Management of Management of Pancreato-biliary Pancreato-biliary MalignancyMalignancy

Moderators:Moderators:

Giuseppe Aliperti, MDGiuseppe Aliperti, MD

Paul Schultz, MDPaul Schultz, MD

Pancreatic Surgeon: Pancreatic Surgeon: Douglas Evans, MDDouglas Evans, MDHamill Foundation Distinguished Professor of Hamill Foundation Distinguished Professor of

SurgerySurgeryChief, Endocrine and Pancreatic SurgeryChief, Endocrine and Pancreatic SurgeryMD Anderson Cancer CenterMD Anderson Cancer Center

Hepatobiliary Surgeon: Hepatobiliary Surgeon: Micheal Choti, MD, MBAMicheal Choti, MD, MBAThe Jacob C. Handelsman Professor of SurgeryThe Jacob C. Handelsman Professor of SurgeryChief, Handelsman Division of Surgical OncologyChief, Handelsman Division 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

Endosonographer: Endosonographer: Frank Gress, MDFrank Gress, MDProfessor of MedicineProfessor of MedicineChief, Division of Gastroenterology and HepatologyChief, Division of Gastroenterology and HepatologySUNY Downstate Medical CenterSUNY Downstate Medical Center

ERCPist: ERCPist: David Carr-Locke, FRCPDavid Carr-Locke, FRCPDirector, The Endoscopy InstituteDirector, The Endoscopy InstituteAssociate Professor, Division of GastroenterologyAssociate Professor, Division of GastroenterologyBrigham and Women’s HospitalBrigham and Women’s Hospital

Surgery for pancreatic Surgery for pancreatic cancerscancers Douglas Evans Douglas Evans 12 minute12 minute

What are the criteria for unresectabilityWhat are the criteria for unresectability

What is a borderline resectable tumorWhat is a borderline resectable tumor– Management of borderline resectable tumorsManagement of borderline resectable tumors– Vascular resection and reconstruction- when is it worth it?Vascular resection and reconstruction- when is it worth it?

Resectable tumors in patients who are poor surgical Resectable tumors in patients who are poor surgical candidatescandidates– Risk-benefit analysisRisk-benefit 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 Cholangiocarcinoma:Cholangiocarcinoma: Michael Choti Michael Choti 12 mins12 mins

How to identify unresectable tumorsHow to identify unresectable tumors

Management of surgically unresectable tumorsManagement of surgically unresectable tumors

Resectable tumors in bad locationsResectable tumors in bad locations

Resectable tumors in bad operative candidatesResectable tumors in bad operative candidates

Suspected cholangiocarcinomas without definitive Suspected cholangiocarcinomas without definitive tissue diagnosistissue diagnosis– When the tumor seems resectableWhen the tumor seems resectable– When the tumor appears unresectableWhen the tumor appears unresectable

Medical management of Medical management of pancreato-biliary cancers: pancreato-biliary cancers: Robert Wolff Robert Wolff 12 mins12 mins

Pre-op chemoradiation Pre-op chemoradiation – All potentially resectable tumors or only borderline resectable All potentially resectable tumors or only borderline resectable

tumorstumors

Post-operative chemoradiation afterPost-operative chemoradiation after– 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 chemoradiationPalliative chemoradiation– What is the role and benefitWhat is the role and benefit

Chemotherapy/chemoXRT non-respondersChemotherapy/chemoXRT non-responders– Role of second and third line therapiesRole of second and third line therapies– Benefits vs toxicityBenefits vs toxicity

EUS in management of EUS in management of pancreato-biliary cancers:pancreato-biliary cancers:Frank Gress Frank Gress 12 mins12 mins

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

Staging cholangiocarcinomas with EUSStaging cholangiocarcinomas with EUS– Role of intraductal USRole of intraductal US

Therapeutic EUSTherapeutic EUS– Pain management with Celiac plexus blockPain management with Celiac plexus block– Intratumoral injection of therapeutic agentsIntratumoral injection of therapeutic agents– Fiducial placement for radiotherapyFiducial placement for radiotherapy

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

Interventional Endoscopy in Interventional Endoscopy in management of Pancreato-biliary management of Pancreato-biliary Cancers: Cancers: David Carr-Locke David Carr-Locke 12 mins12 mins

Palliation of jaundicePalliation of jaundice– CholangiocarcinomaCholangiocarcinoma

Drain one side or both sidesDrain one side or both sides Plastic vs metal stentsPlastic vs metal stents

– Pancreatic cancersPancreatic cancers Plastic vs metal stentsPlastic vs metal stents

Timing of stent change in unresectable tumorsTiming of stent change in unresectable tumors– When stent is occluded or at fixed intervalsWhen stent is occluded or at fixed intervals

Brachytherapy for cholangioCaBrachytherapy for cholangioCa

Gastric outlet obstructionGastric outlet obstruction– Stent placement vs gastric bypassStent placement vs gastric bypass– Timing of stent placementTiming of stent placement

Role of G-J tube for nutritionRole of G-J 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 A 59 year old woman undergoes a R0 Whipple resection of her pancreatic Whipple resection of her pancreatic cancer.cancer.

