Clinical Challenges in Surgery HPB: Pancreatic Head Cancer

Description: Pancreatic adenocarcinoma is a highly lethal cancer with a dismal long-term prognosis requiring complex multidisciplinary planning in order to optimize outcomes. In this episode from the Hepato-Pancreato-Biliary team at Behind the Knife, we discuss a patient presenting with a borderline resectable pancreatic head mass. 

Learning Objectives: In this episode, we review risk factors for pancreatic adenocarcinoma, key steps of the diagnostic work-up and pre-operative planning, and definitions of resectable, borderline resectable, and unresectable tumors. The history of chemotherapy for pancreatic cancer is briefly reviewed, highlighting the importance of multi-agent regimens and role of neoadjuvant therapy. Finally, we highlight the critical steps of the Whipple procedure.

Hosts:
Timothy Vreeland, MD, FACS (@vreelant) is an Assistant Professor of Surgery at the Uniformed Services University of the Health Sciences and Surgical Oncologist at Brooke Army Medical Center

Daniel Nelson, DO, FACS (@usarmydoc24) is an Associate Professor of Surgery at the Uniformed Services University of the Health Sciences and Surgical Oncologist at William Beaumont Army Medical Center

Connor Chick, MD (@connor_chick) is a PGY-4 General Surgery resident at Brooke Army Medical Center

Lexy (Alexandra) Adams, MD, MPH (@lexyadams16) is a PGY-3 General Surgery resident at Brooke Army Medical Center

Links to Papers Referenced in this Episode

Treatment sequencing for resectable pancreatic cancer: influence of early metastases and surgical complications on multimodality therapy completion and survival
J Gastrointest Surg. 2014 Jan;18(1):16-24
https://pubmed.ncbi.nlm.nih.gov/24241967/ 

Preoperative biliary drainage for cancer of the head of the pancreas
N Engl J Med. 2010 Jan 14;362(2):129-37
https://pubmed.ncbi.nlm.nih.gov/20071702/

1423 pancreaticoduodenectomies for pancreatic cancer: A single-institution experience
J Gastrointest Surg. 2006 Nov;10(9):1199-210; discussion 1210-1.
https://pubmed.ncbi.nlm.nih.gov/17114007/

 Adjuvant chemotherapy with gemcitabine and long-term outcomes among patients with resected pancreatic cancer: the CONKO-001 randomized trial
JAMA. 2013 Oct 9;310(14):1473-81. 
https://pubmed.ncbi.nlm.nih.gov/24104372/

Comparison of adjuvant gemcitabine and capecitabine with gemcitabine monotherapy in patients with resected pancreatic cancer (ESPAC-4): a multicentre, open-label, randomised, phase 3 trial
Lancet. 2017 Mar 11;389(10073):1011-1024
https://pubmed.ncbi.nlm.nih.gov/28129987/

FOLFIRINOX or Gemcitabine as Adjuvant Therapy for Pancreatic Cancer
N Engl J Med. 2018 Dec 20;379:2395-2406
https://www.nejm.org/doi/full/10.1056/NEJMoa1809775 

Surgical Outcome Results From SWOG S1505: A Randomized Clinical Trial of mFOLFIRINOX Versus Gemcitabine/Nab-paclitaxel for Perioperative Treatment of Resectable Pancreatic Ductal Adenocarcinoma
Ann Surg. 2020 Sep 1;272(3):481-486.doi: 10.1097/SLA.0000000000004155
https://pubmed.ncbi.nlm.nih.gov/32740235/

ASCO Guidelines Potentially Curable Pancreatic Adenocarcinoma
https://www.asco.org/research-guidelines/quality-guidelines/guidelines/gastrointestinal-cancer#/12146

NCCN Guidelines Pancreatic Adenocarcinoma
https://www.nccn.org/guidelines/nccn-guidelines/guidelines-detail?category=1&id=1455