The Society of Surgical Oncology surgical practice guidelines focus on the signs and symptoms of primary cancer, timely evaluation of the symptomatic patient, appropriate preoperative extent of disease evaluation, and role of the surgeon in
The Society of Surgical Oncology surgical practice guidelines focuson the signs and symptoms of primary cancer, timely evaluation of the symptomaticpatient, appropriate preoperative extent of disease evaluation, and roleof the surgeon in diagnosis and treatment. Separate sections on adjuvanttherapy, follow-up programs, or management of recurrent cancer have beenintentionally omitted. Where appropriate, perioperative adjuvant combined-modalitytherapy is discussed under surgical management. Each guideline is presentedin minimal outline form as a delineation of therapeutic options.
Since the development of treatment protocols was not the specific aimof the Society, the extensive development cycle necessary to produce evidence-basedpractice guidelines did not apply. We used the broad clinical experienceresiding in the membership of the Society, under the direction of AlfredM. Cohen, MD, Chief, Colorectal Service, Memorial Sloan-Kettering CancerCenter, to produce guidelines that were not likely to result in significantcontroversy.
Following each guideline is a brief narrative highlighting and expandingon selected sections of the guideline document, with a few relevant references.The current staging system for the site and approximate 5-year survivaldata are also included.
The Society does not suggest that these guidelines replace good medicaljudgment. That always comes first. We do believe that the family physician,as well as the health maintenance organization director, will appreciatethe provision of these guidelines as a reference for better patient care.
Symptoms and Signs
Evaluation of the Symptomatic Patient
Appropriate timeliness of surgical referral
Preoperative Evaluation for Extent of Disease
Role of the Surgeon in Initial Management The majority of patients with pancreatic cancer present with locallyadvanced or metastatic disease. The surgeon is often the entry point forthe patient into the realm of therapeutic options.
These guidelines are copyrighted by the Society of Surgical Oncology(SSO). All rights reserved. These guidelines may not be reproduced in anyform without the express written permission of SSO. Requests for reprintsshould be sent to: James R. Slawny, Executive Director, Society of SurgicalOncology, 85 W Algonquin Road, Arlington Heights, IL 60005.
Pancreatic cancer remains the fourth leading cause of cancer-relateddeaths in adults in the United States. Its etiology is unknown, and thereis currently no effective method of early diagnosis. The development ofmolecular techniques to diagnose pancreatic cancer at a time when the tumoris localized to the pancreas would allow a greater number of patients toreceive potentially curative therapy. In addition, effective treatmentof subclinical, micrometastatic disease (which exists in the liver of mostpatients at the time of removal of the primary pancreatic tumor) woulddramatically increase long-term survival rates following pancreaticoduodenectomy.These are areas of active laboratory investigation and early preclinicalstudy.
TNM staging based on radiographic and operative findings (Table1) does not directly correlate with treatment recommendations and thereforeis not commonly used. Patients are best classified as having potentiallyresectable (T1-2, selected T3, NX, M0), locally advanced (T3, NX, M0),or metastatic disease (T1-3, NX, M1). Only recently has a pathologic stagingsystem for resected specimens been suggested.
Recent advances in the clinical care of patients with pancreatic cancerhave focused on: (1) decreasing treatment-related toxicity by utilizingaccurate preoperative imaging, and (2) improving the quality and lengthof patient survival through the use of innovative multimodality therapydirected at known patterns of disease recurrence.[2,3]
Surgical resection, as part of a multimodality approach for patientswith resectable pancreatic cancer, represents the only potentially curativetreatment strategy. However, only 16% to 30% of patients who undergo operationwith curative intent have their tumors successfully removed; the remainingpatients are found to have unsuspected liver or peritoneal metastases orlocal tumor extension to the mesenteric vessels. Only patients whosetumors are completely resected enjoy a survival benefit. Therefore, themajority of patients who undergo surgical exploration for presumed cancerof the pancreatic head derive no survival benefit, yet the laparotomy resultsin a perioperative morbidity of 20% to 30%, a mean hospital stay of 14to 20 days (with the recovery period lasting an additional 15 to 20 days),and a median survival of only 6 months. Furthermore, in patients whosetumors are resected with positive margins, survival is no better than inpatients with locally advanced, unresectable disease treated by palliativechemotherapy and irradiation.[2,5]
The need for accurate preoperative assessment is evidenced by the largenumber of positive margin resections recently reported and the highincidence of local tumor recurrence following pancreaticoduodenectomy.[2,4]In addition, in patients with unresectable disease, endoscopic, percutaneous,and laparoscopic methods of biliary decompression make laparotomy for palliationunnecessary.
