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PancreaticCancer
Epidemiology
2019-46,420newcasesinUSA2019-39,590deaths4thmostcommoncancerkiller2ndmostcommonGIcancerkiller(colon#1)PancreaticCancer
Epidemiology1PancreaticCancer
Epidemiology
NewCancerDeaths,UnitedStates,2019.PancreaticCancer
Epidemiology2PancreaticCancer
Epidemiology
Incidenceincreasing1%yearlyPancreaticCancer
Epidemiology3PancreaticCancer
Epidemiology
85%ofnewcasesareadvancedLocallyadvanced:bloodvessels(StageIII)Distantspreadtoliver,lungs(StageIV)PancreaticCancer
Epidemiology4LatePresentation-PoorSurvivalHowlanderetal,SEERCancerStatisticsReview2019.AmericanCancerSociety,CancerFacts&Figures2019.StageIIIIIIIVPercentatdiagnosis60%45%30%15%0%LatePresentation-PoorSurvi5LatePresentation-PoorSurvivalHowlanderetal,SEERCancerStatisticsReview2019.AmericanCancerSociety,CancerFacts&Figures2019.24181260MedianSurvival(mos)StageIIIIIIIV0Even“early”stagediseaseisadvancedLatePresentation-PoorSurvi6NoSurgeryIf..Majorbloodvesselsinvolved(StageIII)Distantmetastases(StageIV)SomeStageIIImaybeexceptionsNoSurgeryIf..7PancreaticResectionDistalPancreatectomy(noAppleby)Whippleoperation(Pancreaticoduodenectomy)PancreaticResectionDistalPan8StandardWhipple
StandardWhipple9StandardWhippleRoux-en-YrarelydoneStandardWhippleRoux-en-Y10PylorusPreservingWhipple
Curerateissamewitheach..MostresectionsarePylorusPreservingWhipplesPylorusPreservingWhipple11PylorusPreservingWhipplePylorusPreservingWhipple12FactorsInfluencingSurvivalFactorsInfluencingSurvival13182consecutivepatientsunderwentaWhippleforpancreaticcancerbetween1987and2019.Patientsfrom1987-2019werecomparedwiththosefrom2019-2019.StudyDesign182consecutivepatientsunder14ResultsResults15SurvivalBiologicalfactorsrelatedtotumorDifferentiationNodalinvolvementPerineuralinvasionResectionmarginsSurvivalBiologicalfactorsrel16DegreeofTumorDifferentiationActuarialsurvivalestimateforpatientswithwell,moderately,andpoorlydifferentiatedadenocarcinomaofthepancreas(P<.001).
50%(1987-2019)DegreeofTumorDifferentiatio17LymphNodesNegativePositive28%22%Actuarialsurvivalfornode-negative(solidline)andnode-positive(dottedline)patientswithadenocarcinomaofthepancreasundergoingapancreaticoduodenectomy(P<.001).38%(1987-2019)LymphNodesNegativePositive28%18PerineuralInvasionNegativePositive36%13%Actuarialsurvivalforpatientswithadenocarcinomaofthepancreasundergoingpancreaticoduodenectomy(P<.001).36%(1987-2019)PerineuralInvasionNegativePos19ResectionMarginsNegativePositive27%Biologicfeaturesofthetumorsthemselvesaretheprimarydeterminantsofprognosis!
27%157pts(1987-2019)R0R1ResectionMarginsNegativePosit2027.4%40.9%76.4%All182PtsSurvivalforEntireCohortAll182Pts(1987-2019)27.4%40.9%76.4%All182PtsSurv21胰腺癌治療進(jìn)展英文課件22350mlEBL475mlEBL35.5%15.8%BloodLossInfluencesSurvival350mlEBL475mlEBL35.5%15.8%23AdjuvantTherapyTreatmentgivenafterresectionEfforttoeradicateanyremainingmicroscopictumorAllptsinUSAreceivechemotherapyafterresection!SomeinUSAalsogetradiationAdjuvantTherapyTreatmentgive24CancermayinvolveHA,PV,superiormesentericveinorarteryUNRESECTABLECancermayUNRESECTABLE25CriteriaforResectionWhynotresecttheinvolvedbloodvessels?CriteriaforResectionWhynot26CriteriaforResectionThosewithvesselinvasionhaveextensivetumorwithmicroscopicspreadthatcannotberemovedcompletelyNotseenonpreopscans,butexperiencetellsusit’sthereIfweresectStageIIItumors,thecancercomesbackquicklyCriteriaforResectionThosewi27“Downstaging”ofPaCa
Ptsgivenchemotherapy6-12mosWetrytokillthemicroscopictumor firstRe-evaluationbyCT,CA19-9ResectionthenpossibleinsomeFirstreportedbyourgroup(2019)NowmorewidelydoneinUSA…So..“Downstaging”ofPaCaSo..28EffectofChemotherapyonTumorTumor:4.4x3.8cmPVinvasion(+)Tumor:2.8x2.5cm(57%reduction)PVinvasion(-)BeforeAfterEffectofChemotherapyonTumo29InitialscanshowsSMAinvolvement6mosscanlookssimilarButpatientfeltwellandCA19-9fellfrom840tonormal..ArchSurg.2019;146(7):836-843.DonahueTR,ReberHAetalWhen/WhethertoOperate?
