Multidisciplinary Assessment of Pancreatic Cancer

George Kim, MD:The importance of a multidisciplinary evaluation tumor board involves allowing us to formulate a treatment plan based on the diagnostic and staging information. So, for our tumor boards on Thursday afternoons, it’s the medical oncologist, the radiation oncologist, the interventionalist, the gastroenterologist, the surgeons, and the pathologist who all meet and discuss cases.

The multidisciplinary tumor board is very helpful for deciding what patients can go on to surgery and how we will sequence our interventions, and having discussions about patients who may not be ready for surgery now because their tumor may be near an important artery or vessel. It’s also important we talk about local advanced disease in which we use combined modality therapies, both radiation and chemotherapy. And it’s also important when we are trying to treat metastatic patients. They may have certain situations where our interventionalist may have an opportunity to go after a solitary liver lesion, or a radiation oncologist may have an opportunity to treat the primary and provide patients symptom-relief. So, these discussions occur during the tumor board, and it’s very important to have all the specialties involved.

The criteria for resection of pancreas cancer is that the tumor has to be localized. Unfortunately, there are not a lot of patients that fit into this stage. It’s roughly 10%, 15%, maybe 20% of the patients, depending on how they are referred and what centers are treating them. The criteria are obviously, and especially in relation to our patient, that the patient cannot have metastatic disease. So, this individual is not eligible for surgery because of the lesions in the liver. You have to have non-metastatic disease.

Now remember where the pancreas is. Most of the tumors will show up in the head of the pancreas, and there are important vascular structures that run through that area, particularly the superior mesenteric artery and the celiac artery. So, the tumor cannot encase these important structures because it’s very hard, or it’s not meaningful for the surgeon to go in there and take it out. Even if he is able to take it out, the chances of recurrence are very high.

Very similarly, there are the venous structures, the portal vein, the superior mesenteric vein, and the confluence. In certain situations, we can give chemotherapy or even radiation, shrink some of the tumors away from that structure, and have a surgeon who is adept at performing the portal confluence reconstruction and that will enable the tumor to be resected. We do need to obviously reconstruct the veins, put in a graft, and then these folks actually can have very meaningful survival.

So, getting back to the eligibility, you can’t have metastatic disease. You can’t have involvement of some of the arteries, but there are opportunities with pretreatment, with chemotherapy, or even radiation, that enable these folks to achieve a resectable state, which is very important. It has to be coordinated through a multimodality clinic.

Transcript edited for clarity.

March 2016

• A 63-year-old Caucasian male was admitted to the hospital from the emergency room with symptoms of epigastric pain that radiated toward the back, abdominal distention, vomiting, and jaundice
• Laboratory tests:
  • Bilirubin and liver enzymes; elevated
  • CBC values WNL
  • Hepatitis B, & C testing, negative
  • CEA: 34.2 ng/mL; CA 19-9 > 12000 U/mL
• Performance status, 1
• CT reveals 3.5 cm × 3.7 cm mass in the head of the pancreas and multiple liver nodules; also, indicates an obstruction of the bile duct
• Ultrasound-guided percutaneous needle biopsy of a liver metastases shows adenocarcinoma histology
• The patient undergoes biliary stent placement based on endoscopic retrograde cholangiopancreatogram (ERCP) findings
• Diagnosis: stage IV pancreatic cancer with liver metastasis
• The patient was started with treatment on gemcitabine andnab-paclitaxel
• CT with contrast after two treatment cycles showed marked shrinkage of the pancreatic lesion and liver nodules.
• CT after 6 cycles showed stable disease

November 2016

• The patient reports symptoms of rapid weight loss, abdominal pain, dark urine, and jaundice; he has declining functional status and is often bedridden
• Systemic therapy is under consideration