Transcript SMV

ACOS
Surgical Oncology
In-Depth Review 2014
Pancreatic carcinoma
Surgical management
Douglas M. Iddings D.O., FACS FACOS
Surgical Oncologist
No disclosures
Objectives
• Review CT findings related to resectability.
• Brief review of Whipple and RAMP procedures.
• Reconstruction options for portal system.
• A closer look at “borderline resectable”.
Questions
• What CT findings are consistent with locally advanced
disease?
• According to the NCCN guidelines, what percentage of
resections for body and tail lesions require an en bloc
resection of an additional organ other than the spleen?
• What are some potential advantages in neo-adjuvant
therapy in “borderline resectable” patients?
Imaging Template for Pancreatic Cancer
• Tumor size and location
• Tumor and veins relationship – SMV,
portal vein and splenic vein
• Tumor and arteries relationship – SMA,
celiac axis, common hepatic artery
• Presence or absence of distant
metastases – liver, lung, peritoneum
MDACC Multidisciplinary Pancreatic Cancer Study Group
Portal vein & SMV anatomy
Vena cava
PV
Splenic Vein
SMV
IMV may enter spl vein or SMV
SMA
Ileal branch
of SMV
Jejunal branch of SMV
Portal vein & SMV anatomy
Vena cava
PV
Splenic Vein
SMV
IMV may enter spl vein or SMV
SMA
Ileal branch
of SMV
Jejunal branch of SMV
Resectable defined
• Resectable: No extension into the celiac, CHA,
SMA stage I or II (cT1-3 +/- possible
lymphadenopathy)
• Borderline: The stuff in the middle
• Locally advanced means unresectable:
Involvement of the celiac, SMA encasement of
>180°, stage III (cT4), aortic or caval
involvement.
Resectable adenocarcinoma of the pancreatic head
SMV
SMA
T
Kitts 527268
Resectable tumor, RRHA
Resectable : Likely to require venous resection
SMV
SMA
T
Cava
Borderline Resectable
SMV
SMA
Varadhachary GR, et al. Ann Surg Oncol. 2006;13(8):1035-46
Katz MHG, et al. J Am Coll Surg. 2008;206(5):833-46
Locally Advanced (Stage III)
SMV
SMA
? Complete Resection
R Status
R Designation
Gross Resection
Microscopic Margin
R0
complete
negative
R1
complete
positive
R2
incomplete
positive
Exocrine Pancreas. In Greene FL, Page DL, Fleming ID, et al., eds.
AJCC Cancer Staging Manual. Chicago, IL: Springer, 2002. pp. 157-164.
Intraoperative Assessment of Resectability
Not clinically informative.
SMA
(Retroperitoneal/uncinate)
Margin
Retroperitoneal
Margin
SMA (Retroperitoneal) Margin
AJCC Cancer Staging Manual 7th Edition
RP margin
SMV
SMA
Overall Survival
Stage of disease
5-year observed survival
SEER 1992-1998
Stage IA
14%
Stage IB
12%
Stage IIA
7%
Stage IIB
5%
Stage III
3%
Stage IV
1%
Survival Curves
Pancreatic Cancer
• 2,216 patients with panc adenocarcinoma
1990-2002
• 337 (15%) surgical resection (panc head/whipple)
4 periop deaths (1%); 5 additional pts lost to F/U
• 91 (28%) of 328 actual 5-year survivors
(4% of 2,216)
Matthew Katz, Jason Fleming, Rosa Hwang, SSO 2008
Critical view
• Retroperitoneal margin
– Majority of surgery is done here
– Majority of the blood loss
PV
SMA
SMV
673729
LRV
IVC
SMA
SMV
Portal system resection
•
•
•
•
Important to obtain a negative margin
Data supports resection
Several reconstruction options
Often is the SMV that requires resection
– Not portal vein
Pancreatic Adenocarcinoma
PD with Vein resection vs. standard PD (univariate analysis)
Variable
No. patients
Median
survival (mo)
95% CI
P value
Overall
291
24.9
21.40-28.46
--
Male
Female
175
116
23.1
27.0
19.05-27.15
22.43-31.50
.47
Standard PD
PD with VR
181
110
26.5
23.4
21.1-31.89
19.50-27.37
.18
T1
T2
T3
25
56
206
30.8
25.9
23.7
16.61-44.92
20.2-31.46
19.94-27.46
.22
N0
N1
146
145
31.9
21.1
24.57-39.30
17.40-24.73
.005
R0
R1
246
45
26.5
21.4
22.29-30.71
17.05-25.68
.14
Adjuvant
therapy
No adjuvant
therapy
209
25.1
21.42-28.85
.92
29
18.5
9.48-27.52
Tseng, J Gastroint Surg 2004;8:935.
Pancreatic Adenocarcinoma
VR vs. standard PD (multivariate analysis)
Covariate
HR
95% CI
P value
Female Gender
.925
.665-1.286
.642
Age (per year)
1.008
.991-1.026
.351
Reoperative PD
1.094
.722-1.66
.671
Vascular resection
1.132
.789-1.625
.499
Operative blood loss
1.0
1.0-1.0
.445
Tumor size
.953
.818-1.11
.537
RP margin positive
1.164
.772-1.755
.469
T stage (AJCC)
.730
Nodal metastasis
1.502
1.10-2.05
.01
Any adjuvant treatment
.962
.412-2.244
.929
Neoadjuvant treatment
1.176
.615-2.248
.623
Postop treatment
.946
.538-1.663
.846
Tseng, J Gastroint Surg 2004;8:935.
