Management of PancreatoManagement of Pancreato--biliary biliary M liM liMalignancyMalignancy

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 SurgeryHamill Foundation Distinguished Professor of SurgeryChief, Endocrine and Pancreatic SurgeryChief, Endocrine and Pancreatic SurgeryChief, Endocrine and Pancreatic SurgeryChief, Endocrine and Pancreatic SurgeryMD Anderson Cancer CenterMD Anderson Cancer Center

Hepatobiliary Surgeon: Hepatobiliary Surgeon: Micheal Choti, MD, MBAMicheal Choti, MD, MBATh J b C H d l P f f STh J b C H d l P f f SThe 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 CenterMD 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 CarrDavid Carr--Locke FRCPLocke FRCPERCPist: ERCPist: David CarrDavid Carr--Locke, FRCPLocke, 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 cancersSurgery for pancreatic cancersg y pg y pDouglas 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 tumorWhat is a borderline resectable tumorWhat is a borderline resectable tumor–– Management of borderline resectable tumorsManagement of borderline resectable tumors–– Vascular resection and reconstructionVascular resection and reconstruction-- when is it worth it?when is it worth it?

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

–– RiskRisk--benefit analysisbenefit analysisyy

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 Cholangiocarcinoma:Surgery for Cholangiocarcinoma:g y gg y gMichael Choti Michael Choti 12 mins12 mins

How to identify unresectable tumorsHow to identify unresectable tumors

M t f i ll t bl tM t f i ll t bl tManagement 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 diagnosisgg

–– When the tumor seems resectableWhen the tumor seems resectable–– When the tumor appears unresectableWhen the tumor appears unresectable

Medical management of pancreatoMedical management of pancreato--biliary biliary cancers: cancers:

Robert Wolff Robert Wolff 12 mins12 mins

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

tumorstumors

PostPost--operative chemoradiation afteroperative 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)

P lli ti h di tiP lli ti h di tiPalliative chemoradiationPalliative chemoradiation–– What is the role and benefitWhat is the role and benefit

Ch th / h XRT Ch th / h XRT ddChemotherapy/chemoXRT nonChemotherapy/chemoXRT non--respondersresponders–– Role of second and third line therapiesRole of second and third line therapies–– Benefits vs toxicityBenefits vs toxicity

EUS in management of pancreatoEUS in management of pancreato--biliary biliary cancers: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 management of Interventional Endoscopy in management of P tP t bili C bili C PancreatoPancreato--biliary Cancers: biliary Cancers: David CarrDavid Carr--Locke Locke 12 mins12 mins

Palliation of jaundicePalliation of jaundice–– CholangiocarcinomaCholangiocarcinoma

Drain one side or both sidesDrain one side or both sidesPlastic vs metal stentsPlastic vs metal stentsPlastic vs metal stentsPlastic vs metal stents

–– Pancreatic cancersPancreatic cancersPlastic vs metal stentsPlastic vs metal stents

Timing of stent change in unresectable tumorsTiming of stent change in unresectable tumorsTiming 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 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 1Case 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 QQ pppassive postpassive post--treatment followtreatment follow--upup

1.1. Active followActive follow--up up

22 Passive followPassive follow--upup2.2. Passive followPassive follow upup

C t f th f ltC t f th f ltComments from the facultyComments from the faculty

AQ2AQ2 Wh t re ppropri te tests for folloWh t re ppropri te tests for follo upupAQ2.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

1 d 2 l1 d 2 l5.5. 1 and 2 only1 and 2 only

6.6. All of the aboveAll of the above

C t f th f ltC t f th f ltComments from the facultyComments from the faculty

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

• 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 ng/ml and 9 levels increase to 60 ng/ml and

th 3 th l t t 95 / l th 3 th l t t 95 / l –– then 3 months later to 95 ng/ml. then 3 months later to 95 ng/ml.

A h ld bA h ld bAppropriate 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--FNAFNA4.4. USUS NN5.5. EGDEGD

C t f th f ltC t f th f ltComments 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 QQ p pp phead. 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

N f th bN f th b5.5. None of the aboveNone of the above

C t f th f ltC t f th f ltComments from the facultyComments from the faculty

AQ5.AQ5. CT guided FNA shows recurrent adenocarcinoma. CT guided FNA shows recurrent adenocarcinoma. QQ ggAppropriate 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 Chemotherapyline Chemotherapy±±RadiationRadiation

4.4. HospiceHospice

C t f th f ltC t f th f ltComments from the facultyComments from the faculty

Question to all facultyQuestion to all facultyQuestion 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 LockeLockeDavid CarrDavid Carr--LockeLocke

Obstructive jaundice in patients after Whipple’s Obstructive jaundice in patients after Whipple’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 stents to use for drainage?What kind of stents to use for drainage?

R l f d bl b llR l f d bl b ll–– Role of double balloon enteroscope?Role of double balloon enteroscope?

Case 2Case 2Case 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 placementa mid CBD stricture. s/p biliary stent placementp y pp y p

EUSEUS--FNA FNA 2 cm focal mass lesion in relation to mid CBD2 cm focal mass lesion in relation to mid CBD–– 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 QQ pp p ppp p pmanagement 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 weeksp g gp g g

C t f th f ltC t f th f ltComments from the facultyComments from the faculty

Frank GressFrank GressFrank GressFrank Gress

What is the value of EUSWhat is the value of EUS--FNA in diagnosis of FNA in diagnosis of biliary stricturesbiliary strictures–– 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 biliary Intraductal FNA or biliary Intraductal reliably diagnosed by EUSreliably diagnosed by EUS--FNA or biliary Intraductal FNA or biliary Intraductal Ultrasound (biliary IDUS)Ultrasound (biliary 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 periportal lymph nodes are also malignant periportal lymph nodes are also encounted. encounted.

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

d h d h dd h d h d1.1. Proceed with surgery and remove the tumor and Proceed with surgery and remove the tumor and lymph nodeslymph nodes

22 Abandon resection of tumor and close the abdomenAbandon resection of tumor and close the abdomen2.2. Abandon resection of tumor and close the abdomenAbandon resection of tumor and close the abdomen

C t f th f ltC t f th f ltComments from the facultyComments from the faculty

AQ8.AQ8. Surgeon decides Surgeon decides againstagainst proceeding with proceeding with QQ gg gg p gp gresection and closes abdomen.resection and closes abdomen.

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

1.1. No further therapyNo further therapy

2.2. ChemoradiationChemoradiation

3.3. Chemotherapy aloneChemotherapy alone

4.4. Radiation aloneRadiation alone

C t f th f ltC t f th f ltComments from the facultyComments from the faculty

Michael ChotiMichael ChotiMichael ChotiMichael Choti

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

surgical bypass and endoscopic stent placement for surgical bypass and endoscopic stent placement for biliary drainagebiliary drainage

d h dd h dAQ9.AQ9. Patient is started on chemoXRT and Patient is started on chemoXRT 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

C t f th f ltC t f th f ltComments from the facultyComments from the faculty

AQ10.AQ10. Active followActive follow--up in patients with up in patients with QQ p pp pcholangiocholangio--carcinoma is recommended incarcinoma is recommended in

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

2.2. Following R1 and R2 resectionFollowing R1 and R2 resection

3.3. Unresectable tumor managed with chemoXRTUnresectable tumor managed with chemoXRTgg

4.4. None of the aboveNone of the above

C t f th f ltC t f th f ltComments from the facultyComments from the faculty

Cl i k f h liCl i k f h liClosing remarks from each panelistClosing remarks from each panelist