CTImagingInitialscanshowsSMAinvolve30PVSMASVSMVIMVLRVLGASAHAPancreasAdrenalPVSMASVSMVIMVLRVLGASAHAPancrea31DownstagingofPaCa
Survival25+survivors5-17yearsObservedfive-yearsurvivalrate:28%13morecloseto5yrswithnorecurrencePossiblefiveyearsurvivalrate:53%DownstagingofPaCa25+survivo32AdjuvantTherapyTreatmentgivenaftersurgery(Whipple/distal)EfforttoeradicateanyremainingmicroscopictumorStandardapproachAdjuvantTherapyTreatmentgive33NeoadjuvantTherapyTreatmentgivenbeforesurgeryinptswithresectabledisease(StageIandII)SomeinUSArecommendthisinsteadofsurgeryfirstAdvantagesanddisadvantagesNeoadjuvantTherapyTreatmentg34TheoreticalAdvantagesAlmostallptshavemicrometastaticdiseaseatdiagnosis… 1cm-28%havemetastases 2cm-73% 3cm-94% Soalmostallptscouldbenefit..
Iacobuzio-Donahueetal2019CellTheoreticalAdvantagesAlmosta35TheoreticalAdvantagesIfgivenaftersurgery,upto25%maynotbetreatedatall..Ifgivenbefore,morelikelytobephysicallyfitandabletotoleratetreatmentOrtreatmentmaystartlateiftherewerecomplicationsTheoreticalAdvantagesIfgiven36EffectofAdjuvantTreatmentDelayonSurvivalIacobuzio-Donahueetal2019CellAvoidTreatmentDelayAfterSurgery70%40%EffectofAdjuvantTreatmentD37TheoreticalAdvantagesofNeoadjuvantTherapyIdentifyptsunlikelytobenefitfromsurgery…
During2-3motreatment,upto 20%ptsshowmetastases.. ..ordeveloppoorperformance statusTheoreticalAdvantagesofNeoa38IsThisanAdvantage?Isthisgoodorbad?
Good..Theyaresparedsurgerythatwouldnothavehelped.. orBad..Theymissedtheirchanceforresectionandpossiblecure..IsThisanAdvantage?Isthisg39NeoadjuvantTherapySowhyhasitnotbecomethestandardapproach?SeveralreasonsaregivenChemotherapytodayhaslittleeffectinmostptsNeoadjuvantTherapySowhyhas40NeoadjuvantTherapyAtmost,1/3ofptsrespondtoneoadjuvanttreatment..So2/3woulddelayresectionby2-3months,withouteffectivetreatmentduringthattime..DiseasecouldprogressNeoadjuvantTherapyAtmost,41NeoadjuvantTherapyAlthoughtodayChemotherapyhaslittleeffectinmostpts..Thiscouldchangewithmoreeffectiveneoadjuvantregimens..
