Clinician-to-Clinician Update Clinician-to-Clinician Update

Resection of Pancreatic Cancer Previously Considered Inoperable

February 2016

Contributed by Edward Greeno, MD, Eric H. Jensen, MD, and J. Shawn Mallery, MD

Historically, in patients with pancreatic cancer, vascular involvement has been considered a contraindication to resection. Advances in imaging and surgical techniques, however, now allow experienced centers to perform partial resection or even total reconstruction of the superior mesenteric and portal veins. Here we describe the case of a 60-year-old woman whose pancreatic tumor would have been considered inoperable just a few years ago, yet she underwent neoadjuvant chemotherapy followed by resection at our center with a positive outcome.

CT-scan case-study CC-Consult-Feb2016
— Figure 1. CT scan showing mass in the head of the pancreas obstructing the common bile duct and involving the portal vein.

Patient

A 60-year-old woman presented to her primary care physician with persistent itching and jaundice. An abdominal ultrasound revealed a mass in the head of the pancreas, and the patient was referred to the Masonic Cancer Clinic at University of Minnesota Medical Center. The multidisciplinary gastrointestinal cancer team—which included the gastroenterologist, a surgical oncologist, and a medical oncologist—conferred on the case. The gastroenterologist conducted an endoscopic ultrasound with fine needle aspiration biopsy. In addition, endoscopic retrograde cholangiopancreatography was performed to place a biliary stent, relieving the patient’s jaundice. The biopsy was positive for pancreatic head adenocarcinoma, and additional imaging in conjunction with the endoscopic ultrasound demonstrated involvement of the portal and superior mesenteric veins. (See Figure 1.)

Management

Because the tumor was considered borderline resectable, the team suggested a 2-month course of neoadjuvant chemotherapy with an aggressive, multi-agent regimen, followed by surgery. The patient agreed, and chemotherapy was begun just a week after her initial presentation to the primary care physician.

The patient experienced a partial response to chemotherapy. She underwent a Whipple procedure, involving partial resection of a segment of the superior mesenteric and portal veins. The pathologist reported microscopically negative margins. Following surgery, the patient underwent an additional 6 months of chemotherapy.

At 1-year follow-up, the patient had normal bowel function, excepting the need for pancreatic enzyme replacement therapy. She reported a good quality of life and that she had returned to her normal routines. She continues to be under close surveillance because her cancer has a high risk of recurrence.

Discussion

In experienced hands, vascular involvement in pancreatic cancer is not necessarily a contraindication to resection. Morbidity and survival outcomes are comparable between those patients who receive partial venous resection or total reconstruction and those patients who do not.1 In addition, with borderline resectable tumors, the use of neoadjuvant chemotherapy, a recent advance in care, can tip the balance in favor of surgery,2 as in the case described above.

References

1. Martin RC 2nd, et al. Arterial and venous resection for pancreatic adenocarcinoma: operative and long-term outcomes. Arch Surg. 2009 Feb;144(2):154-9.

2. Rashid OM, et al. Outcomes of a clinical pathway for borderline resectable pancreatic cancer. Ann Surg Oncol. 2015 Dec 10. DOI: 10.1245/s10434-015-5006-1.

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