Improving Patient Centered Outcomes in Pancreatic Cancer (Text Version)

Slide presentation from the AHRQ 2011 conference.

On September 19, 2011, A.J Moser and Herbert Zeh made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (9 MB). Plugin Software Help.


Slide 1

Improving Patient Centered Outcomes in Pancreatic Cancer 

Improving Patient Centered Outcomes in Pancreatic Cancer

A. James Moser, MD
Herbert J. Zeh, III, MD

Co-Directors, UPMC Pancreatic Cancer Center
Division of Surgical Oncology
University of Pittsburgh School of Medicine (UPMC)

Slide 2

Improving Patient Centered Outcomes in Pancreatic Cancer 

Improving Patient Centered Outcomes in Pancreatic Surgery

  • Develop "personalized" surgical treatment:
    • Modeling of outcomes.
    • Theranostics.
  • Re-thinking clinical trial design.
  • Explore minimally invasive approach to pancreatic surgery program.

Slide 3

Patient Centered Outcomes in Pancreatic Surgery

Patient Centered Outcomes in Pancreatic Surgery

  • Reduced perioperative morbidity.
  • Maintain quality of life.
  • Decreased peri-operative blood loss and transfusion.
  • Increased rate of adjuvant therapy.

Slide 4

Why develop a minimally invasive approach to Pancreas?

Why develop a minimally invasive approach to Pancreas?

  • Pancreatic cancer remains dormant for 10-12 years before clinically detectable?
    • Early detection may allow less invasive surgery to be curative?

Image of a journal article title and a figure from the article.

Slide 5

Why develop a minimally invasive approach to Pancreas?

Why develop a minimally invasive approach to Pancreas?

  • "Prophylactic" pancreatectomy:
    • IPMN = polyp of the pancreas.

Images: Polyps of the pancreas are shown.

Slide 6

Laparoscopic PD

Laparoscopic PD

  • Adequate for ablative surgery.
  • For procedures requiring extensive reconstruction the technique is modified to meet the technological limitations.
  • Poor ergonomics for the surgeon.
  • Limited range of motion of instruments.
  • Two dimensional!
    • Wouldn't do open surgery with one eye.

Slide 7

Robotic Pancreas Resections

Robotic Pancreas Resections

  • Advantages of Robotic Surgery:
    • Magnification 20x-30x.
    • Near 360 degrees range of motion in instruments.
    • Elimination of tremor / improved dexterity.
    • Stereotactic binocular vision—it's 3D like Avatar!

Slide 8

Goals of Robotic Pancreas Program at UPMC

Goals of Robotic Pancreas Program at UPMC

  • Major objectives:
    • Reproduce open technique and outcomes.
    • Widely applicable.
    • Quality Assurance.
  • Rule out Disadvantages:
    • Equivalent safety?
    • Learning curve and time investment.
  • Explore Potential Advantages:
    • Decrease peri-operative morbidity/blood transfusions.
    • Earlier adjuvant chemotherapy.

Slide 9

UPMC Robotic Pancreas Program 09/17/2011

UPMC Robotic Pancreas Program
9/17/2011

Flowchart showing breakdown of studies.

N=195

  • RAPD N=85.
  • RACP N=43.
  • RATP  N=5.
  • RADP N=60.
  • RAF N=2.

Slide 10

Robot-Assisted Minimally-Invasive Distal Pancreatectomy Is Superior to the Laparoscopic Technique

Robot-Assisted Minimally-Invasive Distal Pancreatectomy Is Superior to the Laparoscopic Technique

Slide 11

Methods

Methods

  • Retrospective analysis of all minimally-invasive distal pancreatectomies at UPMC between January 2004 and February 2011.
  • Compared the peri-operative outcomes of our first 30 RADP to 94 consecutive historical control LDP.