OrwiththeabilitytoselectivelychoosearegimenspecificforthemolecularfeaturesofeachtumorNeoadjuvantTherapyAlthought42NeoadjuvantRadioTherapyRadiationTherapy(RTx)ofunclearvalueinmostptsRTxdefinitelydecreaseslocal
recurrenceofcancerButitdoesnotincreasesurvivalinmost..Mostptsdieofdistantdisease(liver,lung,peritoneal)evenwhenlocalrecurrenceislowSoneoadjuvantRTxalsoisnotdonebymostUSAsurgeonsNeoadjuvantRadioTherapyRadi43SurgeryinUSA-2019FurthermajorsurgicaladvancesunlikelyMortalityrate<1%;morbiditystillhighImprovedoutcomeslikelytocomefrommoreeffectivedrugsincombinationwithsurgeryNeoadjuvanttherapywillbeusedmoreMoredownstagingwithbetterdrugsSurgeryinUSA-2019Furtherma44DavidGeffenSchoolofMedicine
atUCLA1955-2019DavidGeffenSchoolofMedicin45RonaldReaganUCLAMedicalCenterOpenedJune2019RonaldReaganUCLAMedicalCen46HowardA.Reber,MDProfessorofSurgeryUCLASchoolofMedicinePancreaticCancer
SurgicalApproachintheUSA-2019AgiHirshbergCenterforPancreaticDiseasesatUCLAHowardA.Reber,MDPancreatic47
Thankyou拯畏怖汾關(guān)爐烹霉躲渠早膘岸緬蘭輛坐蔬光膊列板哮瞥疹傻俘源拯割宜跟三叉神經(jīng)痛-治療三叉神經(jīng)痛-治療拯畏怖汾關(guān)爐烹霉躲渠早膘岸緬蘭輛坐蔬光膊列板哮瞥疹48
拯畏怖汾關(guān)爐烹霉躲渠早膘岸緬蘭輛坐蔬光膊列板哮瞥疹傻俘源拯割宜跟三叉神經(jīng)痛-治療三叉神經(jīng)痛-治療拯畏怖汾關(guān)爐烹霉躲渠早膘岸緬蘭輛坐蔬光膊列板哮瞥疹49PancreaticCancer
Epidemiology
2019-46,420newcasesinUSA2019-39,590deaths4thmostcommoncancerkiller2ndmostcommonGIcancerkiller(colon#1)PancreaticCancer
Epidemiology50PancreaticCancer
Epidemiology
NewCancerDeaths,UnitedStates,2019.PancreaticCancer
Epidemiology51PancreaticCancer
Epidemiology
Incidenceincreasing1%yearlyPancreaticCancer
Epidemiology52PancreaticCancer
Epidemiology
85%ofnewcasesareadvancedLocallyadvanced:bloodvessels(StageIII)Distantspreadtoliver,lungs(StageIV)PancreaticCancer
Epidemiology53LatePresentation-PoorSurvivalHowlanderetal,SEERCancerStatisticsReview2019.AmericanCancerSociety,CancerFacts&Figures2019.StageIIIIIIIVPercentatdiagnosis60%45%30%15%0%LatePresentation-PoorSurvi54LatePresentation-PoorSurvivalHowlanderetal,SEERCancerStatisticsReview2019.AmericanCancerSociety,CancerFacts&Figures2019.24181260MedianSurvival(mos)StageIIIIIIIV0Even“early”stagediseaseisadvancedLatePresentation-PoorSurvi55NoSurgeryIf..Majorbloodvesselsinvolved(StageIII)Distantmetastases(StageIV)SomeStageIIImaybeexceptionsNoSurgeryIf..56PancreaticResectionDistalPancreatectomy(noAppleby)Whippleoperation(Pancreaticoduodenectomy)PancreaticResectionDistalPan57StandardWhipple
StandardWhipple58StandardWhippleRoux-en-YrarelydoneStandardWhippleRoux-en-Y59PylorusPreservingWhipple
Curerateissamewitheach..MostresectionsarePylorusPreservingWhipplesPylorusPreservingWhipple60PylorusPreservingWhipplePylorusPreservingWhipple61FactorsInfluencingSurvivalFactorsInfluencingSurvival62182consecutivepatientsunderwentaWhippleforpancreaticcancerbetween1987and2019.Patientsfrom1987-2019werecomparedwiththosefrom2019-2019.StudyDesign182consecutivepatientsunder63ResultsResults64SurvivalBiologicalfactorsrelatedtotumorDifferentiationNodalinvolvementPerineuralinvasionResectionmarginsSurvivalBiologicalfactorsrel65DegreeofTumorDifferentiationActuarialsurvivalestimateforpatientswithwell,moderately,andpoorlydifferentiatedadenocarcinomaofthepancreas(P<.001).
50%(1987-2019)DegreeofTumorDifferentiatio66LymphNodesNegativePositive28%22%Actuarialsurvivalfornode-negative(solidline)andnode-positive(dottedline)patientswithadenocarcinomaofthepancreasundergoingapancreaticoduodenectomy(P<.001).38%(1987-2019)LymphNodesNegativePositive28%67PerineuralInvasionNegativePositive36%13%Actuarialsurvivalforpatientswithadenocarcinomaofthepancreasundergoingpancreaticoduodenectomy(P<.001).36%(1987-2019)PerineuralInvasionNegativePos68ResectionMarginsNegativePositive27%Biologicfeaturesofthetumorsthemselvesaretheprimarydeterminantsofprognosis!
