In-Depth Review 2014
Douglas M. Iddings D.O., FACS FACOS
Surgical Oncologist

No disclosures

• Review CT findings related to resectability.
• Brief review of Whipple and RAMP procedures.
• Reconstruction options for portal system.
• A closer look at “borderline resectable”.

• 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

Vena cava
PV
Splenic Vein
SMV
IMV may enter spl vein or SMV
SMA
Ileal branch of SMV
Jejunal branch of SMV

Vena cava
PV
Splenic Vein
SMV
IMV may enter spl vein or SMV
SMA
Ileal branch of SMV
Jejunal branch of SMV

• 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
T
SMV
SMA
Kitts 527268
Resectable tumor, RRHA

Resectable : Likely to require venous resection
SMV
T
Cava
SMA

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

R Designation Gross Resection Microscopic Margin
R0
R1 complete complete negative 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 7 th Edition
RP margin
SMV
SMA

Stage of disease 5-year observed survival
SEER 1992-1998
14% Stage IA
Stage IB
Stage IIA
Stage IIB
Stage III
Stage IV
12%
7%
5%
3%
1%

• 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

• Retroperitoneal margin
– Majority of surgery is done here
– Majority of the blood loss

PV
SMA
SMV
673729

IVC
LRV
SMA
SMV

• Important to obtain a negative margin
• Data supports resection
• Several reconstruction options
• Often is the SMV that requires resection
– Not portal vein

Overall
T1
T2
T3
Male
Female
Standard PD
PD with VR
N0
N1
R0
R1
Adjuvant therapy
No adjuvant therapy
Pancreatic Adenocarcinoma
PD with Vein resection vs. standard PD (univariate analysis)
Variable No. patients Median survival (mo)
95% CI P value
291
175
116
181
110
25
56
206
146
145
246
45
209
24.9
23.1
27.0
26.5
23.4
30.8
25.9
23.7
31.9
21.1
26.5
21.4
25.1
21.40-28.46
--
.47
19.05-27.15
22.43-31.50
21.1-31.89
19.50-27.37
16.61-44.92
20.2-31.46
19.94-27.46
24.57-39.30
17.40-24.73
22.29-30.71
17.05-25.68
21.42-28.85
.18
.22
.005
.14
.92
29 18.5
9.48-27.52
Tseng, J Gastroint Surg 2004;8:935.

Pancreatic Adenocarcinoma
VR vs. standard PD (multivariate analysis)
Covariate
Female Gender
Age (per year)
Reoperative PD
Vascular resection
Operative blood loss
Tumor size
RP margin positive
T stage (AJCC)
Nodal metastasis
Any adjuvant treatment
Neoadjuvant treatment
Postop treatment
HR
.925
1.008
1.094
1.132
1.0
.953
1.164
1.502
.962
1.176
.946
95% CI
.665-1.286
.991-1.026
.722-1.66
.789-1.625
1.0-1.0
.818-1.11
.772-1.755
1.10-2.05
.412-2.244
.615-2.248
.538-1.663
.499
.445
.537
.469
.730
.01
P value
.642
.351
.671
.929
.623
.846
Tseng, J Gastroint Surg 2004;8:935.

Resectable : Likely to require venous resection
SMV
T
Cava
SMA

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
SMV
IJ
SMA
SMV
553869

Final path:
R0
Lymph nodes: 0/24 divided bile duct saph vein patch
Rev saph vein graft
PV
Spl V
Spl A
CHA
SMV
492495

Tumor

Tumor

Branch of SMV
To ileum
SMV
Jejunal branch
SMA

Final path:
R1: microscopic focus of adenocarcinoma at SMA margin
Lymph nodes: 0/22
PV
SMV
Ileal branch of SMV
Resection of the ileal branch without reconstruction as the jejunal branch is not involved
SMA
Branch of SMV to jejunum

Final path:
R0
Lymph nodes: 0/20
PV
CHA
Spl V
Replacement of the SMV-PV confluence with an IJ interposition graft (splenic vein divided)
IJ graft
SMA
SMV
606785

1. Arterial abutment (< 180 o ): 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

• 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 No. Pts Med Sur p value
Overall 360 25
N0
N1
174
186
32
22
.002
R0
R1
Maj Comp
300
60
28
22
R0 17 mo
R1 11 mo
No
Yes
263
93
27
22
ESPAC-1
.01
Raut, Ann Surg 2007;246:52-60
Local Failure (All pts) 8%

The Importance of Neoadjuvant Therapy
Pancreaticoduodenectomy: Ductal Adenocarcinoma
M D Anderson (N = 360)
R1 Resection Preoperative
Therapy
YES
NO
13%
19%
Raut, Ann Surg 2007;246:52-60
Local Failure (All pts) 8%

Treatment phase
CTX gem combo Chemo-XRT
Break
~ 6 wks
Classification as Borderline
Restaging
Dropout
Staging CT
Restaging OR
Dropout
Katz MHG, et al. J Am Coll Surg. 2008;206(5):833-46

Final path:
R0
Lymph nodes: 0/24 divided bile duct saph vein patch
Rev saph vein graft
PV
Spl V
Spl A
CHA
SMV
492495

SMV
SplV
SMV
SMA

• 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

• 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

• 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.

• 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

Robotic Whipple Procedure