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IN THE NAME OF GOD

IN THE NAME OF GOD. Outcomes after resection of locally advanced or borderline resectable pancreatic cancer after neoadjuvant therapy. The American Journal Of Surgery By: Z.Jokar. Pancratic ductal adenocarcinoma (PDA). One of the most deadly malignancies

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IN THE NAME OF GOD

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  1. IN THE NAME OF GOD

  2. Outcomes after resection of locally advanced or borderline resectable pancreatic cancer after neoadjuvant therapy The American Journal Of Surgery By: Z.Jokar

  3. Pancratic ductal adenocarcinoma (PDA) • One of the most deadly malignancies • Surgical resection is necessary • Surgery : locally advanced 20% borderline 50%

  4. Compare between : • Neoadjuvant • Upfront resection

  5. Jun.2001 – Dec.2008 locally advanced unresectable 41 (10.1%) borderline resectable 403 362 (89.9%) upfront resection

  6. Staging • Abdominal U.S. • Multi detector CT (contrast)/ MRI • Endoscopic U.S. • CA19-9 • Pathological confirm

  7. Locally advance unresectable: • Tumor involvement > 180 • Thrombosis of the portomesentric venous system • Borderline resection: • Tumor involvement < 180 • Short segment encasement/occlusion of the smv or portal vein amenable to vascular resection and reconstruction

  8. Treatment sequencing & evaluation • External-beam radiotherapy • Chemotherapy (gemcitabine)

  9. Therapeutic response • CT ( 4-6 weeks after end of treatment ) • Response evaluation criteria in solid tumors

  10. Pathologic examinations &responses < 0.05 LNR 0.05 – 0.2 > 0.2 I :complete-almost complete regression/ viable tumor cells <10% Grade ii :partial regression /viable tumor cells 10-90% iii :no-minimal regression /viable tumor cells 10-90%

  11. Statistical analysis • Median number • IQR

  12. Results Neoadjuvant: 27(66%) : borderline 41 patients (59 y /21 malel/ 20 female) 14(44%) : locally advanced 10 patients (42%) previous surgical palliation 17 (41.5%) : only chemotherapy 24 (58.5%) : chemoradiotherapy

  13. Ca19-9 : 246.5 u/ml 93 u/ml • Neoadjuvant group had a higher median value of ca19-9 at diagnosis • Median radiologic tumor size : 35 mm 20 mm

  14. Surgical treatment • No statistically differences • The median length of stay of the neoadjuvant group was significantly longer (14 vs 10 d)

  15. Adjuvant therapy after surgery • Neoadjuvant : 32(78%) • Upfront resection : 291(82%)

  16. Pathology Grade I : 3(7%) Neoadjuvant Grade II : 14(34%) Grade III : 24(59%)

  17. The medictionan number of evaluated nodes was significantly higher for the upfront group (23 vs 15) Neoadjuvant: 70.7% • R0 resection Upfront: 59.7% • R0/R1/R2 Did not differ • R0 margins 35% chemotherapy alone R0 margins 96% chemoradiotherapy

  18. Survival • In upfront group 16(4.4%) were lost to followup • The median survival time did not differ : Neoadjuvant : 35 m Upfront : 37 m

  19. Prognostic factors • Poor survival : R2 resection G3/G4 tumors LNR > 0.2 Body/tail tumors No adjuvant treathment • Only chemoradiation as neoadjuvant treatment was an independent predictor of survival

  20. Comments 10 patients (42%) previous surgical palliation 76% based on high resolution imaging

  21. Preoperative complications were more in neoadjuvant group (systemic complications/hemorrhage/reoperation) The median surgical time • No difference The rate of post operative mortality/morbidity Specific complications • Only the median postoperative length of stay was significantly linger in the neoadjuvant group (14 vs 10d)

  22. Grade I : 3(7%) Neoadjuvant Grade II : 14(34%) Grade III : 24(59%) Grade I : 12% Chemoradiation Grade II :2% Grade III :42% Grade I : 0% Chemotherapy Grade II :17% Grade III :82%

  23. Median radiologic tumor size : 35 mm 20 mm Neoadjuvant :15 • The median number of L.N Upfront :23 Nodal downstaging in neoadjuvant group

  24. R0 margins 35% chemotherapy alone R0 margins 96% chemoradiotherapy • The median survival time did not differ : neoadjuvant : 35 m Upfront : 37 m • Only chemoradiation as neoadjuvant treatment was an independent predictor of survival

  25. Conclusion • Surgical resection after downstaging of locally advanced and borderline resectable pancreatic cancer should be offered to all surgically fit patients without an increased post operative mortality/morbidity • Patients resected after neoadjuvant treatment have at least the same survival rate of patients with resectable disease who undergo primary resection

  26. THANK YOU FOR YOUR ATTENTION

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