Defining Venous Involvement in Borderline Resectable Pancreatic Cancer
Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA. Annals of Surgical Oncology
(Impact Factor: 3.93).
11/2010; 17(11):2832-8. DOI: 10.1245/s10434-010-1284-9
Pancreatic adenocarcinoma impinging the portal and/or superior mesenteric vein (PV-SMV) is classified as borderline resectable, and preoperative chemoradiation is recommended to increase the margin-negative resection rate. There is no consensus about what degree of venous impingement constitutes borderline resectability.
All patients undergoing potentially curative pancreatectomy for pancreatic adenocarcinoma were reviewed. Venous involvement was classified by preoperative computed tomography according to Ishikawa types: (I) normal, (II) smooth shift without narrowing, (III) unilateral narrowing, (IV) bilateral narrowing, (V) bilateral narrowing with collateral veins.
From 1990-2009, 109 patients underwent resection of pancreatic adenocarcinoma involving the PV-SMV. Seventy-four patients received preoperative chemoradiation, whereas 35 did not. Patients who received preoperative therapy had a significantly longer median overall survival rate of 23 months compared with 15 months for patients without preoperative therapy (P = 0.001). Preoperative chemoradiation was associated with higher R0 resection rate and negative lymph nodes (both P < 0.0001) but did not affect the need for vein resection. When stratified by Ishikawa types, preoperative therapy was associated with improved overall survival among patients with types II and III but not types IV and V. Similarly, the correlation between preoperative therapy and R0 resection rate was observed only among patients with Ishikawa types II and III.
Preoperative therapy for borderline resectable pancreatic adenocarcinoma is associated with higher margin-negative resection and survival rates in patients with Ishikawa type II and III tumors, defined as a smooth shift or unilateral narrowing of the PV-SMV. Patients with bilateral venous narrowing were less likely to benefit from preoperative treatment.
Available from: Jörg Kleeff
- "Accurate selection of the patients who are eligible for macroscopic (R0 or R1) resection with adjuvant chemotherapy is also vital, since median survival following incomplete macroscopic surgical resection (R2) of the primary tumour is comparable to that of patients with inoperable locally advanced disease treated with chemotherapy [34e38,40e42]. There is also a growing consensus on the radiological definitions of 'resectable', 'borderline resectable' and 'unresectable', and the National Comprehensive Cancer Network in the USA has endorsed a modified consensus from the Americas Hepato-Pancreato-Biliary Association, the Society of Surgical Oncology and the Society for Surgery of the Alimentary Tract  . Current imaging modalities used for preoperative staging include abdominal ultrasound, computed tomography, magnetic resonance imaging and endoscopic ultrasonography. "
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ABSTRACT: Pancreatic ductal adenocarcinoma (PDAC), which accounts for more than 90% of all pancreatic tumours, is a devastating malignancy with an extremely poor prognosis, as shown by a 1-year survival rate of around 18% for all stages of the disease. The low survival rates associated with PDAC primarily reflect the fact that tumours progress rapidly with few specific symptoms and are thus at an advanced stage at diagnosis in most patients. As a result, there is an urgent need to develop accurate markers of pre-invasive pancreatic neoplasms in order to facilitate prediction of cancer risk and to help diagnose the disease at an earlier stage. However, screening for early diagnosis of prostate cancer remains challenging and identifying a highly accurate, low-cost screening test for early PDAC for use in clinical practice remains an important unmet need. More effective therapies are also crucial in PDAC, since progress in identifying novel therapies has been hampered by the genetic complexity of the disease and treatment remains a major challenge. Presently, the greatest step towards improved treatment efficacy has been made in the field of palliative chemotherapy by introducing FOLFIRINOX (folinic acid, 5-fluorouracil, irinotecan and oxaliplatin) and gemcitabine/nab-paclitaxel. Strategies designed to raise the profile of PDAC in research and clinical practice are a further requirement in order to ensure the best treatment for patients. This article proposes a number of approaches that may help to accelerate progress in treating patients with PDAC, which, in turn, may be expected to improve the quality of life and survival for those suffering from this devastating disease.
