Surgery News - December 2008 - (Page 17) DECEMBER 2008 • SURGERY NEWS ONCOLOGY 17 Preop Staging Pinpoints Resectable Pancreatic Cancer B Y S H E R RY B O S C H E R T Else vier Global Medical Ne ws S A N F R A N C I S C O — Exploratory surgery for pancreatic cancer is outdated, and should be replaced by preoperative staging of the disease via high-quality CT scan to determine resectability, according to Dr. Douglas B. Evans. Using this staging information plus stage-specific neoadjuvant therapy before surgery produced a median survival of 40 months in a series of 160 patients with borderline resectable pancreatic cancer— patients who otherwise would have been at risk for incomplete resection and shorter survival times. “Surgery was probably necessary, but not sufficient to get this result,” Dr. Evans said, describing the data at the Oncology Congress sponsored by Elsevier CME and Reed Medical Education. (This news organization is owned by Elsevier.) He and his colleagues at the University of Texas M.D. Anderson Cancer Center, Houston, have been practicing multidisciplinary care and preoperative staging for pancreatic cancer since the 1990s. It’s still common elsewhere, however, for a patient to present with symptoms, get a CT scan showing a pancreatic head mass and bile duct obstruction, and be scheduled for exploratory surgery. ‘That’s probably how many patients are managed around the country,” said Dr. Evans, professor of surgical oncology at the cancer center. Between 1999 and 2006, the investigators classified 160 of 2,454 patients with pancreatic cancer as borderline resectable. They treated the borderline cases initially with chemotherapy, chemoradiation, or both. Patients who completed preoperative therapy and who had sufficient performance status were considered for surgery. Patients with aggressive disease or evolving medical comorbidities dropped out during the 2-4 months of neoadjuvant therapy before reaching resection. Among the 41% of patients who made it all the way to resection, the median survival was 40 months, which was “quite encouraging,” Dr. Evans said. Median survival was 13 months for patients who did not undergo resection ( J. Am. Coll. Surg. 2008;206:833-46). The results suggest that objective definitions of disease stage allowed neoadjuvant therapy to be directed to a subset of patients who were most likely to benefit from surgery, the investigators concluded. The proportions of patients who completed therapy and underwent resection were similar in subgroups of borderline resectable cases: 32 (38%) of 84 patients with arterial abutment of the tumor, 22 (50%) of 44 patients with possible liver or lung metastases, and 12 (38%) of 32 older patients with significant comorbidities, he added. The widespread adoption of simple definitions for resectable, borderline resectable, or locally advanced tumors “would make probably the largest difference in how pancreatic cancer patients are cared for” in the history of treatment for the disease, he said. This would allow accurate staging of the disease and stage- specific therapy, “something that is not done routinely for this disease.” The M.D. Anderson definitions for these stages of pancreatic cancer are currently the most widely published. Even simpler definitions from a consensus conference of several surgical societies, sponsored by the American Hepato-Pancreato-Biliary Association in early 2008, are expected to be published soon, Dr. Evans said. The consensus definitions define resectable pancreatic tumors as those with no extension to the celiac artery, superior mesenteric artery, or confluence of the superior mesenteric vein and portal vein, plus stage I or II disease. Borderline resectable tumors have venous abutment or encasement (with an option for reconstruction), or no more than 180 degrees of arterial abutment. Locally advanced tumors show a greater-than-180-degree encasement of the celiac artery or superior mesenteric artery, or stage III disease, he said. The M.D. Anderson definitions are similar, but they count tumors with venous abutment or encasement as resectable, and include some stage III disease as borderline resectable. At his institution, resectable tumors may be treated with up-front surgery or a neoadjuvant approach; he favors the latter. Borderline resectable tumors get preoperative systemic therapy and/or chemoradiation. Locally advanced tumors, defined by arterial encasement, are considered not to be resectable, and surgery is not an option. “This categorization of patients has been incredibly helpful,” he said. ■ Membership in the American College of Surgeons? H E R E ’ S W H Y I T ’ S I M P O R TA N T: AS A BODY REPRESENTING ALL OF SURGERY, THE COLLEGE: • Provides a cohesive voice addressing societal issues related to surgery. • Is working toward having an increasingly proactive and timely voice in setting a national tone and agenda with regard to health care. • Is dedicated to promoting the highest standards of surgical care through education of and advocacy for its Fellows and their patients. • Serves as a national forum through which surgeons can reinforce the values and ethics that traditionally have characterized the surgical profession. HERE ARE SOME OF THE MANY BENEFITS BEING A MEMBER OF THE COLLEGE AFFORDS YOU: • Free preregistration at the Clinical Congress • Access to the College’s free coding consultation hotline • Subscription to ACS NewsScope, the College’s weekly electronic newsletter • Subscription to the Bulletin of the American College of Surgeons • Subscription to the Journal of the American College of Surgeons • Access to all College-sponsored insurance, credit card, and other helpful programs • Free posting of resume on ACS Career Opportunities • Access to Surgeons Diversified Investment Fund THERE IS STRENGTH IN NUMBERS. Our members represent every specialty, practice setting, and stage of practice. Their views and concerns are helping to shape the College’s agenda for the future. If you aren’t a member of the American College of Surgeons, apply for Fellowship today. If you are already a member, maintain that status and consider getting involved in the work of the College. Only by banding together and using our collective strength can we bring about positive change for our patients and ourselves—and for surgeons of the future. Information on becoming a member of the College and an application form are available online at w w w.f ac s .org/dept /fellowship/index .html or contact Cynthia Hicks, Credentials Section, Division of Member Services, via phone at 1-800/293-9623, or via e-mail at chicks@facs.org. http://www.facs.org/dept/fellowship/index.html http://www.facs.org/dept/fellowship/index.html
Table of Contents Feed for the Digital Edition of Surgery News - December 2008 Surgery News - December 2008 Contents The 20/20 Vision: Health Reform News From the College: Nominations Thoracic: Breathing Easier Postop Management: Renal Failure Surgery News - December 2008 Surgery News - December 2008 - Contents (Page 1) Surgery News - December 2008 - Contents (Page 2) Surgery News - December 2008 - Contents (Page 3) Surgery News - December 2008 - Contents (Page 4) Surgery News - December 2008 - Contents (Page 5) Surgery News - December 2008 - The 20/20 Vision: Health Reform (Page 6) Surgery News - December 2008 - The 20/20 Vision: Health Reform (Page 7) Surgery News - December 2008 - The 20/20 Vision: Health Reform (Page 8) Surgery News - December 2008 - The 20/20 Vision: Health Reform (Page 9) Surgery News - December 2008 - News From the College: Nominations (Page 10) Surgery News - December 2008 - News From the College: Nominations (Page 11) Surgery News - December 2008 - Thoracic: Breathing Easier (Page 12) Surgery News - December 2008 - Thoracic: Breathing Easier (Page 13) Surgery News - December 2008 - Thoracic: Breathing Easier (Page 14) Surgery News - December 2008 - Thoracic: Breathing Easier (Page 15) Surgery News - December 2008 - Postop Management: Renal Failure (Page 16) Surgery News - December 2008 - Postop Management: Renal Failure (Page 17) Surgery News - December 2008 - Postop Management: Renal Failure (Page 18) Surgery News - December 2008 - Postop Management: Renal Failure (Page 19) Surgery News - December 2008 - Postop Management: Renal Failure (Page 20)
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