Management of Management of PancreatoPancreato--biliarybiliaryMalignancyMalignancy

Moderators:Moderators:

Giuseppe Giuseppe AlipertiAliperti, MD, MD

Paul Schultz, MDPaul Schultz, MD

Pancreatic Surgeon: Pancreatic Surgeon: Douglas Evans, MDDouglas Evans, MDHamillHamill Foundation Distinguished Professor of SurgeryFoundation Distinguished Professor of SurgeryChief, Endocrine and Pancreatic SurgeryChief, Endocrine and Pancreatic SurgeryMD Anderson Cancer CenterMD Anderson Cancer Center

Hepatobiliary Surgeon: Hepatobiliary Surgeon: MichealMicheal ChotiChoti, MD, MBA, MD, MBAThe Jacob C. The Jacob C. HandelsmanHandelsman Professor of SurgeryProfessor of SurgeryChief, Chief, HandelsmanHandelsman Division of Surgical OncologyDivision of Surgical OncologyJohns Hopkins Medical InstituteJohns Hopkins Medical Institute

Oncologists: Oncologists: Robert Wolff, MDRobert Wolff, MDAssociate Professor, GI medical OncologyAssociate Professor, GI medical OncologyDeputy Head, Division of Cancer MedicineDeputy Head, Division of Cancer MedicineMD Anderson Cancer CenterMD Anderson Cancer Center

EndosonographerEndosonographer: : Frank Frank GressGress, MD, MDProfessor of MedicineProfessor of MedicineChief, Division of Gastroenterology and HepatologyChief, Division of Gastroenterology and HepatologySUNY Downstate Medical CenterSUNY Downstate Medical Center

ERCPistERCPist: : David CarrDavid Carr--Locke, FRCPLocke, FRCPDirector, The Endoscopy InstituteDirector, The Endoscopy InstituteAssociate Professor, Division of GastroenterologyAssociate Professor, Division of GastroenterologyBrigham and WomenBrigham and Women’’s Hospitals Hospital

Surgery for pancreatic cancersSurgery for pancreatic cancersDouglas Evans Douglas Evans 12 minute12 minute

What are the criteria for What are the criteria for unresectabilityunresectability

What is a borderline What is a borderline resectableresectable tumortumor–– Management of borderline Management of borderline resectableresectable tumorstumors–– Vascular resection and reconstructionVascular resection and reconstruction-- when is it worth it?when is it worth it?

ResectableResectable tumors in patients who are poor surgical tumors in patients who are poor surgical candidatescandidates

–– RiskRisk--benefit analysisbenefit analysis

Role of surgeon in unresectable tumorsRole of surgeon in unresectable tumors

What are objective criteria for identifying What are objective criteria for identifying adequate/good surgical resultsadequate/good surgical results

Surgery for Surgery for CholangiocarcinomaCholangiocarcinoma::Michael Michael ChotiChoti 12 12 minsmins

How to identify unresectable tumorsHow to identify unresectable tumors

Management of surgically unresectable tumorsManagement of surgically unresectable tumors

ResectableResectable tumors in bad locationstumors in bad locations

ResectableResectable tumors in bad operative candidatestumors in bad operative candidates

Suspected Suspected cholangiocarcinomascholangiocarcinomas without definitive without definitive tissue diagnosistissue diagnosis

–– When the tumor seems When the tumor seems resectableresectable–– When the tumor appears unresectableWhen the tumor appears unresectable

Medical management of Medical management of pancreatopancreato--biliarybiliarycancers: cancers: Robert Wolff Robert Wolff 12 12 minsmins

PrePre--op op chemoradiationchemoradiation–– All potentially All potentially resectableresectable tumors or only borderline tumors or only borderline resectableresectable

tumorstumors

PostPost--operative operative chemoradiationchemoradiation afterafter–– R0 resection (negative margins)R0 resection (negative margins)–– R1 resection (microscopic positive margins)R1 resection (microscopic positive margins)–– R2 resection (macroscopic positive margins)R2 resection (macroscopic positive margins)

Palliative Palliative chemoradiationchemoradiation–– What is the role and benefitWhat is the role and benefit

Chemotherapy/Chemotherapy/chemoXRTchemoXRT nonnon--respondersresponders–– Role of second and third line therapiesRole of second and third line therapies–– Benefits Benefits vsvs toxicitytoxicity

EUS in management of EUS in management of pancreatopancreato--biliarybiliarycancers:cancers:Frank Frank GressGress 12 12 minsmins

Staging pancreatic cancers with EUSStaging pancreatic cancers with EUS–– Where and how does it help?Where and how does it help?

