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28 Cards in this Set

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Pancreas: TNM Staging

(Both clinical and path)
Pancreas: TNM Staging
T1 - Limited to pancreas, <= 2cm
T2 - Limited to pancreas, > 2cm
T3 - Extends beyond pancreas but without involvement of celiac axis or SMA
T4 - Involves celiac exis or SMA (unresected)

N1 Regional nodes

M1 Distant mets
Pancreas: Group Staging
Pancreas: Group Staging

IA: T1N0M0
IB: T2N0M0
IIA: T3N0M0
IIB: T1-3N1M0
III: T4 Any N M0
IV: Any T Any N M1
Pancreas: Optimal pathologic nodal staging
Pancreas: Optimal pathologic nodal staging

Minimal 10 lymph nodes
Pancreas: Metastatic sites
Pancreas: Metastatic sites
1 Liver
2 Peritoneal cavity
3 Lungs
Pancreas: Anatomic divisions
Pancreas: Anatomic divisions

Head - Right of the SM-portal vein complex

Body - Between SM-portal vein complex and aorta

Tail - Between aorta and hilum of spleen
Pancreas: Extent of resection
Pancreas: Extent of resection

R0: Complete resection with grossly and microscopically negative margins

R1: Grossly neative but positive microscopic margins

R2: Grossly and microscopically positive margins
Pancreas: Whipple operation
Pancreas: Whipple operation

Pancreaticoduodenectomy
Pancreas

If the peritoneum is seeded (even if limited to the lesser sac region) or peritoneal fluid contains microscopic evidence of carcinoma, what's the patient's M stage?
Pancreas

If the peritoneum is seeded (even if limited to the lesser sac region) or peritoneal fluid contains microscopic evidence of carcinoma, what's the patient's stage?

M1 --> IV
Pancreas: Prognosis

Localized s/p resection
Locally advanced
Metastatic
Pancreas: Prognosis

Localized s/p resection
- Long-term survival 20%
- Median survival 12-20 months

Locally advanced
- Medial survival 6-10 months

Metastatic - 3-6 months
Pancreas

Most important prognostic factor for decreased survival?
Pancreas

Most important prognostic factor - incomplete resection
Pancreas

Where is the resection margin most likely to be positive?
Pancreas

Where is the resection margin most likely to be positive?

At the retroperitoneal (or mesenteric) margin along the right lateral border of the SMA.

This margin is defined as the soft tissue margin directly adjacent to the proximal 3-4 cm of SMA and is inked for evaluation.
Pancreas

If there is incomplete resection results in grossly positive retroperitoneal margin, what's the impact of surgery?
Pancreas

If there is incomplete resection results in grossly positive retroperitoneal margin, what's the impact of surgery?

Incomplete resection resulting in a grossly positive retroperitoneal margin provides no survival advantage from surgical resection compared to those who receive chemoRT and no surgery.
Pancreas

What are the portions of the duodenum?
Pancreas

What are the portions of the duodenum?

1st: Duodenal bulb or cap

2nd: Descending; hugs the pancreas

3rd: Transverse; lies horizontally at the level of the 3rd lumbar vertebra

4th: Ascending; at the level of the second lumbar vertebra in intimate contact with the aorta
Pancreas

What is the origin of the word "duodenum"?
Pancreas

What is the origin of the word "duodenum"?

A Latin derivation from the Greek "dodekadaktulon" or "12 fingers" because of the duodenum's length = 12 finger breadths.
Pancreas

Used as a single agent, or in combination, for metastatic pancreatic cancer
A. Cisplatin
B. Taxol
C. Irinotecan
D. 5-FU
E. Gemcitabine
Pancreas

Used as a single agent, or in combination, for metastatic pancreatic cancer

E. Gemcitabine
Pancreas

Stage pancreatic adenocarcinoma, invasive into the duodenum and surrounding the SMA
A. II
B. III
C. IIIA
D. IIIB
E. IV
Stage pancreatic adenocarcinoma, invasive into the duodenum and surrounding the SMA

B. III
Match the following with any of the following percentages
1. Frequency of K-ras mutations
2. Sensitivity of CT scanning for detecting respectability
3. Local/regional relapse as a component of failure after a Whipple procedure in non-adjuvantly-treated patients
4. Average 5-year survival after resection (+/- adjuvant therapy)

A. 5-20%
B. 20-30%
C. 50%
D. 70%
E. 90%
Match the following with percentages
1. Frequency of K-ras mutations - 90%
2. Sensitivity of CT scanning for detecting resectability - 70%
3. Local/regional relapse as a component of failure after a Whipple procedure in non-adjuvantly-treated patients - 70%
4. % of presenting patients with distant mets - 50%
5. Average 5-year survival after resection (+/- adjuvant therapy) - 5-20%
A. 5-20%
B. 20-30%
C. 50%
Pancreas 2005-260

In the GITSG randomized trial of pts with locally unresectable pancreatic cancer, patients received either 40 Gy with 5FU, 60 Gy with 5FU, or 60 Gy alone. Which one of the following is correct?
A. 60 Gy improves the median survival compared with 40 Gy.
B. 5FU with RT improves the median survival compared with RT alone.
C. The median survival with RT alone is 10 months.
D. More recent randomized trials have demonstrated an improved overall survival with RT and Gemcitabine vs RT and 5FU.
Pancreas 2005-260

In the GITSG randomized trial of pts with locally unresectable pancreatic cancer, patients received either 40 Gy with 5FU, 60 Gy with 5FU, or 60 Gy alone. Which one of the following is correct?

