Modified Appleby Procedure Proves Promise for the Treatment of Pancreatic Cancer

The modified Appleby procedure, a technique that removes two-thirds of the pancreas, the spleen, and the celiac axis, offers patients with pancreatic cancer another treatment option.¹

The Appleby procedure was originally created for locally advanced gastric cancer. However, recent studies suggest a modified procedure also improves outcomes for patients with pancreatic cancer due to advances in systemic treatments. This adds another treatment to the growing list of available treatment modalities for pancreatic cancer.

The modified Appleby procedure allows for a negative margin resection of some locally advanced tumors. In pancreatic body and tail ductal adenocarcinomas, which are often diagnosed with local vascular invasion of the various branches of the celiac axis, many of these tumors have traditionally been considered unresectable. A case report and literature review found that a pancreatic body or tail mass encasing the celiac vessels can be treated with neoadjuvant treatment, which ultimately enables surgery to be completed, instead of referring the patient straight to palliative care.²

"Obviously when people hear the term pancreatic cancer, it's a scary diagnosis, but the good news is we have made a lot of headway over the past 5 to 10 years,” said Jonathan Sham, MD, a surgical oncologist at the Seattle Cancer Care Alliance (SCCA) who performs the Appleby procedure, in an episode of Oncology Soundbite, a podcast produced by SCCA.¹ “We used to talk to patients about a 5-year survival of 10% to 20% after surgery. Now, with surgery combined with modern chemotherapy, we're talking about 5-year survivals in the 40% to 50% range.”

According to Sham, the Appleby procedure was invented in the 1950s for gastric cancer by a Canadian surgeon known as Lyon Appleby, MD. In the last 10 years, care providers have begun to modify the procedure for pancreatic cancer. During the procedure, the stomach is left alone but half of the pancreas, the spleen, and the celiac axis, which supplies blood to the liver, are removed. After the surgery, blood flow to the liver is supplied by the pancreatic head, which has a lot of collateralized blood flow. During surgery, the distal common hepatic artery is clamped, and almost universally, blood flow will switch directions.

The decision for an Appleby procedure should be made in conjunction with a specialized team. A surgeon or a medical oncologist cannot make the decision alone, according to Sham. Instead, a multidisciplinary team is needed for the treatment of pancreatic cancer.

According to Sham, a patient first needs chemotherapy. Patients who progress on chemotherapy are not a good candidate for surgery since even if the tumor is removed, the cancer is likely to recur after surgery. Prior to surgery, Sham gives patients 4 to 6 months of neoadjuvant chemotherapy in order to determine if the patient is a good candidate for the modified Appleby procedure.

“Our first patient who underwent this procedure is 8 months out, with no evidence of disease and doing great," Sham said in the episode.

According to Sham, it’s all about selecting the right patient who would benefit from an aggressive surgical approach. Patients who develop metastasis in their liver or lungs are not ideal candidates.

“I wouldn't say this is a super common procedure only because oftentimes, these cancers just can't be resected because they're either involving too many blood vessels, or more commonly, they've spread to distant sites,” said Sham. “So, if a patient has an advanced tumor, and then during chemotherapy, develops metastasis, say in the liver or the lungs, we know that surgery is probably not going to help that patient either. And so again, it's all about selecting the right patients who can benefit from this aggressive surgical approach.”

_RERERENCES:

_{1. Pancreatic Cancer: New surgery gives hope to more patients, outcomes continue to improve. Seattle Cancer Care Alliance. January 19, 2021. Accessed March 15, 2021. https://bit.ly/2PfPqsb}

_{2. Morris M, Price T, Callahan Z, Yeo CJ. Celiac Axis Resection with Distal Pancreatectomy (Modified Appleby Procedure) Allows for R0 Resection of Pancreatic Body and Tail Mass Following Neoadjuvant Therapy: Case Report and Literature Review. Case Rep Pancreat Cancer. 2016;2(1):53-57. doi:10.1089/crpc.2016.0011}

_{3. Sham, J. SCCA offers Appleby Procedur‪e‬. Seattle Cancer Care Alliance. Oncology Sound Byte. 2021. Accessed March 22, 2021. https://apple.co/31e3Onv}