Contrast-enhanced helical CT can accurately assess the relationshipof the tumor to the celiac axis and superior mesenteric artery (SMA). Potentiallyresectable primary tumors in the pancreatic head or uncinate process aredefined preoperatively (on CT) by: (1) the absence of extrapancreatic disease;(2) no evidence of tumor extension to the celiac axis or SMA; and (3) apatent superior mesenteric vein (SMV) and portal vein. Patients withlocally advanced disease are not subjected to the potential morbidity andprolonged recovery period associated with a laparotomy, but instead, canreceive biliary decompression, if needed, by means other than a laparotomy.
Aggressive multimodality treatment is reserved for patients with potentiallyresectable primary tumors defined by the CT criteria stated previously.
Current treatment programs build on past experience, largely in unresectabletumors, using preoperative or postoperative chemotherapy and radiationtherapy combined with surgery.[7,8] The Gastrointestinal Tumor Study Group(GITSG) first demonstrated a survival advantage for pancreatic cancer patientstreated with adjuvant chemoradiation (40 Gy of external-beam irradiationplus concomitant fluorouracil [5-FU]) following pancreaticoduodenectomy,compared with patients treated with surgical resection alone (median survival,20 vs 11 months).
This treatment advantage was confirmed in a group of 30 additional patientstreated with postoperative chemoradiation. Delivery of adjuvant therapy,however, was hindered by the prolonged recovery time of most patients followingpancreaticoduodenectomy. Many patients required more than 10 weeks to achievea performance status necessary for treatment with chemoradiation.
The inability of some patients to tolerate postoperative therapy, combinedwith the growing popularity of neoadjuvant therapy in patients with othersolid tumors, caused investigators to consider giving radiation and chemotherapyprior to surgery in patients with potentially resectable pancreatic cancer.The use of preoperative chemoradiation is supported by the following considerations:(1) Radiation therapy is more effective in well-oxygenated cells that havenot been exposed to the devascularization of surgery. (2) Radiation therapybefore surgical exploration may prevent the implantation and disseminationof tumor cells at the time of laparotomy, thereby decreasing subsequentperitoneal failure. (3) Patients with disseminated disease evident on restagingstudies after chemoradiation are not subjected to laparotomy.
The following management principles can be applied to most patientswith presumed adenocarcinoma of the pancreas:
1. Staley CA, Cleary KR, Abbruzzese JL, et al: Need for standardizedpathologic evaluation of pancreaticoduodenectomy specimens: Pancreaticoduodenectomyspecimens. Pancreas 12:373-380, 1996.
2. Evans DB, Abbruzzese JL, Rich TA: Cancer of the pancreas, in DeVitaVT Jr, Hellman S, Rosenberg SA (eds): Cancer: Principles and Practice ofOncology, 5th ed, pp 1054-1087. Philadelphia, Lippincott, 1997.
3. Spitz FR, Abbruzzese JL, Lee JE, et al: Preoperative and postoperatiavechemoradiation strategies in patients treated with pancreaticoduodenectomyfor adenocarcinoma of the pancreas. J Clin Oncol 15:928-937, 1997.
4. Fuhrman GM, Charnsagavej C, Abbruz-zese JL, et al: Thin-section contrastenhanced computed tomography accurately predicts resectability of malignantpancreatic neoplasms. Am J Surg 167:104-113, 1994.
5. Nitecki SS, Sarr MG, Colby TV, et al: Long-term survival after resectionfor ductal adenocarcinoma of the pancreas: Is it really improving? AnnSurg 221:59-66, 1995.
6. Willet CG, Lewandrowski K, Warshaw AL, et al: Resection margins incarcinoma of the head of the pancreas: Implications for radiation therapy.Ann Surg 217:144-148, 1993.
7. Evans DB, Staley CA, Lee JE, et al: Adenocarcinoma of the pancreas:Recent controversies, current management, and future therapies. GI Cancer1:149-161, 1996.
8. Staley CA, Lee JE, Cleary KA, et al: Preoperative chemoradiation,pancreaticoduodenectomy, and intraoperative radiation therapy for adenocarcinomaof the pancreatic head. Am J Surg 171:118-125, 1996.
9. Kalser MH, Ellenberg SS: Pancreatic cancer: Adjuvant combined radiationand chemotherapy following curative resection. Arch Surg 120:899-903, 1985.
10. Gastrointestinal Tumor Study Group: Further evidence of effectiveadjuvant combined radiation and chemotherapy following curative resectionof pancreatic cancer. Cancer 59:2006-2110, 1987.
11. Leach SD, Rose JA, Lowy AM, et al: Significance of peritoneal cytologyfindings in patients with potentially resectable adenocarcinoma of thepancreatic head. Surgery 118:472-478, 1995.
12. Robinson EK, Lee JE, Pisters PWT, et al: Reoperatiave pancreaticoduodenectomyfor periampullary carcinoma. Am J Surg 172:432-438, 1996.