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Alice C. Wei, MDCM, MSc, FRCSC, FACS Princess Margaret Cancer Centre

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

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Alice C. Wei, MDCM, MSc, FRCSC, FACS Princess Margaret Cancer Centre

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  1. Resectability in pancreatic cancerThe surgeon’s definition and viewDebate 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?

  3. Role of surgery for pancreatic adenocarcinoma • Resection offers potential for long term survival • median OS ~ 14- 21 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 R HPB (Oxford). 2013 Jan;15(1):49-60 Cleary SC, J Am Coll Surg. 2004 May;198(5):722-31 Mayo SC, J Am Coll Surg. 2012 January; 214(1): 33–45 Abrams RA, Ann Surg Oncol (2009) 16:1751–1756

  4. Pancreatectomy has evolved • 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 2 • VanHeak, Ann Surg. 2005;242(6):781-8 • Mayo SC, JACS, 2012; 214(1): 33–45 • Nathan H,JACS, 2009; 208(4):528-538

  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 graft SMV and SMA resection with SFV graft

  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, 2009.16:1727–1733 • NCCN guidelines version 2.2012, 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 OS borderline resectable pancreas cancer resected vs. unresected patients 3 • Callery MP, Ann Surg Oncol, 2009.16:1727–1733 • NCCN guidelines version 2.2012, assessed March 18 2013 • 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° 1. NCCN, guidelines version 2.2012, assessed March 18 2013 2. Callery MP, Ann Surg Oncol, 2009.16:1727–1733

  10. Borderline resectable: differences between classification systems1 1. Katz MH, Ann Surg Oncol, 2013 Feb 23 (online version)

  11. NCCN criteria for unresectable disease1,2 metastases • Distant metastases • ≥180 degrees SMA or celiac encasement • Non- reconstructible SMV/PV involvement • Aortic invasion or encasement tumor 1. NCCN, guidelines version 2.2012, assessed March 18 2013 2. Callery MP, Ann Surg Oncol, 2009.16:1727–1733

  12. Conclusions • Pancreatectomy • 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

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