Staging Staging cholangiocarcinomascholangiocarcinomas with EUSwith EUS–– Role of intraductal USRole of intraductal US

Therapeutic EUSTherapeutic EUS–– Pain management with Celiac plexus blockPain management with Celiac plexus block–– IntratumoralIntratumoral injection of therapeutic agentsinjection of therapeutic agents–– FiducialFiducial placement for radiotherapyplacement for radiotherapy

Recurrent cancer after WhippleRecurrent cancer after Whipple–– Role of EUSRole of EUS

Interventional Endoscopy in management of Interventional Endoscopy in management of PancreatoPancreato--biliarybiliary Cancers: Cancers: David CarrDavid Carr--Locke Locke 12 12 minsmins

Palliation of jaundicePalliation of jaundice–– CholangiocarcinomaCholangiocarcinoma

Drain one side or both sidesDrain one side or both sidesPlastic Plastic vsvs metal metal stentsstents

–– Pancreatic cancersPancreatic cancersPlastic Plastic vsvs metal metal stentsstents

Timing of Timing of stentstent change in unresectable tumorschange in unresectable tumors–– When When stentstent is occluded or at fixed intervalsis occluded or at fixed intervals

BrachytherapyBrachytherapy for for cholangioCacholangioCa

Gastric outlet obstructionGastric outlet obstruction–– StentStent placement placement vsvs gastric bypassgastric bypass–– Timing of Timing of stentstent placementplacement

Role of GRole of G--J tube for nutritionJ tube for nutrition–– Do they help or they increase morbidity and mortalityDo they help or they increase morbidity and mortality

Case 1Case 1

A 59 year old woman undergoes a R0 Whipple A 59 year old woman undergoes a R0 Whipple resection of her pancreatic cancer.resection of her pancreatic cancer.

Receives postReceives post--operative chemooperative chemo--radiationradiation

Patient doing wellPatient doing well

AQ1AQ1. Should the patient have an active or . Should the patient have an active or passive postpassive post--treatment followtreatment follow--upup

1.1. Active followActive follow--up up

2.2. Passive followPassive follow--upup

Comments from the facultyComments from the faculty

AQ2.AQ2. What are appropriate tests for followWhat are appropriate tests for follow--upup

1.1. Ca19Ca19--99

2.2. CT abdomenCT abdomen

3.3. CT pelvisCT pelvis

4.4. PET scanPET scan

5.5. 1 and 2 only1 and 2 only

6.6. All of the aboveAll of the above

Comments from the facultyComments from the faculty

Result Expected Units CA 19-9 Ag 3.9 0.0 - 35.0 Units/ml

• Minimal soft tissue infiltration at surgical clips

•unchanged at 3 months and 6 months

AQ3.AQ3. 9 months after surgery,9 months after surgery,

–– her CA19her CA19--9 levels increase to 60 9 levels increase to 60 ngng/ml and /ml and

–– then 3 months later to 95 then 3 months later to 95 ngng/ml. /ml.

Appropriate next test in this patient would be Appropriate next test in this patient would be

1.1. CT scanCT scan-- chest/abdomen/pelvischest/abdomen/pelvis2.2. MRI scanMRI scan3.3. PET scanPET scan4.4. EUSEUS--FNAFNA5.5. EGDEGD

Comments from the facultyComments from the faculty

Soft tissue at surgical bed with main PV narrowing

AQ4.AQ4. PET scan shows hot spot in the bed of pancreatic PET scan shows hot spot in the bed of pancreatic head. Appropriate next test would behead. Appropriate next test would be

1.1. EUSEUS--FNAFNA

2.2. CTCT--guided FNAguided FNA

3.3. Repeat CT scan in 6Repeat CT scan in 6--12 weeks12 weeks

4.4. Treat empirically with second line chemotherapyTreat empirically with second line chemotherapy

5.5. None of the aboveNone of the above

Comments from the facultyComments from the faculty

AQ5.AQ5. CT guided FNA shows recurrent adenocarcinoma. CT guided FNA shows recurrent adenocarcinoma. Appropriate next step in management would beAppropriate next step in management would be

1.1. Refer to surgery for removal of recurrent tumorRefer to surgery for removal of recurrent tumor

2.2. RadiotherapyRadiotherapy

3.3. 22ndnd line line ChemotherapyChemotherapy±±RadiationRadiation

4.4. HospiceHospice

Comments from the facultyComments from the faculty

Question to all facultyQuestion to all faculty

What kind of followWhat kind of follow--up is appropriate in patients with up is appropriate in patients with pancreatic cancer after treatmentpancreatic cancer after treatment