Slide 12

Table 1. Outcomes Following Laparoscopic and Robotic-assisted Distal Pancreatectomy

Table 1. Outcomes Following Laparoscopic and Robotic-assisted Distal Pancreatectomy

CharacteristicsLaporoscopicRobotic-assistedp-value
N9430 
Age (years)59±1659±130.95
Female Gender61 (65%)20 (67%)0.86
Caucasian91 (97%)26 (87%)0.058
BMI (kg/m2)29.0±7.127.9±5.10.434
ASA Score  0.8
   I/II42 (45%)11 (37%)0.41
   III/IV51 (55%)19 (63%)0.41
Previous abdominal surgery48 (51%)22 (73%)<0.05
CT tumor size (cm)2.9±1.92.6±1.40.45
Endoscopic ultrasound size (cm)2.6±1.62.7±1.30.985

Values represent mean ±SD, or n (%)

Slide 13

Table 2. Pathologic Indications for Distal Pancreatectomy

Table 2. Pathologic Indications for Distal Pancreatectomy

Final HistologyLaporoscopic
n=94
Robotic-assisted
n=30
p-value
Pancreatic duodenal adenocarcinoma14 (15%)13 (43%)<0.05
Mucinous cystic neoplasm30 (31%)4 (13%)<0.05
Neuroendocrine tumor21 (22%)9 (27%)0.46
Intraductal papillary mucinous neoplasm11 (12%)5 (17%)0.534
Solid pseudopapillary neoplasm6 (6.4%)_0.33
Other12 (13%) §1 (3) ††0.184

§ Includes autoimmune pancreatitis (n=2), chronic pancreatitis (n=1), serous cystadenoma (n=3), pseudocyst (n=1), mucinous cystadenocarcinoma (n=1), spindle cell lesion, (n=1), benign epithelial cyst (n=2) and oligocystic adenoma (n=1).
†† Includes lymphoepithelial cyst (n=1)

Slide 14

Table 3. Perioperative Outcomes Following Laparoscopic and Robotic-assisted Distal Pancreatectomy

Table 3. Perioperative Outcomes Following Laparoscopic and Robotic-assisted Distal Pancreatectomy

Outcome ParameterLDP N=94RADP N=30p-value
Procedure duration (min ± SD)372±141293±93<0.01*
Planned splenectomy77 (82)28 (93%)0.157
Estimated blood loss (ml)150 (100, 300)150 (100, 300)0.688
Frequency of blood transfusion (%)2.25±1.362.33±0.580.921
Median EBL (ml) in upper quartile (>75th percentile for blood loss)550 (400, 650)375 (300, 550)<0.05
Converted to open15 (16) 0 (0%) <0.05*
Postoperative admission to ICU31 (33)7 (23)0.370
Pancreatic fistula39 (41)14 (46)0.676
   ISGPF Grade A23 (24)6 (20)NS
   ISGPF Grade B11 (12)4 (13)NS
   ISGPF Grade C5 (5)4 (13)NS
90-day morbidity  0.658
   Minor (Clavien 1/2)¥47 (50)14 (46) 
   Major (Clavien 3/4)¥13 (14)6 (20) 
Length of stay, days7.1±4.06.1±1.70.183
90-day readmission22 (23)11 (37)0.162
30-day mortality1 (1.1)0 (0%)1.0

Normally-distributed values are expressed as mean ± SD or n (%); otherwise median (25th, 75th percentile) as interquartile range (IQ).

¥Clavien classification of surgical complications.16

Slide 15

Table 5. Effects of Conversion During LDP on Perioperative Outcome

Table 5. Effects of Conversion During LDP on Perioperative Outcome

CharacteristicsConverted LDP
N=15
Completed LDP
N=79
p-value
Age54 (46, 69)62 (51, 72)0.206
Gender (F)9 (60)76 (65.82)0.770
BMI28 (27.4, 33)27 (24.5, 32.9)0.474
ASA (III/IV)8 (53)43 (55)1.00
OR duration345 (268, 593)341 (250, 452)0.557
Splenectomy15 (100)62 (79)0.065
EBL425 (300, 700)150 (100, 300)<0.001*
Frequency of blood transfusion4 (27)8 (10)0.096
Pancreatic ductal adenocarcinoma6 (40.0)8 (10.13)<0.01*
Tumor size (cm)4 (3.5, 4.5)3 (2, 4)0.3
R0 Margin status (PDA only)3 (50.0)4 (50.0)1
Lymph nodes harvested (PDA)9 (7, 11)17 (10, 19)0.845
ICU admission, days8 (53.33)23 (29.11)0.079
Pancreatic fistula7 (46.67)32 (41.03)0.778
Length hospital stay, days8 (6, 10)6 (5, 7)<0.01*

Normally-distributed values are expressed as mean ± SD or n (%); otherwise median (25th, 75th percentile) as interquartile range (IQ).