Receives post-operative chemo-Receives post-operative chemo-radiationradiation

Patient doing wellPatient doing well

AQ1AQ1. Should the patient have . Should the patient have an active or passive post-an active or passive post-treatment follow-uptreatment follow-up

1.1. Active follow-up Active follow-up

2.2. Passive follow-upPassive follow-up

Comments from the Comments from the facultyfaculty

AQ2.AQ2. What are appropriate tests for What are appropriate tests for follow-upfollow-up

1.1. Ca19-9Ca19-9

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 Comments from the facultyfaculty

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 CA19-9 levels increase to 60 ng/ml her CA19-9 levels increase to 60 ng/ml and and

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

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

1.1. CT scan- chest/abdomen/pelvisCT scan- chest/abdomen/pelvis2.2. MRI scanMRI scan3.3. PET scanPET scan4.4. EUS-FNAEUS-FNA5.5. EGDEGD

Comments from the Comments from the facultyfaculty

Soft tissue at surgical bed with main PV narrowing

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

1.1. EUS-FNAEUS-FNA

2.2. CT-guided FNACT-guided FNA

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

4.4. Treat empirically with second line Treat empirically with second line chemotherapychemotherapy

5.5. None of the aboveNone of the above

Comments from the Comments from the facultyfaculty

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

1.1. Refer to surgery for removal of recurrent Refer to surgery for removal of recurrent tumortumor

2.2. RadiotherapyRadiotherapy

3.3. 22ndnd line Chemotherapy line Chemotherapy±Radiation±Radiation

4.4. HospiceHospice

Comments from the Comments from the facultyfaculty

Question to all facultyQuestion to all faculty

What kind of follow-up is appropriate in What kind of follow-up is appropriate in patients with pancreatic cancer after patients with pancreatic cancer after treatmenttreatment

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

– Which are those clinical situationsWhich are those clinical situations

David Carr-LockeDavid Carr-Locke

Obstructive jaundice in patients after Obstructive jaundice in patients after Whipple’s resection for pancreatic Whipple’s resection for pancreatic cancercancer– Are attempts at ERCP worth the effort?Are attempts at ERCP worth the effort?– What kind of stents to use for drainage?What kind of stents to use for drainage?– Role of double balloon enteroscope?Role of double balloon enteroscope?

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. s/p biliary stent a mid CBD stricture. s/p biliary stent

placementplacement

EUS-FNA EUS-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 Cytology atypical cells with lots of

inflammation.inflammation. However not diagnostic for cancerHowever not diagnostic for cancer

AQ6.AQ6. Appropriate next step Appropriate next step in the management of this in the management of this patient is patient is 1.1. Surgical explorationSurgical exploration

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

Comments from the Comments from the facultyfaculty

Frank GressFrank Gress

What is the value of EUS-FNA in What is the value of EUS-FNA in diagnosis of biliary stricturesdiagnosis of biliary strictures– Is it useful in ruling out unresectable Is it useful in ruling out unresectable

cancerscancers– Are there any benign etiologies that are Are there any benign etiologies that are

easily and reliably diagnosed by EUS-FNA easily and reliably diagnosed by EUS-FNA or biliary Intraductal Ultrasound (biliary or biliary Intraductal Ultrasound (biliary IDUS)IDUS)

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

During surgery During surgery – the diagnosis of cancer is the diagnosis of cancer is

confirmed and confirmed and – malignant periportal lymph nodes malignant periportal lymph nodes

are also encounted. are also encounted.

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

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

2.2. Abandon resection of tumor and close the Abandon resection of tumor and close the abdomenabdomen

Comments from the Comments from the facultyfaculty

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

Further management of this patient Further management of this patient should involve placement of a metal should involve placement of a metal biliary stent biliary stent andand

1.1. No further therapyNo further therapy

2.2. ChemoradiationChemoradiation

3.3. Chemotherapy aloneChemotherapy alone

4.4. Radiation aloneRadiation alone

Comments from the Comments from the facultyfaculty

Michael ChotiMichael Choti

In patients with hilar/perihilar In patients with hilar/perihilar cholangiocarcinoma, how do you choose cholangiocarcinoma, how do you choose between between surgical bypass and endoscopic stent surgical bypass and endoscopic stent

placement for biliary drainageplacement for biliary drainage

AQ9.AQ9. Patient is started on Patient is started on chemoXRT and chemoXRT and

– has good response. has good response.

Should this patient be re-evaluated Should this patient be re-evaluated for another attempt at surgical for another attempt at surgical resectionresection

1.1. YesYes

2.2. NoNo

Comments from the Comments from the facultyfaculty

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

1.1. Resectable tumor that is removed with Resectable tumor that is removed with R0 resectionR0 resection

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 Comments from the facultyfaculty

Closing remarks from each Closing remarks from each panelistpanelist