% Size, LN,
margin, grade
Han 2006 123 15 mo 12% - Stage, margin
Ferrone 2008 618 - 12% 5% Stage, Margin

20. Long‐term postoperative survival for
pancreatic‐cancer related pancreatectomy among
patients surviving to one year.
1980s, median=23.2 mths
1990s, median=25.6 mths
2000s, median=24.5 mths
(P‐values compare the specified
decade to the 1980s)
Winter et al., Annals of Surgical
Oncology 2012

21. Pre-Operative Therapy Selects
Patients Better than Upfront Surgery
● Avoids surgery in patients with rapidly
progressive disease (unfavorable tumor biology).
● Avoids surgery in patients unable to tolerate the
stress of pre-operative therapy (those revealed
to be unfit).

22. Paradigm Shift?
 Neoadjuvant therapy for all patients
 Potential benefits:
 Avoid surgery in patients with widely
micrometastatic disease
 Down-size tumor to avoid vein resection
 Examination of tumor biology
 Opposition:
 Resectable patients progress to unresectable
 Complications of chemo prevent/delay surgery,
increase complications

23. Pancreatic Cancer in 2014
• Surgery can be done safely
• Venous resection acceptable for R0
resection.
• Selection the ‘real’ candidate surgical
patient.
• Need better systemic therapy to impact
long-term survival.

24. Faculty of Medicine Siriraj Hospital