6 minute read
Pancreatic Cancer
Symposium (II)
HOW TO EXPAND AND OPTIMIZE SURGICAL CRITERIA OF LOCALLY ADVANCED PANCREATIC CANCER
Chien-Hui Wu Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan Surgical Oncologist, Pancreatic Cancer Precision Medicine Center of Excellence, National Taiwan University Hospital, Taipei, Taiwan
After the concept of borderline resectable pancreatic cancer was established by the National Comprehensive Cancer Network in 2006, several definitions of borderline resectable pancreatic cancer were given by different organizations, such as the MD Anderson Cancer Center (MDACC), Alliance trial, Americas Hepato-Pancreato-Biliary Association (AHPBA), Society for Surgery of the Alimentary (SSAT) and Society of Surgical Oncology (SSO). In clinical practice, the initial treatment decision may be highly dependent on the quality of preoperative imaging and the surgeon’s surgical experience, as the definition of resectability is based on anatomical criteria. Since the improvements in surgical techniques, chemotherapy, and radiotherapy, more research has focused not only on anatomical aspects but also on technical or biological aspects. Technically, borderline resectable pancreatic cancer is highly dependent on the ability to resect/reconstruct arteries and veins. In contrast to the celiac and superior mesenteric arteries, the portal vein and common hepatic artery are considered to be reconstructable. Recently, borderline resectability of pancreatic cancer was redefined through international consensus criteria based on anatomical, biological (elevated serum carbohydrate antigen 19-9), and conditional (Eastern Cooperative Oncology Group performance) dimensions. In the era of precision medicine, the definition of borderline resectable pancreatic cancer goes beyond the anatomic relationship between the tumor and vessels. Neoadjuvant chemotherapy and surgery are associated with improved outcomes. Due to the molecular diversity of borderline resectable pancreatic cancer and its impact on prognosis and treatment response, a paradigm shift to a genome-driven approach is required. This is particularly important in preoperative, potentially curative cases, where a more individualized approach is used to guide individualized treatment.
Symposium (II)
HOW TO EXPAND AND OPTIMIZE SURGICAL CRITERIA OF LOCALLY ADVANCED PANCREATIC CANCER
CLINICAL SIGNIFICANCE OF MESOPANCREAS DISSECTION FOR PANCREATIC CANCER
Akio Saiura Department of Hepatobiliary-Pancreatic Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
Nerve plexus around pancreas head (plPh) is a unique anatomy in pancreatic surgery and susceptible to tumor invasion. Therefore, dissection around superior mesenteric artery (SMA) and Celiac artery (CA) is the key point during pancreaticoduodenectomy. Various SMA-first or artery-first approaches have been reported. We developed artery-first approach using supra-colic anterior approach tailoring the dissection around SMA (mesopancreas). We developed tailoring dissection around SMA using supracolic anterior approach. The pancreas head is connected to retroperitoneum by inferior pancreticoduodenal artery (IPDA) and nerve plexus of the pancreas head (plPh). In our approach, SMA/plPh is dissected from the ventral side. We adjust the dissection lof the nerve plexus around SMA (plSMA) into three levels. Level1 dissection is a simple division without lymph node or nerve plexus dissection which is indicated to premalignant or low grade malingnant tumor. Level2 (LV2) dissection is an en bloc lymph node dissection with the second plexus of the nerve plexus of the pancreas head (PlPh2) preserving the plSMA. This procedure is most widely applied and the standard dissection inpatients with malignant tumor in the pancreas head. Level3 dissection is LV dissection plus hemicrcumferencial plSMA, which is mainly performed to borderline resectable pancreatic head cancer (BRPC). For BRPC abutting the SMA (BR-SMA) up to 180 degrees, plSMA resection would often need to be extended more than 180 degrees, although total circumferential resection was strictly avoided, and such dissection was defined as beyond LV3 (B-LV3). In patients with pancreatic cancer, LV2, LV3 and B-LV3 were indicated. Our approach has several advantages, opened view, correspondence to in situ location, common landmark and a vascular field. These points can facilitate early judgement of tumor status and dissection levels. In this symposium, we will show the technique and result of pancreatectomy using supracolic anterior approach with systematic mesopancreatic dissection.
