Determining Resectability and Subsequent Therapy in Pancreatic Cancer

In a conversation with CancerNetwork^® about the application of intraoperative radiation therapy (IORT) for patients with pancreatic cancer, Kamran Idrees, MD, MSCI, MMHC, FACS, highlighted the factors that surgical oncologists must consider when determining the resectability of a patient’s disease.

Idrees is the chief of the Division of Surgical Oncology & Endocrine Surgery, an associate professor of surgery, an Ingram Associate Professor of Cancer Research, and director of Pancreatic and Gastro-Intestinal Surgical Oncology at Vanderbilt University Medical Center.

According to Idrees, patients who may be eligible for surgical care can be sorted into 3 major groups: those with metastatic disease, those with resectable disease, and those with borderline resectable or locally advanced disease. Patients with resectable disease are able to receive chemotherapy plus surgery, whereas those with borderline resectable disease may be eligible to receive treatment consisting of chemotherapy, radiotherapy, surgery, and IORT.

Transcript:

Historically, the management of pancreatic cancer—as long as the tumor is resectable—has revolved around surgery. We know that even if the surgery is performed and the pancreatic tumor is completely resected, most of the patients will [have recurrence] within the first few years, either locally or to distant organs such as the liver and lung. Now, what that tells us is that surgery is necessary to offer a chance for cure for these patients with pancreatic cancer, but it’s not sufficient. Hence, the treatment of [patients with] pancreatic cancer has shifted towards a multimodal therapy.

The goal for a surgeon is to select the right patient, making sure the patient is strong enough to undergo surgery and does not have prohibitive medical conditions. There is no actual cut off in terms of age to perform pancreatic surgery. The second goal for the surgeon is to do the right operation, achieve negative margins, and to minimize or eliminate any complications so that the patients can move on to the next stage of the treatment, which is chemotherapy.

When I evaluate a patient with pancreatic cancer, I will usually put them in 3 big buckets. The first group, unfortunately, is the patients who will present with metastatic cancer at the time of diagnosis. Unfortunately, the treatment for those patients is going to be systemic chemotherapy, not surgery or radiation. The next bucket is either resectable [disease], or the third bucket, which is called borderline resectable or locally advanced [disease]. That determines the operability or resectability of these pancreatic cancer tumors, which we make on cross sectional imaging. And the imaging modality that is usually utilized, at least at our institution, is a triple phase CT scan. Here, you can see the pancreas is, what I will call it, located at a "high-price real estate." There are key structures such as the blood vessels to a majority of our small intestine and large intestine, as well as key blood vessels that supply organs such as the liver, which makes the determination for resectability. If any of these vessels are involved, we will categorize them as either borderline resectable or locally advanced tumors based on the involvement of the veins or arteries. If none of these vessels are involved, those are resectable tumors.

Here’s an example of a CT scan with a patient with borderline resectable pancreatic cancer. You can see how the pancreatic tumor is at least involved in greater than 180 degrees of superior mesenteric vein, as well as the abutment of superior mesenteric artery. If the patients have resectable disease, usually, they can undergo surgery followed by chemotherapy or chemotherapy followed by surgery. For those patients who are in the borderline resectable or locally advanced bucket, the standard treatment is to start with systemic chemotherapy followed by radiation therapy, if needed, followed by surgery, and [with or without] intraoperative radiation therapy.