157 pts
Survival
Negative
R0 R1
60% 40% 20% 0% 0 12
Positive
27% 27%
24
36
48
60
Months of Follow Up
(1987-2005)
Negative
Positive
Biologic features of the tumors themselves are the primary determinants of prognosis!
Adjuvant Therapy
• Treatment given after •
• •
resection Effort to eradicate any remaining microscopic tumor All pts in USA receive chemotherapy after resection! Some in USA also get radiation
Pylorus Preserving Whipple
Factors Influencing Survival
Study Design
182 consecutive patients underwent a Whipple for pancreatic cancer between 1987 and 2005. Patients from 19871995 were compared with those from 1996-2005.
Arch Surg. 2011;146(7):836-843. Donahue TR, Reber HA et al
Initial scan shows SMA involvement
6 mos scan looks similar
But patient felt well and CA19-9 fell from 840 to normal..
(colon #1)
Pancreatic Cancer
Epidemiology
New Cancer Deaths , United States, 2014.
Pancreatic Cancer
Epidemiology
Incidence increasing 1% yearly
Pancreatic Cancer
No Surgery
If..
• Major blood vessels involved
(Stage III) • Distant metastases (Stage IV) • Some Stage III may be exceptions
Pancreatic Resection
• Distal Pancreatectomy (no Appleby) • Whipple operation
Neoadjuvant Therapy
• Treatment given before surgery in •
pts with resectable disease (Stage I and II) Some in USA recommend this instead of surgery first Advantages and disadvantages
Lymph Nodes
Lymph Nodes
100% 80%
Negative
38%
Survival
60% 40% 20% 0% 0 12 24
Positive
28% 22%
36
48
60
Months of Follow Up
(1987-2005)
Negative
Positive
Actuarial survival for node-negative (solid line) and node-positive (dotted line) patients with adenocarcinoma of the pancreas undergoing a pancreaticoduodenectomy (P<.001).
Effect of Chemotherapy on Tumor
Before After
Tumor: 4.4 x 3.8cm PV invasion (+)
Tumor: 2.8 x 2.5cm (57% reduction) PV invasion (-)
When/Whether to Operate? CT Imaging
III
IV
Late Presentation - Poor Survival
24 18
Even “early” stage disease is advanced
12 6
0
I II Stage III IV
Median Survival (mos)
0
Howlander et al, SEER Cancer Statistics Review 2012. American Cancer Society, Cancer Facts & Figures 2013.
Epidemiology
• 85% of new cases are advanced • Locally advanced: blood vessels
(Stage III) • Distant spread to liver, lungs (Stage IV)
Late Presentation - Poor Survival
Actuarial survival for patients with adenocarcinoma of the pancreas undergoing pancreaticoduodenectomy (P<.001).
Resection Margins
Resection Margins
100% 80%
Cancer may involve HA, PV, superior mesenteric vein or artery
UNRESECTABLE
Criteria for Resection
• Why not resect the
involved blood vessels?
Criteria for Resection
Pancreatic Cancer Surgical Approach in the USA - 2014
Howard A. Reber, MD Professor of Surgery UCLA School of Medicine
Agi Hirshberg Center for Pancreatic Diseases at UCLA
Observed five-year survival rate: 28%
Adjuvant Therapy
• Treatment given after surgery •
•
(Whipple/distal) Effort to eradicate any remaining microscopic tumor Standard approach
Survival for Entire Cohort
Overall Survival
All All 182 182Pts Pts
100%
76.4%
80%
Survival
60% 40% 20% 0% 0
(1987-2005)
40.9% 27.4%
12
24
36
48
60
Months of Follow Up
Tumor Differentiation
100% 80%
Survival
60% 40% 20% 0% 0 12 24 36 48
50%
60
Months of Follow Up
(1987-2005)
Well
Moderate
Poor
Actuarial survival estimate for patients with well, moderately, and poorly differentiated adenocarcinoma of the pancreas (P<.001).
•
“Downstaging” of PaCa
So..
• • • • • •
Pts given chemotherapy 6-12 mos We try to kill the microscopic tumor first Re-evaluation by CT, CA19-9 Resection then possible in some First reported by our group (1998) Now more widely done in USA…
60%
Percent at diagnosis
45% 30% 15% 0%
I II Stage
Howlander et al, SEER Cancer Statistics Review 2012. American Cancer Society, Cancer Facts & Figures 2013.
(Pancreaticoduodenectomy)
Standard Whipple
Standard Whipple
Roux-en-Y rarely done
Pylorus Preserving Whipple
Cure rate is same with each.. Most resections are Pylorus Preserving Whipples