Stage-specific survival

Months From Dx
All patients: 9.3

Stage I, II: 15.4
resected: 241
resected: 24.1
not resected 10.3

Stage III 9.9
borderline 17.6

Stage IV 6.1

MDACC: Pancreatic Cancer Program Database 1991-2007, N = 4,395
Katz MHG, Hwang RF, et al. TNM staging of pancreatic adenocarcinoma.
CA Cancer J Clin. 2008;58(2):111-25.

Intraoperative Assessment of Resectability

• Inaccurate

• Incomplete gross resection provides no survival benefit compared to chemoradiation without surgery

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SYNOPTIC REPORT
Specimen: Pancreaticoduodenectomy
Tumor Diagnosis: DUCTAL ADENOCARCINOMA
Degree of Differentiation: Moderate
The tumor size is 2.8 cm in diameter
Extrapancreaticextensionpresent
Extrapancreatic extension present
Lymphovascular present
Perineural invasion present
SMA margin uninvolved with distance of 18mm to inked margin
Bile duct margin uninvolved
Pancreatic transection margin uninvolved
Proximal stomach or duodenum margin uninvolved
Distal duodenumorjejunum margin uninvolved
Distal duodenum or jejunum margin uninvolved

Regional Lymph Nodes:
Total number involved: 3
Total number examined: 30, including hepatic artery and periaortic
(P t A dB)
(Parts A and B)
Vessels removed: None stated

Final pTNM Staging (AJCC 6th edition):
pT3 Tumor extends beyond the pancreas
pN1 Regional lymph node metastasis
pMX Distant metastasis cannot be assessed

Definitions: SSO/AHPBA CC

Resectable:
no extension to celiac, CHA, SMA
patent SMV-PV confluence
stage I, II (T1-3, Nx, M0)

Locally Advanced:
celiac,SMAencasement (>1800) celiac, SMA encasement ( 180)
stage III (T4, Nx, M0) Borderline: Borderline: arterial abutment (<1800) stageIII(minimal T4) stage III (minimal T4

Resectable : likely to require venous resection

Imaging Template for Pancreatic Cancer

• Tumor size and location
• Tumor and veins relationship –SMV, portal veinandsplenicvein portal vein and splenic vein
• Tumor and arteries relationship –SMA, celiacaxis commonhepaticartery celiac axis, common hepatic artery
• Presence or absence of distant metastases li er l ngperitonem metastases –liver, lung, peritoneum

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)

MDACC Classification System for Borderline
Resectable Disease

Type A: Anatomically borderlineresectable tumor (tumor abuts artery for <1800) ( y )

Type B: Indeterminant extrapancreatic metastasis

Type C: Patient of marginal performance status

Summary

• Local tumor resectability is best determined by high quality CT (exploratory surgery is out- dated) dated)

• Resectable tumors may be treated with upfront surgery or a neoadjuvant approach

• Borderline resectable tumors are best treated with upfront systemic therapy/chemoradiation

• Locally advanced tumors, as defined by arterial encasement, are not resectable and surgery is not a realistic treatment option

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