CT, chemorad protocol offers 2nd chance to patients w/ unresectable pancreatic tumors

A new approach to the management of a devastating form of pancreatic cancer could offer hope to patients who were previously told their tumors were inoperable. Using a combination of radiographic restaging, multimodality treatment, and advanced surgical techniques, the majority of patients in a recently published study who would have received only palliative, noncurative therapy were deemed to have resectable tumors and saw survival benefits following treatment, according to results appearing in the July issue of the Journal of the American College of Surgeons.

Pancreatic adenocarcinoma is a particularly deadly form of pancreatic cancer with a survival rate of 5 percent at five years. It can be cured with surgical removal of the tumor, but only 20 percent of patients undergo surgery as many tumors are considered inoperable and incurable if they grow into adjacent vital blood vessels.

Lead study author Jason B. Fleming, MD, and colleagues from the University of Texas MD Anderson Cancer Center, Houston, used a different method of classifying patients for treatment. “In our approach, a patient’s anatomic tumor classification is then combined with biologic and comorbidity data to risk stratify patients and tailor therapy through a multimodality approach,” they wrote.

For patients with tumors deemed unresectable at surgical exploration, the technique involves restaging using CT scans and collaborative interpretation between surgeons and radiologists. The tumor is then treated preoperatively with chemoradiation before surgical resection with planned removal and reconstruction of involved vital blood vessels near the tumor.

The study reported on 88 patients referred to MD Anderson from 1990 to 2010. Radiographic restaging reclassified 61 patients as having resectable tumors and 20 as having borderline resectable tumors. Reoperative pancreatectomy was performed in 66 patients with 94 percent of resections providing complete removal of tumors. Most patients (91 percent) received preoperative chemoradiation, though a small fraction underwent surgery first.

Vascular resection or reconstruction was required in 46 percent of patients and 76 percent required complex revision of previously created biliary/gastrointestinal bypass, according to the study results. Twenty percent of patients suffered major complications and three patients died perioperatively.

Median overall survival for successfully resected patients was 29.6 months, compared with 10.6 months for patients with locally advanced unresectable disease at initial referral and 5.1 months in patients who developed metastatic disease before resection.

"We've been able to achieve survival numbers for these patients that are comparable to those receiving surgery for clearly operable tumors," Fleming said in a release.

The key to screening patients for treatment and staging of their cancer was the interpretation of the CT scans before the operation, according to Fleming. “The interpretation needs to be performed in conjunction with the radiologist, but also with heavy involvement by the surgeon. The goal should be to give the surgeon a clear idea of tumor location and vessel involvement before beginning the operation,” he said.

Fleming explained that the MD Anderson protocol uses a scoring system along with structured documentation for the radiologist to more accurately assess the extent of tumor-vessel involvement. "With good imaging and good interpretation you have a high likelihood of being able to predict involvement of the vessels before surgical treatment, not after," he said.