–– Are there any situations where intensive follow up is Are there any situations where intensive follow up is worthwhile andworthwhile and

–– Which are those clinical situationsWhich are those clinical situations

David CarrDavid Carr--LockeLocke

Obstructive jaundice in patients after WhippleObstructive jaundice in patients after Whipple’’s s resection for pancreatic cancerresection for pancreatic cancer–– Are attempts at ERCP worth the effort?Are attempts at ERCP worth the effort?

–– What kind of What kind of stentsstents to use for drainage?to use for drainage?

–– Role of double balloon Role of double balloon enteroscopeenteroscope??

Case 2Case 2

65 year man presents with new onset 65 year man presents with new onset obstructive jaundice obstructive jaundice

ERCP ERCP –– a mid CBD stricture. a mid CBD stricture. s/ps/p biliarybiliary stentstent placementplacement

EUSEUS--FNA FNA –– 2 cm focal mass lesion in relation to mid CBD2 cm focal mass lesion in relation to mid CBD–– Cytology atypical cells with lots of inflammation.Cytology atypical cells with lots of inflammation.

However not diagnostic for cancerHowever not diagnostic for cancer

AQ6.AQ6. Appropriate next step in the Appropriate next step in the management of this patient is management of this patient is

1.1. Surgical explorationSurgical exploration

2.2. Follow up imaging in 6 weeksFollow up imaging in 6 weeks

Comments from the facultyComments from the faculty

Frank Frank GressGress

What is the value of EUSWhat is the value of EUS--FNA in diagnosis of FNA in diagnosis of biliarybiliary stricturesstrictures–– Is it useful in ruling out unresectable cancersIs it useful in ruling out unresectable cancers

–– Are there any benign etiologies that are easily and Are there any benign etiologies that are easily and reliably diagnosed by EUSreliably diagnosed by EUS--FNA or FNA or biliarybiliary Intraductal Intraductal Ultrasound (Ultrasound (biliarybiliary IDUS)IDUS)

Patient is taken for surgery. Patient is taken for surgery.

During surgery During surgery

–– the diagnosis of cancer is confirmed and the diagnosis of cancer is confirmed and

–– malignant malignant periportalperiportal lymph nodes are also lymph nodes are also encountedencounted. .

AQ7.AQ7. Appropriate next step would beAppropriate next step would be

1.1. Proceed with surgery and remove the tumor and Proceed with surgery and remove the tumor and lymph nodeslymph nodes

2.2. Abandon resection of tumor and close the abdomenAbandon resection of tumor and close the abdomen

Comments from the facultyComments from the faculty

AQ8.AQ8. Surgeon decides Surgeon decides againstagainst proceeding with proceeding with resection and closes abdomen.resection and closes abdomen.

Further management of this patient should Further management of this patient should involve placement of a metal involve placement of a metal biliarybiliary stentstent andand

1.1. No further therapyNo further therapy

2.2. ChemoradiationChemoradiation

3.3. Chemotherapy aloneChemotherapy alone

4.4. Radiation aloneRadiation alone

Comments from the facultyComments from the faculty

Michael Michael ChotiChoti

In patients with In patients with hilar/perihilarhilar/perihilar cholangiocarcinomacholangiocarcinoma, , how do you choose between how do you choose between

surgical bypass and endoscopic surgical bypass and endoscopic stentstent placement for placement for biliarybiliary drainagedrainage

AQ9.AQ9. Patient is started on Patient is started on chemoXRTchemoXRT and and –– has good response. has good response.

Should this patient be reShould this patient be re--evaluated for another evaluated for another attempt at surgical resectionattempt at surgical resection

1.1. YesYes

2.2. NoNo

Comments from the facultyComments from the faculty

AQ10.AQ10. Active followActive follow--up in patients with up in patients with cholangiocholangio--carcinoma is recommended incarcinoma is recommended in

1.1. ResectableResectable tumor that is removed with R0 tumor that is removed with R0 resectionresection

2.2. Following R1 and R2 resectionFollowing R1 and R2 resection

3.3. Unresectable tumor managed with Unresectable tumor managed with chemoXRTchemoXRT

4.4. None of the aboveNone of the above

Comments from the facultyComments from the faculty

Closing remarks from each panelistClosing remarks from each panelist