Symposium (II)
HOW TO EXPAND AND OPTIMIZE SURGICAL CRITERIA OF LOCALLY ADVANCED PANCREATIC CANCER
CONVERSION SURGERY FOR PANCREATIC CANCER PATIENTS WITH PORTAL VEIN AND ARTERY RESECTION AND RECONSTRUCTION
Hiroki Yamaue Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
【Introduction】
To improve the survival of patients with pancreatic cancer, preoperative neoadjuvant therapy has been reported to be an independent prognostic factor especially in borderline resectable cancer, and conversion surgery should be considered after intensive chemotherapy even in locally advanced pancreatic cancer. In conversion surgery, aggressive surgery including arterial resection should be required to obtain R0 status without increasing incidence of the postoperative complications.
【Surgical management for locally
advanced pancreatic cancer and clinical
impact of neoadjuvant chemotherapy】
R0 surgery is an essential requirement for long survival in patients with pancreatic cancer, however, pancreatic cancer should be considered as a systemic disease in the view point of its tumor biology. Therefore, one should consider that R0 surgery is an only issue for the impact of survival in patients with advanced pancreatic cancer (Hirono, Yamaue, et al. Pancreas 2016). The overall survival (OS) of BR-artery (A) patients was significantly shorter than that of the patients with borderline resectable pancreatic cancer with portal vein/ superior mesenteric vein (PV/SMV) involvement (n=76) and resectable pancreatic cancer (n=105) who underwent surgical resection (median OS: 13.6 vs. 20.6 months, P<0.001). The OS of BR-A patient with neoadjuvant therapy followed by surgical resection was significantly longer than those with upfront surgery (median OS: 20.2 vs. 12.9 months, P=0.047). Therefore, some additional strategy is strongly needed, especially recently developed chemotherapeutic regimen including FOLFIRINOX and Gemcitabine plus nab-paclitaxel (Okada, Yamaue et al. Cancer Chemother Pharmacol 2016, Okada, Yamaue et al. Anticancer Res 2017). First, neoadjuvant chemotherapy (NAC) and chemoradiotherapy (NACRT) will be discussed in this lecture, using new regimen (Okada, Yamaue et al. Oncology 2017).
【PancreatoDuodenectomy with Common Hepatic Artery Resection; PD-CHAR】 Next advanced surgery is combined arterial resection during pancreatoduodenectomy, and common hepatic artery (CHA) is resected and reconstructed by splenic artery. The borderline resectable or locally advanced pancreatic cancer located in pancreatic neck or dorsal pancreas tends to invade CHA, and also bifurcation of CHA and gastroduodenal artery. In these cases, CHA
has to resect to obtain R0 status and reconstructed by other arteries including jejunal artery, middle colic artery, and splenic artery. Splenic artery has been preferably used in our institution and we had a good outcome in terms of short and long term results. However, it has remains unclear and debatable whether arterial resection really bring a good outcome.
【Summary】
The treatment strategy for patients with borderline resectable and locally advanced pancreatic cancer has been still controversial, and further studies and discussion will be needed to confirm the appropriate treatment. Especially, according to the results of RCTs, the surgical technique should be improved to get R0 surgical margin in borderline resectable pancreatic cancer, and allow the patients to be given a suitable preoperative and postoperative adjuvant therapy.
Symposium (II)
HOW TO EXPAND AND OPTIMIZE SURGICAL CRITERIA OF LOCALLY ADVANCED PANCREATIC CANCER
Nai-Jung Chiang National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan Department of Oncology, National Cheng Kung University Hospital, Tainan, Taiwan
Pancreatic ductal adenocarcinoma (PDAC) is associated with dismal prognosis. Only 30%40% of patients presented with locally advanced (LA) PDAC at the time of diagnosis and mostly are metastatic PDAC. The benefit of neoadjuvant chemotherapy (NAT) is to downstage primary tumor size and control potential distant metastasis. Patients with aggressive tumor that progress under NAT wound not be fit for operation due to the difficulty of R0 resection and high risk of recurrence. Currently, NAT is generally applied in the treatment of LA PDAC but not worldwide consensus in borderline resectable (BR) and resectable PDAC. The rate of conversion surgery after NAT varies widely from 4% to 75%. The common regimens of NAT include FOLFIRINOX and gemcitabine-based chemotherapy, such as gemcitabine plus nabpaclitaxel with or without radiotherapy. Patients receiving conversion surgery had significantly longer survival compared to those without resection. Because there are different inclusion and resectability criteria in published studies, prospectively randomized clinical trials are needed to evaluate the definite role of NAT and the optimal time and population for conversion surgery in LA PDAC. I will review the current evidence of NAT in LA PDAC majorly and partly in BR and resectable PDAC, focusing on pivotal randomized controlled clinical trials.
