Re-Resection of isolated recurrent Pancreatic Cancer. Thilo Hackert May 31, 2013

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1 Re-Resection of isolated recurrent Pancreatic Cancer Thilo Hackert May 31, 2013

2 PDAC Recurrence Surgical Topics follow-up after PDAC resection type of recurrence management - local - solitary metastasis - CTX - RCTX - surgery +/- IORT evidence?

3 PDAC Recurrence 145 resected PDAC patients R0 R1 70 patients 75 patients recurrence pattern? van den Broeck et al., EJSO 2009

4 PDAC Recurrence first isolated local recurrence 19 patients (13%) surveillance worthwhile? van den Broeck et al., EJSO 2009

5 PDAC Recurrence ESPAC-1 EORTC overall no. of recurrence: 158 patients only locally: 53 (35%) 11% Gem+RT vs. 24% Gem only distant metastases: 53 (35%) 18% Gem+RT vs. 20% Gem both: 43 (27%) 40% Gem+RT vs. 42% Gem Neoptolemos et al., NEJM 2004, Van Laethem et al, JCO 2010

6 PDAC Follow-Up EPC University of Heidelberg Department of Surgery Department of Radiotherapy National Center of Tumor Diseases

7 Outpatient Department 01/08-12/09 Impact of Follow-Up second-line chemotherapy n= visits n=2029 patients follow-up 2253 visits n=833 PDAC follow-up: 3-monthly clinical QoL questionnaire blood sample (CA 19-9) CT scan reoperation n=39

8 Local Recurrence Hot Spots 9 mm - 4 months postop 10 mm - 7 months postop 13 mm - 9 months postop 16 mm - 12 Months postop

9 Recurrence Resection 410 PDAC patients 17 re-operations (4.1%) for suspected recurrence 12 true recurrences Uhl et al., Dig Surg 2009

10 Recurrence Resection lymph node recurrence behind the SMV Uhl et al., Dig Surg 2009

11 Recurrence Resection long-term survival possible (40% > 10 years) Uhl et al., Dig Surg 2009

12 PDAC Recurrence 1707 resected PDAC patients, patients re-resection (1.3%) 10 local recurrence 12 isolated metastasis morbidity 32% mortality 0% Boone et al., HPB 2013

13 PDAC Recurrence p<0.05 time interval < 15 m 8.2 m > 15 m 40.6 m no difference local vs. metastatic survival from primary surgery median 60.6 m Boone et al., HPB 2013

14 Recurrence Operations Heidelberg 97 PDAC patients with proven recurrence 57 pat. (59%) isolated local recurrence 40 pat. (41%) distant metastases 41 / 57 pat. (72%) resected Strobel et al., Ann Surg Oncol 2012

15 Recurrence Operations HD 10/01 10/09 Strobel et al., Ann Surg Oncol 2012

16 Recurrence Operations HD 10/01 10/09 Strobel et al., Ann Surg Oncol 2012

17 Recurrence Operations HD 10/01 10/09 a b LRV * A A IVC IVC surgical morbidity 10.4% mortality 0.9% Strobel et al., Ann Surg Oncol 2012

18 Recurrence Operations HD 10/01 10/09 exploration can be combined with IORT in case of unresectability Strobel et al., Ann Surg Oncol 2012

19 Resection in local Recurrence: HD 10/01 10/09 recurrence resection is safe & feasible survival superior to palliation not yet standard careful patient selection Strobel et al., Ann Surg Oncol 2012

20 IORT Intraoperative radiotherapy for unresectable pancreatic cancer: a multi-institutional retrospective analysis of 144 patients. K. Ogawa K, K. Karasawa, Y. Ito, Y.Ogawa, K. Jingu, H. Onishi, S.Aoki, H. Wada, M. Kokobu, E. Ogo, H. Etoh, T. Kazumoto, M. Takayama, K. Nemoto, Y. Nishimura, JROSG Working Subgroup of Gastrointestinal Cancers. Department of Radiology, University of the Ryukyus, Nishihara-cho, Okinawa, Japan. kogawa@med.u-ryukyu.ac.jp 144 PDAC patients resection 12.5 % (18/144) no resection 87.5 % (126/144) IORT Gy, additional EBRT & CTX impact of IORT? Ogawa et al., Int J Radiat Oncol Bilo Phys 2011

21 IORT local control 44.6 % 2 years survival 1.7 % 2 years median survival 10.5 months multivariate analysis: CTX use as the only significant factor IORT may be beneficial for local control prognosis defined by CTX! Ogawa et al., Int J Radiat Oncol Bilo Phys 2011

22 Resection for M1 PDAC aortocaval LN metastasis liver metastasis

23 Metastases Resection in PDAC case reports / studies total n = 103 patients median survival months Michalski et al., Dig Surg 2008

24 Metastases Resection in PDAC maximum number of patients: n=22 Michalski et al., Dig Surg 2008

25 Resection for M1 PDAC Is liver resection in metastases of exocrine pancreatic carcinoma justified? J. Klempnauer, G.J. Ridder, P. Piso, R. Pichlmayr Klinik für Abdominal- und Transplantationschirurgie, Medizinischen Hochschule Hannover liver resection for metastases PDAC n = 20 ampullary cancer n = 2 synchronous n = 16 metachronous n = 7 Klempnauer et al., Chirurg 1996

26 Resection for M1 PDAC R0: 69% synchronous 100% metachronous metachr. median survival synchr. 8.3 m synchronous 5.8 m metachronous 1-y survival 40 % synchronous 41 % metachronous Klempnauer et al., Chirurg 1996

27 Resection for M1 Cancer October 2001 until July PDAC resections (R0 / R1) 287 M0 disease / 29 M1 disease Shrikhande et al., Ann Surg Oncol 2007

28 Resection for M1 Cancer operative parameters & morbidity no significant differences Shrikhande et al., Ann Surg Oncol 2007

29 Resection for M1 PDAC survival site of metastases n.s. liver met. resection vs. palliative Shrikhande et al., Ann Surg Oncol 2007

30 Conclusion Recurrence Resection isolated local recurrence induction CRT exploration resection + IORT metachronous metastases resection is no standard, possible in selected patients follow-up is worthwhile

31 General, Visceral and Transplantation Surgery University of Heidelberg, Germany

32 Metastases Resection in Pancreatic Cancer 37-y old female patient Whipple due to neuro-endocrine carcinoma 6 months postoperqatively LN & peritoneal metastases

33 Metastases Resection in Pancreatic Cancer peri-aortal LN metastases interaorto-caval LN metastases

34 Metastases Resection in Pancreatic Cancer left kidney vein ultra-radical lymph node & peritoneal dissection aorta inf. mesenteric artery (17/53 LN positive) postoperatively CTX mesenteric lymph node dissection survival 32 months