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ACOS Surgical Oncology In-Depth Review 2014

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.

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ACOS Surgical Oncology In-Depth Review 2014

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  1. ACOS Surgical Oncology In-Depth Review 2014 Pancreatic carcinoma Surgical management Douglas M. Iddings D.O., FACS FACOS Surgical Oncologist

  2. No disclosures

  3. 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”.

  4. 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?

  5. 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

  6. 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

  7. 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

  8. 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.

  9. Resectable adenocarcinoma of the pancreatic head SMV SMA T Kitts 527268 Resectable tumor, RRHA

  10. Resectable : Likely to require venous resection SMV SMA T Cava

  11. 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

  12. Locally Advanced (Stage III) SMV SMA

  13. ? Complete ResectionR 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.

  14. Intraoperative Assessment of Resectability Not clinically informative.

  15. SMA (Retroperitoneal/uncinate) Margin

  16. Retroperitoneal Margin

  17. SMA (Retroperitoneal) Margin AJCC Cancer Staging Manual 7th Edition RP margin SMV SMA

  18. Overall Survival

  19. Survival Curves

  20. 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

  21. Critical view • Retroperitoneal margin • Majority of surgery is done here • Majority of the blood loss

  22. PV SMA SMV 673729

  23. LRV IVC SMA SMV

  24. 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

  25. Pancreatic AdenocarcinomaPD with Vein resection vs. standard PD (univariate analysis) Tseng, J Gastroint Surg 2004;8:935.

  26. Pancreatic AdenocarcinomaVR vs. standard PD (multivariate analysis) Tseng, J Gastroint Surg 2004;8:935.

  27. Resectable : Likely to require venous resection SMV SMA T Cava

  28. 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

  29. 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 SMA SMV SMV 553869

  30. 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

  31. Tumor

  32. Tumor

  33. SMV Jejunal branch SMA Branch of SMV To ileum

  34. 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

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