Slide 16

Table 4. Pathologic Outcomes Following Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma

Table 4. Pathologic Outcomes Following Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma

CharacteristicLDPRADPp-value
Frequency (n, %)14 (19)13 (43)<0.005*
Tumor size (cm)3.4±1.63.1±1.20.604
R1 margin status7 (50)0 (0)<0.01*
Nodal harvest (median, IQR)9 (7, 11)19 (17, 24)<0.01*

Normally-distributed values are expressed as mean ± SD or n (%); otherwise median (25th, 75th percentile) as interquartile range (IQ).

Slide 17

Comparison of Robotic (RADP) and Laparoscopic (LDP) Approach to Distal Pancreatectomy

Comparison of Robotic (RADP) and Laparoscopic (LDP) Approach to Distal Pancreatectomy

  • Robotic assisted minimally invasive distal pancreatic resection appears comparable to laparoscopic approach in safety and feasibility.
  • RADP was associated with decreased frequency of conversion to open, increased number of total Lymph node harvested, higher rate of R0 resections and decreased significant blood loss.
  • These data suggest that use of the Robotic Platform may allow more patients to successfully undergo minimally invasive distal pancreatectomy.
  • Larger multicenter studies are needed to validate these findings.

Slide 18

UPMC Robotic Pancreas Program 09/17/2011

UPMC Robotic Pancreas Program
9/17/2011

Repeat of Slide 9.

Slide 19

Image: Titles and authors for two articles are shown.

Image: Titles and authors for two articles on robot-assisted pancreative resection and reconstruction are shown.

Slide 20

Table 1: Demographics of Entire RAPD Cohort

Table 1: Demographics of Entire RAPD Cohort

ParameterOutcome
Age, mean ±SD (range)68±16 (27-85)
Gender Female26 (52%)
Prior surgery29 (58%)
BMI, mean ±SD (range)27±5 (19-37)
Medical Comorbidities 
   Multiple Major11 (22%)
   Major17 (34%)
   Minor2 (4%)
   None20 (40%)
ASA Score 
   II21 (42%)
   III28 (56%)
   IV1 (2%)

Data are presented as mean ±SD, or n (%).

Slide 21

Table 2: Pathologic Indications for RAPD

Table 2: Pathologic Indications for RAPD

Final HistologyN (%)
Malignant37 (74%)
Pancreatic duodenal adenocarcinoma14 (28%)
Neuroendocrine tumor10 (20%)
Ampullary adenocarcinoma9 (18%)
Cholangiocarcinoma2 (4%)
Pseudopapillary neoplasm2 (4%)
Premalignant12 (23%)
Intraductal papillary mucinous neoplasm10 (19%)
Mucinous cystic neoplasm1 (2%)
Duodenal adenoma1 2%)
Benign1 (3%)
Oligocystic serous cystadenoma1 (2%)

Slide 22

Table 3: Perioperative Outcomes of RAPD Cohort

Table 3: Perioperative Outcomes of RAPD Cohort

ParameterOutcome
Procedure duration (min), median (IQR)568 (536-629)
Converted to open8 (16%)
Blood loss (mL), median (IQR)350 (150-625)
Blood transfusion11 (22%)
Pancreatic duct (mm), median (IQR)3.0 (3.0-5.0)
Soft pancreatic remnant36 (72%)
Length of stay (d), median (IQR)10.0 (8.0-13.0)

Slide 23

Table 4: Pathologic Outcomes Following RAPD for Invasive Periampullary Adenocarcinoma

Table 4: Pathologic Outcomes Following RAPD for Invasive Periampullary Adenocarcinoma

CharacteristicsPDA, Amp, CCA
N (%)25 (50%)
TNM* (n=25) 
   T1N02 (8%)
   T2N04 (16%)
   T3N06 (24%)
   T3N110 (40%)
   T4N12 (8%)
AJCC Stage 
   1A2 (8%)
   1B4 (16%)
   IIA6 (24%)
   IIB13 (52%)
Tumor size (cm)2.7 cm, IQR 0.7
Lymph nodes harvested18, IQR 5
R0 margin33 (89%)
R1 margin4 (11%)
Adjuvant tx indicated (n=15)11 (73.3)
Adjuvant tx duration (wks)11.5 (8.8-12.5)

Data presented as median (IQR) or n (%) for PDA, AMP, and CCA only.

