Open Access 01-08-2008 | Hepatic and Pancreatic Tumors
The Added Value of Multidisciplinary Care for Patients with Pancreatic Cancer
Published in: Annals of Surgical Oncology | Issue 8/2008
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The article by Pawlik and colleagues in this issue of Annals of Surgical Oncology provides objective data in support of a multimodality approach to the care of the pancreatic cancer patient. The current manuscript builds on the long-standing tradition of excellence in the care of this disease established by John Cameron and takes advantage of their unique institutional talents in diagnostic imaging (Elliot Fishman) and pathology (Ralph Hruban). Indeed, an obvious potential criticism of this manuscript is that they can do things at Johns Hopkins which simply can not be done elsewhere and therefore, this work is not translatable to other centers with less experience. However, we would argue that the specific results presented by Pawlik and colleagues are translatable to other less experienced centers if definitions and templates were to be developed and uniformly applied to the care of patients with pancreatic cancer throughout this country. For example:
Clinical stage of disease
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AJCC stage
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Tumor–vessel relationship on computed tomography
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SMA
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Celiac axis
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CHA**
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SMV-PV
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Resectable (all 4 required to be resectable)*
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I/II
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Normal tissue plane between tumor and vessel
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Normal tissue plane between tumor and vessel
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Normal tissue plane between tumor and vessel
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Patent (may include tumor abutment or encasement)
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Borderline resectable (only 1 of the 4 required)
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III
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Abutment
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Abutment
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Abutment or short segment encasement
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May have short segment occlusion if reconstruction possible
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Locally advanced (only 1 of the 4 required)
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III
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Encasement
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Encasement
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Extensive encasement with no technical option for reconstruction
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Occluded with no technical option for reconstruction
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CT Characteristic
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---|---|
Tumor size
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Measured in cm
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Tumor location
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Cephalad head, caudal head, uncinate, body, and tail
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Tumor-vein (SMV, PV, SMV-PV confluence) relationship
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Abutment (≤180°), encasement (>180°) or occlusion
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Tumor-artery (SMA, celiac axis, CHA, replaced hepatic artery) relationship
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Abutment (≤180°), encasement (>180°) or occlusion
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Extent of local tumor based on above descriptions
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Resectable, borderline resectable, locally advanced
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Hepatic arterial anatomy
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Note all aberrant vessels
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Extent of extra-pancreatic disease and location
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Presence, absence, or borderline (indeterminate for metastasis); location in liver, peritoneum, lung
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Clinical stage of disease
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AJCC stage
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Treatment options
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---|---|---|
Resectable
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I/II
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1. Protocol-based, stage-specific neoadjuvant therapy
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2. Off-protocol neoadjuvant therapy (usually gemcitabine-based chemoradiation)
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3. Surgery followed by protocol-based adjuvant therapy for patients who have undergone an R0/R1 resection
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Borderline resectable
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III
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1. Protocol-based, stage-specific multimodality therapy
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2. Off-protocol therapy usually consisting of a gemcitabine doublet followed by chemoradiation and surgery (if no disease progression)
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Locally advanced
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III
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1. Protocol-based stage-specific multimodality therapy
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2. Off-protocol chemoradiation if pain is uncontrolled
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3. Off-protocol systemic therapy followed by chemoradiation (if no disease progression following systemic therapy)
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Metastatic
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IV
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1. Protocol-based systemic therapy
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2. Off-protocol systemic therapy
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3. Best supportive care
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