New treatment protocol extends survival in some cases of once inoperable pancreatic cancer
Gerald Hurowitz, M.D.·Published 27 June 2012·9 min read
Key points
Investigators at the University of Texas MD Anderson Cancer Center, Houston, have reported on a new approach to treating previously inoperable complex pancreatic adenocarcinoma that has significantly increased long-term survival for some patients.
In some cases, surgeons will not operate on patients with pancreatic cancer that has spread significantly in the local area, due to the many risks.
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the care of the surgical patient.
Investigators at the University of Texas MD Anderson Cancer Center, Houston, have reported on a new approach to treating previously inoperable complex pancreatic adenocarcinoma that has significantly increased long-term survival for some patients. Pancreatic adenocarcinoma is one of the most devastating forms of pancreatic cancer with survival rates of only 5 percent at five years. Surgical removal of these tumors offers a chance for cure, but it is estimated that only about 20 percent of patients can undergo this treatment. The tumor in the pancreas often grows into adjacent vital blood vessels, and this is the most common reason a surgeon will consider pancreatic cancer to be inoperable and incurable. However, the MD Anderson investigators have achieved an important milestone in the surgical treatment of the disease in terms of improving prognosis for patients who meet the criteria for a newly developed protocol.
In a study published in the July issue of the Journal of the American College of Surgeons, the investigators reported on 88 patients who had been told their tumors were inoperable after an initial surgical attempt at removal, 66 of whom completed a multidisciplinary treatment regimen with successful tumor removal. This approach has been refined at MD Anderson over the last 20 years and involves a more accurate and collaborative interpretation of CT scans of the tumor between surgeons and radiologists; chemotherapy and radiation treatment of the tumor; and finally an advanced approach to surgical resection with planned removal and reconstruction of involved vital blood vessels near the tumor.
"We've been able to achieve survival numbers for these patients that are comparable to those receiving surgery for clearly operable tumors," reported lead study author Jason B. Fleming, MD, FACS. On average, patients in this study lived about 30 months after tumor removal, which is almost three times longer than the 11 months for patients who are never able to have their tumors surgically removed.
The study enrolled high-risk patients who had been originally diagnosed at outside institutions with operable, localized cancer. However, at their initial operations the intent to remove the tumor was aborted when the disease turned out to be more extensive than originally detected.
The study involved a cohort of patients referred to MD Anderson from 1990 to 2010, many of whom were ultimately able to undergo a successful operation to remove the tumors. While the results of small series and isolated cases in which this approach was used have been published, this is the largest study including only those patients who had a previous unsuccessful attempt to remove the tumor, according to Dr. Fleming.
The pancreas is located in the back of the abdomen, near vital arteries and veins that provide blood to the intestines and liver. If the tumor encroaches on these vessels, the operation to remove the tumor can also involve reconstructing these important blood vessels, raising the complexity of the procedure. Reconstructing these vessels in a way that restores appropriate blood flow is critical for the overall wellness and survivability of patients after the operation.
Written and revised by
Gerald Hurowitz, M.D.
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Inoperable Pancreatic Cancer Inoperable pancreatic cancer is a cancer tumor that because of its location and/or stage rules out surgery as a treatment. Many pancreatic tumors are inoperable by the time they are discovered. This occurs because they have usually already advanced to a late stage. Early stages of pancreatic cancer do not display specific symptoms, so the tumors grow unnoticed until they are large enough or have spread to enough areas that they begin causing things such as abdominal pain, high blood sugar, and jaundice to name a few. In fact, only about 15 to 20 percent of tumors can still be surgically removed at the time of diagnosis. And only 30 percent of people who can undergo the surgery live longer than 5 years.
Most pancreatic cancer is deemed inoperable because it has invaded neighboring blood vessels, metastasized or spread to organs, or grown directly into surrounding structures. It is still technically possible to operate on the pancreas, but by this time surgery on the pancreas is almost pointless and carries far more risks than it does benefits.
The initial location of the pancreatic cancer tumor has an influence on whether or not surgery will be an option. A tumor can grow on the head, body, or tail of the pancreas. If it is occurs on the head, its symptoms appear early, thus doctors may catch it before it spreads. But if it is on the body or tail, it usually does not display symptoms. So by the time the tumor is found, it has spread to its neighbors.
Another sign of whether or not you have inoperable pancreatic cancer is where the cancer has spread. For instance, if it is only in the lymph nodes around the pancreas, the spread is considered locoregional and is operable, or resectable. But if the cancer is found in other areas, it is usually inoperable (unresectable), though surgeons must make the final decision.
The investigators stratified each patient's risk for metastatic disease based on tumor involvement with local blood vessels, suspicious biopsy results and the nature of the tumor, and overall health status aside from pancreatic cancer. Patients who met these criteria underwent the protocol.