Available from: Yan-Shen Shan
- "In 2006, a new category of borderline resectable pancreatic cancer was proposed by Varadhachary based on the extent of artery involvement and technical capability of reconstructing the vein . The Fox Chase Cancer Center also suggested that tumor-induced unilateral shift or narrowing of the SPMV confluence as one of criteria of borderline resectable . In resectable pancreatic cancer, the reported positive margin rate (R1 + R2) ranged from 19% to 68% and the positive margin strongly predicts the short survival and early recurrence rate . "
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To evaluate the predictors for resectability and survival of patients with locally advanced pancreatic cancer (LAPC) treated with gemcitabine-based neoadjuvant therapy (GBNAT).
Between May 2003 and Dec 2009, 41 tissue-proved LAPC were treated with GBNAT. The location of pancreatic cancer in the head, body and tail was 17, 18 and 6 patients respectively. The treatment response was evaluated by RECIST criteria. Surgical exploration was based on the response and the clear plan between tumor and celiac artery/superior mesentery artery. Kaplan–Meier analysis and Cox Model were used to calculate the resectability and survival rates.
Finally, 25 patients received chemotherapy (CT) and 16 patients received concurrent chemoradiation therapy (CRT). The response rate was 51% (21 patients), 2 CR (1 in CT and 1 in CRT) and 19 PR (10 in CT and 9 in CRT). 20 patients (48.8%) were assessed as surgically resectable, in which 17 (41.5%) underwent successful resection with a 17.6% positive-margin rate and 3 failed explorations were pancreatic head cancer for dense adhesion. Two pancreatic neck cancer turned fibrosis only. Patients with surgical intervention had significant actuarial overall survival. Tumor location and post-GBNAT CA199 < 152 were predictors for resectability. Post-GBNAT CA-199 < 152 and post-GBNAT CA-125 < 32.8 were predictors for longer disease progression-free survival. Pre-GBNAT CA-199 < 294, post-GBNAT CA-125 < 32.8, and post-op CEA < 6 were predictors for longer overall survival.
Tumor location and post-GBNAT CA199 < 152 are predictors for resectability while pre-GBNAT CA-199 < 294, post-GBNAT CA-125 < 32.8, post-GBNAT CA-199 < 152 and post-op CEA < 6 are survival predictors in LAPC patients with GBNAT.
Available from: Paul Stephen Ritch
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ABSTRACT: The exceedingly high rates of distant metastatic recurrence following successful surgical resection of early-stage tumors would suggest that pancreatic adenocarcinoma is a systemic disease at the time of diagnosis in the vast majority of patients, and therefore a compelling case can be made for a neoadjuvant treatment approach in almost all patients. Although the first national trial of neoadjuvant therapy for resectable pancreatic cancer (ACOSOG Z5041) only recently opened, single-institution experiences have supported this form of treatment sequencing for nearly two decades. However, outside of large referral centers with disease-specific investigators committed to clinical and translational research in pancreatic cancer, confusion remains over how to define, on preoperative imaging, what is resectable and what is not (so called locally advanced or borderline resectable pancreatic cancer). In an attempt to clarify the anatomy of resectable, borderline, and locally advanced disease, Varadhachary and colleagues from the University of Texas M. D. Anderson Cancer Center proposed, in this journal in 2006, an objectively defined, computed tomography (CT)-based classification which distinguished borderline resectable from both resectable and locally advanced pancreatic cancer. 1 The Varadhachary definitions considered venous abutment and encasement (without occlusion) to be resectable, in the absence of tumor extension to the celiac or superior mesenteric (SMA) arteries, as this operational definition was developed for the conduct of clinical trials of neoadjuvant treatment sequencing. There was no intent to use this definition outside of such clinical trials, and this definition of ‘‘resectable’’ was not intended to support a surgery-first strategy for patients who may require vascular resection and reconstruction. The Varadhachary definitions also assumed the technical capability to resect and reconstruct the superior mesenteric-portal vein (SMPV) confluence when necessary and that the major determinant of margin status (R status) was the tumor‐artery (celiac, hepatic, SMA) relationship (Table 1). Katz and colleagues in 2008 reported 160 patients with borderline resectable disease (using the Varadhachary definition) treated at M. D. Anderson Cancer Center and introduced three types of borderline resectable disease, now often referred to as Katz type A, B, and C. 2 Type A patients were those with borderline resectable tumor anatomy as defined in the Varadhachary manuscript. Type B patients were borderline resectable because of a concern for possible extrapancreatic metastatic disease and included those with CT findings suspicious for, but not diagnostic of, metastatic disease as well as those with known local‐regional lymph node metastases. It may be reasonable in 2010 to add to this
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