Pancreatic Cancer. Staging: T1 and T2
Staging: T1 and T2, which are resectable in anybody’s book, are tumors limited to the pancreas. Limited extension to the duodenum or to the ductus, T3, that’s still resectable in many hands. T4, to the stomach, spleen, colon, or the one that usually bars resection is the great vessels, which are the closest. And there is just zero or 1 depending on whether the regional nodes are involved. If further nodes are involved, it’s M1. The group staging: stage I, is T1 or T2. Stage II is T3, still N0. Stage III are node-positive lesions. Stage IV is divided between the metastatic lesions, which are obviously unresectable, and stage IVa which is T4 disease but without distant spread and, depending upon the extent of vascular invasion, might be resected by aggressive surgeons at some centers.
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Surgery for pancreatic cancer is the radical pancreatoduodenectomy, the Whipple procedure. You take out a lot of tissue. Here it’s all listed for you. Less than 25% of presenting pancreatic cancers will be resectable by the usual standards; which means, major vessel involvement bars resection. Historically the operative mortality of this procedure was very high. In some series, even higher than 30%. It’s gotten a lot better in recent years. We’ll see some of those series in just a second. Median survival historically has been 6-24 months, usually less than 20% long term survival. Here is just a schematic representation of what is resected at the Whipple procedure, and then the gastric outflow tract is reconstructed, the pancreatic outflow tract is reconstructed, and the bile duct is also anastomosed to a loop of small bowel.
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Applicability of surgery: most surgeons will operate stage I and stage II. They usually don’t know if it’s stage III and they usually will operate stage III. Many will operate stage III. That’s often not determined until the surgical path is back. It takes an aggressive surgeon to go after stage IVa. More of them will resect the SMV portal complex than will resect arterial. Harry Wonabeau at Brown even resects SMA’s. This is a Memorial series as was presented by Brennan and his chapter in an earlier edition of Da Vita. Out of 818 patients they resected less than 20%. Of those that were resected with follow-up, 16% were alive at five years, 12% were alive without disease at five years. So the overall disease free survival at five years was 2% in that series. Here it is as a pie graph. Here’s all their patients. All the patients as they presented, about a quarter of them had such obvious distant disease that they weren’t even considered candidates for surgery. Of the three-quarters that were explored, two-thirds of them – 54% of the total patients – were bypassed but not resected, and less than 20% were resected. Here’s the same pie looking at the resected patients. Here’s the ones that were surviving at five years. It’s not a good disease. In case you think Memorial doesn’t do very well, you can look at the series from Yale New Haven as well; 200 patients over ten years. They explored about the same percentage of them, a little over half. They resected 8%. So of those 196 patients all together, there were 27 survivors at one year. There’s only one survivor at five years. By the way, that five year survivor was one of the non-resected patients. Makes you think that there might have been a pathologic error in the diagnosis, and emphasizes the point of recognizing islet cell tumors.
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Here’s more recent surgical results, and they are getting better. I think the one I would point to, because it is a large one and it’s very good, this is the Hopkins series. Cameron and Yo and that group. Less than 1% operative mortality in the last ten years, 21% five year survival, which is very good. This improved five year survival reflects partly improved surgical technique, reduced mortality, but also it reflects – I think, in part – in the last ten years or so there has been increasing use of adjuvant chemo-radiotherapy, which is effective.