27%157pts(1987-2019)R0R1ResectionMarginsNegativePosit6927.4%40.9%76.4%All182PtsSurvivalforEntireCohortAll182Pts(1987-2019)27.4%40.9%76.4%All182PtsSurv70胰腺癌治療進(jìn)展英文課件71350mlEBL475mlEBL35.5%15.8%BloodLossInfluencesSurvival350mlEBL475mlEBL35.5%15.8%72AdjuvantTherapyTreatmentgivenafterresectionEfforttoeradicateanyremainingmicroscopictumorAllptsinUSAreceivechemotherapyafterresection!SomeinUSAalsogetradiationAdjuvantTherapyTreatmentgive73CancermayinvolveHA,PV,superiormesentericveinorarteryUNRESECTABLECancermayUNRESECTABLE74CriteriaforResectionWhynotresecttheinvolvedbloodvessels?CriteriaforResectionWhynot75CriteriaforResectionThosewithvesselinvasionhaveextensivetumorwithmicroscopicspreadthatcannotberemovedcompletelyNotseenonpreopscans,butexperiencetellsusit’sthereIfweresectStageIIItumors,thecancercomesbackquicklyCriteriaforResectionThosewi76“Downstaging”ofPaCa
Ptsgivenchemotherapy6-12mosWetrytokillthemicroscopictumor firstRe-evaluationbyCT,CA19-9ResectionthenpossibleinsomeFirstreportedbyourgroup(2019)NowmorewidelydoneinUSA…So..“Downstaging”ofPaCaSo..77EffectofChemotherapyonTumorTumor:4.4x3.8cmPVinvasion(+)Tumor:2.8x2.5cm(57%reduction)PVinvasion(-)BeforeAfterEffectofChemotherapyonTumo78InitialscanshowsSMAinvolvement6mosscanlookssimilarButpatientfeltwellandCA19-9fellfrom840tonormal..ArchSurg.2019;146(7):836-843.DonahueTR,ReberHAetalWhen/WhethertoOperate?
CTImagingInitialscanshowsSMAinvolve79PVSMASVSMVIMVLRVLGASAHAPancreasAdrenalPVSMASVSMVIMVLRVLGASAHAPancrea80DownstagingofPaCa
Survival25+survivors5-17yearsObservedfive-yearsurvivalrate:28%13morecloseto5yrswithnorecurrencePossiblefiveyearsurvivalrate:53%DownstagingofPaCa25+survivo81AdjuvantTherapyTreatmentgivenaftersurgery(Whipple/distal)EfforttoeradicateanyremainingmicroscopictumorStandardapproachAdjuvantTherapyTreatmentgive82NeoadjuvantTherapyTreatmentgivenbeforesurgeryinptswithresectabledisease(StageIandII)SomeinUSArecommendthisinsteadofsurgeryfirstAdvantagesanddisadvantagesNeoadjuvantTherapyTreatmentg83TheoreticalAdvantagesAlmostallptshavemicrometastaticdiseaseatdiagnosis… 1cm-28%havemetastases 2cm-73% 3cm-94% Soalmostallptscouldbenefit..
Iacobuzio-Donahueetal2019CellTheoreticalAdvantagesAlmosta84TheoreticalAdvantagesIfgivenaftersurgery,upto25%maynotbetreatedatall..Ifgivenbefore,morelikelytobephysicallyfitandabletotoleratetreatmentOrtreatmentmaystartlateiftherewerecomplicationsTheoreticalAdvantagesIfgiven85EffectofAdjuvantTreatmentDelayonSurvivalIacobuzio-Donahueetal2019CellAvoidTreatmentDelayAfterSurgery70%40%EffectofAdjuvantTreatmentD86TheoreticalAdvantagesofNeoadjuvantTherapyIdentifyptsunlikelytobenefitfromsurgery…
During2-3motreatment,upto 20%ptsshowmetastases.. ..ordeveloppoorperformance statusTheoreticalAdvantagesofNeoa87IsThisanAdvantage?Isthisgoodorbad?
Good..Theyaresparedsurgerythatwouldnothavehelped.. orBad..Theymissedtheirchanceforresectionandpossiblecure..IsThisanAdvantage?Isthisg88NeoadjuvantTherapySowhyhasitnotbecomethestandardapproach?SeveralreasonsaregivenChemotherapytodayhaslittleeffectinmostptsNeoadjuvantTherapySowhyhas89NeoadjuvantTherapyAtmost,1/3ofptsrespond
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