Pancreas Cancer 2015

Pancreas Cancer2015Daniel Kollmorgen, MDSurgical OncologyThe Iowa ClinicI have no financial conflictsNOVEMBERPancreatic Cancer Awareness Month

WageHope.org

Pancreatic Adenocarcinoma90% of all pancreas cancersIncidence 46,000 new cases annuallyIncidence increasing4th leading cause of cancer deathPrognosis5 year survival:7%2030 Projection: 2nd most common cause of cancer related death134 AMERICANS diagnosed daily, 111 will die from disease5Risk FactorsSmoking: 2xAge: most over 60Obesity: 20% increaseFamily History: 2-3x (first degree relative)Male > FemaleAfrican American > Caucasian, Asian, HispanicChronic PancreatitisHereditary conditionsGeneticsHereditary Breast and Ovarian CancerBRCA2 (3-6 x increase)Familial MelanomaP16 (20-47 x increase)Familial PancreatitisPRSS1 (26-87 x increase)NeurofibromatosisNF1Other: HNPCC, PJS, VHL, Hboc 3-6x, fam mel 20-47x, Fam panc 26-87x, Lynch 10x, PJS 132x7PresentationSymptomsPainless JaundiceBack PainWeight LossSignsNew Onset DiabetesPalpable GBNew DVTIncidentalPancreas cyst noted in 1% of all Abdominal CTs

Work Up/DiagnosticsLabsCA19-9UltrasoundCT

ERCPPTCMRIEUSPETStagingT N MAt Presentation / 5 year SurvivalI/II : 9% /26% III : 28%/10%IV : 53%/2%CT standardizationResectable vs Borderline Locally advancedMetastaticStandard ApproachPatient Issues / Co morbiditiesDetailed H&P, labshttp://riskcalculator.facs.orgImaging / AnatomyPancreatic protocolIV and oral contrastArterial and Venous phasesMultiplanar reconstructionBorderline Resectable: tumor OR patient?

CT InterpretationResectable: No contact with celiac, SMA, or common hepatic artery180 degree artery involvementExtensive vein involvement

Resectable

OperationsPancreaticoduodenectomy (Whipple)StandardPylorus PreservingLeft Pancreatectomy (Distal)Spleen PreservingTotal PancreatectomyCeliac resection

Anatomy

Multi Disciplinary ConferenceSpectrum of PhysiciansSurgery, Med Onc, Rad Onc, Diagnostic Rad, IR, GIAnatomy/ LocationNutritionGeneticsSocial SupportCoordinator/NavigatorClinical TrialsSocial / Support IssuesCoordinationLiteracy IssuesPalliative CareHospiceFamily SupportFinancial IssuesFamily History / GeneticsWhipple Good News3-6 hour operation7-10 days in hospital4-6 weeks recoveryOnly way to be a survivorTriple therapy survival: 20-25% Mortality Dropping

Redefining ResectableWhipple Bad NewsMortality: 30%Pancreatic fistula: 10%Delayed gastric emptying: 15%Endocrine and Exocrine insufficiencyDelay to Adjuvant therapy

ChemotherapyAdjuvant = 5FU or GemcitibineNo standard therapyGemzar preferred due to toxicityCombinationsAlbumin bound paclitaxelErlotinib (TKI)Cisplatin

Chemotherapy IIMetastatic = FOLFIRINOXOxaliplatin, leucovorin, iriontecan, 5-FUPreferred over Gemcitabine12 month survival: 48% v 20%High toxicity fit patients32% hospitalizationGemcitabine + Nab-paclitaxel comparableNeoadjuvantFOLFIRINOX33% went on to R0 resection

Radiation TherapyMixed reviews in adjuvant settingNCCN guidelinesone of 8 adjuvant choicesMeta analysis 2012: 15 studiesNo change in DFS, 2 year survival, or OSOutdated delivery(?)New (?) ConceptsBlind Whipple

Early Detection Neoadjuvant ApproachMinimally InvasiveCentralizing care

New Concepts IIRadiation TechniquesIMRTSBRT TrueBeam, Cyberknife, etcIORTMolecular ConceptsBiomarkersCa 19-9Stromal DisruptionPARP InhibitorsEarly DetectionSeries of mutations Kras, p53, p16, SMAD4Precursor lesionsPanINIPMNCharacterization of precursorsMorphologyDNA: mutations, LOHTrials in high risk patients

Neoadjuvant RationaleBetter OxygenationDownstaging (?)Better Patient SelectionDeclare Natural History25% advance on restagingIncrease R0 resectionMore patients complete therapy

Neoadjuvant OutcomesNo phase III trialsNo clear (single/best) regimenWhich meds? How much?Chemo or ChemoRT?Imaging rarely changesVascular involvementAlliance 21101FOLFIRINOX, capcitabene/RT, OR, gemcitabine

Laparoscopic SurgeryDistal PancreatectomyDecrease: EBL, ICU, hospital stayNo change in oncologic outcome

WhippleHighly selected seriesComplication rate unchangedMorbidity 50%

Volume CountsCentralizationHigh volume center (>5 cases/year)Mortality