Resectable : Likely to require venous resection
SMV
SMA
T
Cava
Division of the jejunal branch of the SMV which was
accessed by developing the plane of dissection
between the SMA and SMV
PV
SMA
SMV
553869
Jejunal branch of the SMV has been divided and the involved segment of the ileal branch is resected and an
IJ interposition graft used to reconstruct the SMV
PV
Spl V
PV
SMA
IJ
SMV
SMA
SMV
553869
Final path:
R0
Lymph nodes: 0/24
Rev saph
vein graft
divided
bile duct
CHA
PV
Spl A
saph vein
patch
Spl V
SMV
492495
Tumor
Tumor
SMV
Jejunal branch
SMA
Branch of SMV
To ileum
Final path:
R1: microscopic focus of adenocarcinoma at SMA margin
Lymph nodes: 0/22
PV
SMV
Branch of SMV
to jejunum
SMA
Ileal branch of SMV
Resection of the ileal branch without reconstruction as the jejunal branch is not involved
Final path:
R0
Lymph nodes: 0/20
PV
IJ
graft
CHA
Spl V
Replacement of
the SMV-PV
confluence with
an IJ interposition
graft (splenic vein
divided)
SMA
SMV
606785
A closer look at
Borderline resectable
Borderline Resectable
1. Arterial abutment (< 180o): SMA, celiac
2. Short segment abutment/encasement of the
CHA/PHA (typically at GDA origin)
3. Segmental venous occlusion with option for
reconstruction
(Many consider any aspect of venous invasion
as Borderline Resectable)
Varadhachary GR, et al. Ann Surg Oncol. 2006;13(8):1035-46
Katz MHG, et al. J Am Coll Surg. 2008;206(5):833-46
MDACC Classification System for
Borderline Resectable Disease
• Type A: Anatomically borderline resectable tumor
• Type B: Indeterminant extrapancreatic metastasis
• Type C: Patient of marginal performance status
Katz MHG, et al. J Am Coll Surg. 2008;206(5):833-46
Treatment of Borderline Resectable Pancreatic Cancer
Underlying hypothesis / assumption
1. Neoadjuvant treatment sequencing used to:
• select those with favorable biology
• treat radiographically occult M1 disease
• enhance the chance of a complete (R0,
R1) resection
2. Outcome for R1 different than R2 (ie, better)
Accurate Pathology and Multimodality Therapy
Pancreaticoduodenectomy: Ductal Adenocarcinoma
M D Anderson (N = 360)
Variable
Overall
N0
N1
R0
R1
No. Pts
360
174
186
300
60
Med Sur p value
25
32
.002
22
R0
28
.03 17 mo
R1 11 mo
22
Maj Comp
No
Yes
263
93
27
22
Raut, Ann Surg 2007;246:52-60
Local Failure (All pts) 8%
ESPAC-1
.01Surg 2001
Ann
The Importance of Neoadjuvant Therapy
Pancreaticoduodenectomy: Ductal Adenocarcinoma
M D Anderson (N = 360)
Preoperative
Therapy
R1 Resection
YES
13%
NO
19%
Raut, Ann Surg 2007;246:52-60
Local Failure (All pts) 8%
Borderline Resectable PC
MDACC Treatment Approach
Treatment phase
CTX
gem combo
Chemo-XRT
Restaging
Classification
as Borderline
Break
~ 6 wks
Dropout
Restaging OR
Dropout
Staging CT
Katz MHG, et al. J Am Coll Surg. 2008;206(5):833-46
Final path:
R0
Lymph nodes: 0/24
Rev saph
vein graft
divided
bile duct
CHA
PV
Spl A
saph vein
patch
Spl V
SMV
492495
SplV
SMV
SMA
SMV
Body and tail lesions
• R.A.M.P.
– Radical anti-grade modular pancrectectomy
– Medical to lateral approach
– 40% of lesions require resection of another
organ in addition to the spleen
• GU: Adrenal, kidney
• GI: Transverse colon, stomach or duodenum
Summary of questions
Question
• What CT findings are consistent with locally
advanced disease?
– >180 degree encasement of the SMA
– Any celiac involvement/abutment
– Long segment of thrombosed portal vein
• Unreconstructable portal involvement
– Aortic or inferior vena cava invasion or involvement
Question
• According to the NCCN guidelines, what
percentage of resections for body and tail lesions
require resection of an additional organ other than
the spleen?
– An R0 for a distal pancrectomy mandates an en-bloc
organ removal beyond that of the spleen alone in up to
40% of patients.
Question
• What are some of the potential advantages in neoadjuvant therapy in “borderline resectable”
patients?
– Select those with favorable biology
– Treat radiographic occult/questionable M1 disease
– Enhance the chance of a complete (R0) resection
THE END
Robotic Whipple Procedure