B. 5FU with RT improves the median survival compared with RT alone.
Pancreas 2005-257
GITSG 9173 randomized patients with resected pancreatic cacner to either adjuvant combined radiation and 5FU or no further treatment following surgery. The medial survival in patients receiving surgery alone was closest to which one of the following?
A. 6 months
B. 12 months
C. 18 months
D. 24 months
Pancreas 2005-257
GITSG 9173 randomized patients with resected pancreatic cacner to either adjuvant combined radiation and 5FU or no further treatment following surgery. The medial survival in patients receiving surgery alone was closest to which one of the following?

B. 12 months
2006-237. Which of the following statements about pancreatic cancer is true?
A. K-ras gene mutations are associated with approximately 90% of patients with pancreatic adenocarcinomas
B. Approx 50% of patients have resectable tumors at initial diagnosis.
C. Approx 30% of patients who do not receive adjuvant therapy experience locoregional relapse as a component of failure after undergoing a Whipple procedure.
D. The sensitivity rate of CT scans to detect tumor resectability is 30%.
2006-237. Which of the following statements about pancreatic cancer is true?

Answer: A. Modern, contrast-enhanced CT scanning can correctly predict respectability about 70% of the time. Local/regional relapse as a component of failure after a Whipple procedure in non-adjuvantly treated patients is about 70%.
2006-238. Which statements about adjuvant CRT for resected pancreatic cancer is false?
A. GITSG trial, which compared the use of adjuvant CRT vs obs for curatively resected pan ca: median survival time was nearly doubled with adj therapy.
B. EORTC 1999 randomized trial compared adj 5-FU CI + concurrent split-course RT (20 Gy plus 20 Gy) to obs alone for resected pancreatic and biliary tumors.
C. This EORTC study found only a trend toward improved survival for pts receiving adj therapy.
D. ESPAC-1 trial improved upon earlier trials by delivering continuous-course vs split-course RT.
2006-238. Which of the following statements about recent randomized trials examining the role of adjuvant chemoradiotherapy for patients with resected pancreatic cancer is false?

D. The ESPAC-1 trial improved upon earlier trials by delivering continuous-course rather than split-course radiation therapy.
2007-213. Which of the following statements about pancreatic cancer is false?
A. Approximately 10% to 20% of pancreatic cancers are associated with hereditary factors.
B. New-onset diabetes mellitus may be the first clinical feature in 10% of patients.
C. Tumors of the pancreatic head arise to the right of the superior mesenteric-portal vein confluence and include tumors of the uncinate origin.
D. The most common physical finding at initial presentation is Courvoisier’s sign.
2007-213. Which of the following statements about pancreatic cancer is false?
factors.
patients.

D. The most common physical finding at initial presentation is Courvoisier’s sign.
Pancreas 2008-19

Which of the following statements about adjuvant therapy for pancreatic cancer is true?
A Gemcitabine improves disease-free survival.
B RT must be given to improve survival.
C ESPAC-1: CCRT improved survival.
D Virginia Mason trial demonstrated lower than expected survival rates.
Pancreas 2008-19

Which of the following statements about adjuvant therapy for pancreatic cancer is true?
A Gemcitabine improves disease-free survival.
B RT must be given to improve survival.
C ESPAC-1: CCRT improved survival.
D Virginia Mason trial demonstrated lower than expected survival rates.
Pancreas 2008-173

Involvement of which of the following vessels is LEAST likely to result in a margin-negative resective of a pancreatic cancer?
A Portal vein
B Superior mesenteric vein
C superior mesenteric artery
D Splenic artery
Pancreas 2008-173

Involvement of which of the following vessels is LEAST likely to result in a margin-negative resective of a pancreatic cancer?
A Portal vein
B Superior mesenteric vein
C superior mesenteric artery
D Splenic artery
Pancreas: EORTC 40891
Pancreas: EORTC 40891

218 patients with pancreatic and periampullary adenoca
1987-1995
Randomized: Adj RT+5FU vs Obs
RT: 20Gy/10Fx-2 wks-20Gy/10Fx
5FU: CI only during RT, none afterward
Results: No significant improvement in median survival or 2-yr surival
Conclusion: Adj CCRT not standard treatment
Pancreas: ESPAC1
Pancreas: ESPAC1
Resected pancreatic ductal adenoca
Randomized in 2x2 design
- ChemoRT/Chemo/Obs/Both
Results for 5yr survival
- CRT 10% vs 20% without CRT
- Chemo 21% vs 8% without chemo
Conclusion: Survival benefit with chemo but not chemoRT
Pancreas: GITSG in 1981
Pancreas: GITSG 9173
- 194 patients with unresectable pancreatic cancer
- Randomized
-- 40Gy split course + 5FU bolus
-- 60Gy split course + 5FU bolus
-- 60Gy alone
Results
- Improved survival with CRT
- No significant diff between CRT regimens
- Prognostic variables
-- Pretreatment performance status
-- Pretreatment CEA
Pancreas: GITSG 9173
Pancreas: GITSG 9173
43 resectable patients
Surgery or
Surgery then 40Gy split course+5FU
Results
- Increased OS
-- 43% vs 18% at two years
-- 14% vs 5% at five years
Added 30 nonrandomized patients --> 2yr OS 46%