Slide 24

Table 5: Postoperative Complications Following RAPD

Table 5: Postoperative Complications Following RAPD

ParameterOutcome
Pancreatic fistula11 (22%)
   Grade A5 (10%)
   Grade B2 (4%)
   Grade C4 (8%)
30-day morbidity 
   Minor (Clavien I/II)13 (26%)
   Major (Clavien III/IV)15 (30%)
Reoperation3 (6%)
90-day readmission15 (30%)
90-day mortality1 (2%)

Slide 25

Conclusions

Conclusions:

  • Robotic assisted Pancreatic resections are currently feasible and safe.
  • Evolution of the technique will likely continue making comparative studies difficult.
  • Multicenter collaborations necessary to study comparative effectiveness.

Slide 26

Minimally Invasive Pancreatic Surgery Consortium (MIPSC)

Minimally Invasive Pancreatic Surgery Consortium (MIPSC)

  • Contributing Members:
    • University of Pittsburgh.
    • Mayo Clinic.
    • Cleveland Clinic.
    • Pisa Italy.
  • Second Annual meeting November 2011.
  • Goals:
    • Multicenter prospective database.
    • Standardization of procedures.
    • Comparative effectiveness studies.

Slide 27

UPMC Pancreatic Cancer Program

UPMC Pancreatic Cancer Program

zehh@upmc.edu

moseraj@upmc.edu

Slide 28

RAPD Set Up

RAPD Set Up

Images: Photographs of the RAPD equipment are shown.

Slide 29

Tying It All Together . . .

Tying It All Together...

Slide 30

Case Presentation

Case Presentation

  • 76 y/o female symptomatic found to have elevated amylase and lipase after abdominal pain.
  • CT main duct IPMN.
  • Followed for several years.
  • Recent EUS demonstrated increased in disease in head of gland.

Slide 31

Case Presentation

Case Presentation

Image: MRI of a patient's abdomen are shown.

Slide 32

Case Presentation

Case Presentation

Image: A photograph of the removed pancreas section is shown.

Slide 33

Case Presentation

Case Presentation (continued)

IMPN of main duct:

  • Uncomplicated Robotic Assisted Pancreaticoduoenectomy.
  • Discharged POD #10.
  • Final Pathology:
    • IPMN with dysplasia.

Slide 34

Case Presentation: #2

Case Presentation: #2

  • 72 y/o male abdominal pain three months, followed by jaundice.
  • CT Large mass in the HOP:
    • Loss of fat plane between mass and PV/SMV.
  • EUS –:
    • Loss of fat plane PV/SMV.
  • ERCP:
    • Double duct.
    • Short metal stent.
  • Cytology:
    • Acinar Cell Carcinoma.

Slide 35

Case Presentation: #2

Image: An MRI of a patient's abdomen is shown.

Slide 36

Case Presentation: #2

Case Presentation : #2 (continued)

  • Received six cycles of modified FOLFOX.
  • Repeat Staging demonstrated partial response in tumor and no metastatic disease.

Slide 37

Case Presentation: #2

Image: An MRI of a patient's abdomen is shown.

Slide 38

Case Presentation: #2

Case Presentation: #2 (continued)

  • Uncomplicated Robotic Assisted Pancreaticoduoenectomy.
  • Discharged POD 5.
  • Final Pathology:
    • Acinar Cell Carcinoma with significant Rx effect.
    • Negative margins.

Slide 39

Case Presentation: #2

Case Presentation: #2 (continued)

  • Received additional three cycles of modified FOLFOX.
  • Alive and disease free at 24 months.
Current as of March 2012
Internet Citation: Improving Patient Centered Outcomes in Pancreatic Cancer (Text Version). March 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2011/moser/index.html