Chapter 75: Perspective on Pancreatic Neoplasms

CANCERS OF THE PERIAMPULLARY REGION AND PANCREAS

Drs. Gajdos, McCarter, Edil, Paniccia, and Schulick provide an extremely comprehensive chapter on the evaluation and treatment of patients with cancer of the periampullary region and especially the pancreatic head (Chapter 73). ­Importantly, there has been a tremendous advance in both the understanding of the molecular biology of pancreatic cancer as well as our ability to accurately image the pancreas and periampullary region prior to surgery. Advances in computed tomography (CT) and magnetic resonance imaging (MRI) have allowed for accurate assessment of critically important tumor-vessel relationships. Such accurate assessment of the relevant anatomy is important for both pretreatment staging and for planning the operation, especially if vascular resection and reconstruction may be indicated. The ability to preoperatively classify patients as having resectable, borderline resectable, or locally advanced pancreatic cancer (LAPC) allows for optimal treatment sequencing (often including neoadjuvant therapy), the evaluation of patients for investigator-­initiated and cooperative group clinical trials, and the referral of patients to higher volume centers.¹ Indeed, to the extent that outcome is improved for patients with localized disease at high-volume centers (by high-volume surgeons), patients will need to be accurately staged (CT imaging) and, when necessary, have biliary stents placed safely in order to facilitate referral to a specialty center. The ability to perform endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) biopsy will prevent diagnostic uncertainty and allow for medical oncology consultation and multidisciplinary care.

Fortunately, the past decade has witnessed the development of consensus for the CT staging of pancreatic cancer. In an attempt to clarify the anatomy of resectable, borderline resectable, and locally advanced disease, Varadhachary and colleagues from The University of Texas M.D. Anderson Cancer Center proposed an objectively defined, CT-based classification that distinguishes borderline resectable pancreatic cancer from both resectable pancreatic cancer and LAPC.² This definition was developed for the conduct of clinical trials of neoadjuvant treatment sequencing and was not intended to support a surgery-first strategy for patients who may require vascular resection and reconstruction. The Varadhachary definitions also assumed the technical capability to resect and reconstruct the superior mesenteric–­portal vein (SMPV) confluence (when necessary) and that the major determinants of margin status (R status) were the tumor-artery (celiac, hepatic, and superior mesenteric ­artery) relationships. In contrast to the management of resectable and borderline resectable pancreatic cancer, surgery has typically not been applied to patients with locally advanced or metastatic disease. Patients with LAPC were considered to have inoperable tumors; surgery was felt not to be technically possible. With recent improvements in response rates for systemic therapy, an increasing number of patients with LAPC are found to have stable or responding disease after a prolonged course of systemic therapy (4-6 months or more) with or without having received radiation therapy. Such patients have only 1 site of measurable disease—the primary tumor—and therefore are often sent for surgical consultation to consider removal of the only remaining abnormality seen on cross-sectional imaging. ...