“Inoperable” Pancreatic Cancer
The patients who do the best and live the longest with pancreatic cancer are the ones in which the surgeon is able to remove the tumor. At initial presentation, over half of patients with pancreatic cancer have metastatic disease. Only 15% of patients present with a tumor that is operable by traditional criteria. However, for every patient with an operable tumor, there are two patients (or 30% of the total) who present with locally advanced disease involving local major vascular structures, but with no evidence of disease spread. These patients were classically described as inoperable. However, strategies designed to recruit these ‘inoperable’ patients into the surgical cohort have the potential to triple the impact of surgery on this disease. Two such strategies are neoadjuvant chemo-radio therapy and vascular resection with reconstruction.
When chemotherapy or radiation are given prior to an operation, the treatment is termed “neoadjuvant.” Recent improvement in the effectiveness of chemotherapeutic agents and innovations in the delivery of radiotherapy have enabled physicians to reduce the size of many pancreatic cancers and to change the relationship of the tumor to the local major vascular structures making surgery feasible.
Several neoadjuvant chemotherapy protocols are available to patients at Winthrop. One commonly used regimen uses 3 drugs. Patients take Xeloda, which is an oral medication, on days 1-14. On days 4 and 11 patients receive an infusion of Gemzar and Abraxane (GAX). Patients then get a week of rest to complete the 21 day cycle. Patients undergo 4 to 6 cycles of GAX followed by radiologic restaging. The objective response rate to this regimen is greater than 50% (as compared to a response rate of 12% for Gemzar alone). Few patients (<5%) will have progressive disease. After completing chemotherapy, patients undergo radiologic restaging. In the absence of disease progression patients then proceed to an attempt at surgical resection, which is successful in 82% of patients, but may require reconstruction of one of the local major blood vessels.
Vascular resection and reconstruction
The major vascular structures in the local area include the superior mesenteric and portal veins and the hepatic and superior mesenteric arteries. When these vessels are involved, the tumor is considered inoperable by traditional criteria. Over the past decade our group and others have developed surgical techniques which enable the removal of these vessels with the tumor followed by reconstruction of the blood vessel to reestablish blood flow. When used in conjunction with neoadjuvant therapy, about 80% of these tumors can eventually be resected.
Outcomes for the inopearable patient
Patients who initially present with ‘inoperable’ pancreatic cancer can expect to have equivalent survival to those that present with ‘operable’ cancer, if the surgeon is ultimately able to remove the tumor after neoadjuvant therapy with or without a vascular reconstruction.