The key to screening patients for treatment and staging of their cancer is radiographic imaging, specifically in the interpretation of CT scans of the tumors before the operation, Dr. Fleming explained. "The interpretation needs to be performed in conjunction with the radiologist, but also with heavy involvement by the surgeon," he said. "The goal should be to give the surgeon a clear idea of tumor location and vessel involvement before beginning the operation," he said.
New Surgical Method for Inoperable Pancreatic Cancer?
In some cases, surgeons will not operate on patients with pancreatic cancer that has spread significantly in the local area, due to the many risks. A new surgical technique that uses many small pulses of electricity may change that.
This surgical technique known as irreversible electroporation (IRE) was pioneered in cancers of the liver - it's an advanced form of the more commonly used electric knife technology.
The technique is being modified for possible use with pancreatic cancer.
Pancreatic cancers are difficult to detect until the tumor has grown large enough to change nearby organs. Treatment is difficult due to the delicate tissue of the pancreas, as well as several major blood vessels located next to it.
The high precision of the irreversible electroporation provides new options for all pancreatic cancer patients, including those with advanced disease.
Guided by imaging systems, a team of surgeons and radiologists can destroy or remove the tumor without damaging nearby structures.
"We think in another 12 to 15 months we will have a lot more evidence to support the use of IRE for inoperable pancreatic cancer patients," said Govindarajan Narayanan, M.D., chief of vascular and interventional radiology at the University of Miami.
The MD Anderson protocol also uses a scoring system along with structured documentation for the radiologist to more accurately assess the extent of tumor-vessel involvement, according to Dr. Fleming. "With good imaging and good interpretation you have a high likelihood of being able to predict involvement of the vessels before surgical treatment, not after," he said. About 46 percent of the patients in this study required some type of vascular resection, according to Dr. Fleming.
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Of the 88 patients enrolled in the study, 50 of them came from academic centers, 25 from community hospitals, and 13 from international centers. However, hospital type and surgeon skill are not necessarily indicators of the setting in which this protocol can be used, Dr. Fleming said. Removing the pancreatic tumor and then sparing the veins and arteries requires not only a high level of technical surgical skill but also a focused team of medical specialists collaborating on complex pancreatic cancer, Dr. Fleming said.
The MD Anderson study underscores the need for patients with inoperable pancreatic adenocarcinoma to seek out a second opinion, Dr. Fleming said. "I would say to these patients and loved ones that it is important to advocate for yourself and your family, to seek out opinions, and not necessarily go with the first thing you hear as the answer," Dr. Fleming said. "This study is an example of patients who have benefited by persisting. 'Hope exists' is the message we want these patients to hear," he concluded.
Why does pancreatic cancer kill so quickly? Pancreatic cancer is typically diagnosed at a late stage because it doesn't cause symptoms until it's too late. Weight loss, abdominal pain, jaundice [a yellowing of the skin due to toxic buildup in the liver]- those are the most common symptoms. They usually start after the tumor is a significant size. By then, chances are, it has metastasized [that is, spread to other parts of the body].
Only about 10 to 15 percent of pancreatic cancers are diagnosed when they could be considered for surgery. And the prognosis is poor even in patients who do have surgery, because it comes back about 85 percent of the time. At best, 25 to 30 percent of patients are alive five years after surgery.
When doctors do pancreatic cancer surgery, they take out 95 percent of the pancreas, including the tumor, and then they leave a small remnant of the pancreas in there that serves [the insulin-producing] functions.
If a person can live without a fully functional pancreas, then what, ultimately, kills most pancreatic cancer patients? When most patients die of pancreatic cancer, they die of liver failure from their liver being taken over by tumor.
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What are some of main symptoms as the cancer progresses?
Unexplained weight loss, abdominal pain, nausea, vomiting. Back pain is another one, because the pancreas is very posterior in the body. Back pain is also the most common complaint that patients go to an emergency room for, and most of the time it's just muscle pain - it's not pancreatic cancer.
The press reported that Upshaw's wife brought him to the hospital because he was having trouble breathing. What might have caused that? It could be for a number of reasons, such as if the disease has spread to the lungs. If he was so run-down from having lost a significant amount of weight, and he was weak and fatigued, he could have had difficulty breathing, too. It's hard to say.
Another important thing with pancreatic cancer is that it's one of the cancers that is frequently associated with blood clots. He could have had a blood clot in the lung, called a pulmonary embolism. It's possible that that's what killed him.
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About the American College of Surgeons
The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the care of the surgical patient. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 78,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org(.)
This work was supported by the Various Donor Fund for Pancreatic Cancer Research, The University of Texas MD Anderson Cancer Center.
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