Surgical Management of Locally Advanced Pancreas Cancer

(1)

Surgical Management of Locally Advanced Pancreas Cancer

Section 1

Your participation is voluntary and anonymous. We do not foresee any risks to you or your patients incurred by completing this survey. Refusal to participate will involve no penalty or loss of benefits to which you are otherwise entitled, and you may discontinue participation at any time. If you choose to complete the survey, your consent to participate is assumed. Thank you for your time and consideration.

NOTE: This survey includes 5-7 minutes of multiple choice questions, followed by 6 brief clinical vignettes. If you leave the survey, your progress will be saved, and you may return to complete it at any time (on the same browser and electronic device).

Please provide the answer that most accurately represents your practice.

Have you operated on patients with pancreatic ductal adenocarcinoma (PDAC) in the last 5 years?

How would you characterize your surgical practice?

Yes No.

Fully trained independently practicing surgeon Surgical trainee in fellowship

Surgical trainee in residency Medical student

(2)

In what geographic region do you practice?

How would you characterize the focus of your surgical practice?

How many years have you been in practice?

How would you describe your practice (select all that apply)?

North America South America Europe

Asia Australia

General Surgery Surgical Oncology

Hepato-Pancreatico-Biliary Surgery Transplant Surgery

Other

Community hospital (no training programs) Non-university teaching hospital

University teaching hospital Government hospital

Urban (Your hospital serves a community of >100,000) Rural (Your hospital serves a community of ≤100,000) I care for patients in multiple hospitals

(3)

Does your practice area (hospital or community) have specialists in pancreatic cancer available for consultation (select all that apply)?

Do you practice in hospitals that offer clinical trials for patients with PDAC?

Section 2

Please choose the answer that most accurately represents your personal practice.

In a typical year, roughly how many new patients with PDAC do you see in clinic?

Yes, medical oncologists specialized in PDAC Yes, radiation oncologists specialized in PDAC

Yes, interventional radiologists specialized in hepatobiliary procedures and/or mesenteric angiography

Yes, gastroenterologists specialized in ERCP, EUS, FNA, and other advanced endoscopic procedures (stenting)

No

Yes No

0 - 25 26 - 75 76 - 150 151 - 250 More than 250

(4)

In a typical year, roughly how many pancreatectomies for PDAC do you perform?

In a typical year, roughly how many pancreatectomies for PDAC are performed at your institution?

Which of the following modalities do you typically use or prefer to have available when initially staging a PDAC patient? (select all that apply)

0 - 10 11 - 25 26 - 50 51 - 100 More than 100

0 - 25 26 - 50 51 - 100 101 - 200 More than 200

Liver Function Tests CEA level

CA 19-9 level Ultrasound

Endoscopy / EUS CT Scan

PET Scan MRI

Diagnostic Laparoscopy

Other

(5)

How do you manage the interval evaluation of patients with PDAC undergoing neoadjuvant therapy?

What criteria do you use to define the resectability of patients with PDAC (select all that apply)?

I defer to the medical or radiation oncologists, and I reevaluate the patient after the completion of therapy

I reevaluate the patient, along with the medical or radiation oncologists, with every occurrence of reimaging

I reevaluate the patient prior to completion of therapy, but less often than medical or radiation oncology

AHPBA/SSO/SSAT

National Comprehensive Cancer Network MD Anderson Cancer Center

Intergroup (Alliance) Japan Pancreas Society

Other Graphic of Resectability Criteria:

(6)

Do you participate in a Multi-Disciplinary Cancer Conference (MCC) or Tumor Board?

How often does the MCC or tumor board meet?

How often do you attend the MCC or tumor board?

Section 3

Do you use diagnostic laparoscopy prior to open resection of PDAC?

Yes No

Every week 2-3x per month Monthly

Every few months

Always Often Sometimes Infrequently

Routinely Selectively

(7)

Do you routinely offer minimally-invasive pancreaticoduodenectomy to patients with PDAC, if technically feasible?

If technically feasible, what type of minimally-invasive pancreaticoduodenectomy do you offer patients with PDAC?

Do you offer venous resections and reconstructions to select patients with advanced PDAC requiring a pancreaticoduodenectomy?

Do you offer arterial resections and reconstructions to select patients with advanced PDAC requiring a pancreaticoduodenectomy?

Do you recommend neoadjuvant systemic therapy to your patients with advanced PDAC?

Yes No

Laparoscopic or Lap-assisted Robotic or Robotic-assisted Both Laparoscopic and Robotic

Yes No

(8)

What type of neoadjuvant systemic therapy do you prefer or typically recommend to your patients with advanced PDAC (assuming no medical contraindications and ECOG 0)?

What duration of neoadjuvant systemic therapy do you prefer to typically recommend to your patients with advanced PDAC (assuming no medical contraindications and ECOG 0)?

Do you recommend neoadjuvant radiation therapy to your patients with advanced PDAC?

Always Often Sometimes Never

FOLFIRINOX

gemcitabine and paclitaxel protein-bound (Abraxane) gemcitabine and capecitabine (or S-1)

gemcitabine alone

I defer to the medical oncologist Other

at least 2 months at least 4 months at least 6 months

Other

Always Often Sometimes Never

(9)

When do you typically recommend neoadjuvant radiation therapy to patients with PDAC?

What type of neoadjuvant radiation therapy do you prefer or typically recommend to your patients with advanced PDAC (assuming no medical contraindications and ECOG 0)?

Section 4

How often do you consider the following to be a contraindication to exploration for advanced PDAC of the pancreatic head or uncinate process (including after neoadjuvant therapy)?

All non-metastatic patients with PDAC

Borderline resectable and locally advanced patients Locally advanced patients only

All patients with any vessel involvement All patients with arterial involvement All patients with venous involvement

Chemoradiotherapy (External Beam or Intensity Modulated) delivered over 5-6 weeks Stereotactic Body Radiation Therapy (SBRT) delivered over 1-2 weeks

Other

Never Rarely Occasionally Often Always

Patient Age

Medical Comorbidities (e.g. cardiac disease)

(10)

If you consider age a contraindication, above what age?

If you consider an elevated or rising CA 19-9 a contraindication, above what value(s)?

Section 5

ECOG performance status 2 or 3 Compensated

Cirrhosis

Inability to tolerate

chemotherapy

Previous Exploration Palliative Bypass

Ascites

Elevated or rising CA

19-9

Progression of disease on

neoadjuvant therapy

Cavernous

Transformation of the Porta Hepatis

Isolated Stable Liver Metastases (1 or 2) Isolated Stable Lung Metastases (1 or 2)

(11)

For the following 6 cases, please choose the answer that best represents your recommendation at this point in time. Assume all patients have ECOG performance status of 0 and no medical comorbidities or contraindications to operation. To assess resectability, please use the written descriptions and the CT images accompanying each case.

NOTE: Videos depict the most recent imaging following completion of all neoadjuvant therapies. Abutment is defined as ≤180 degrees of contact. Encasement is defined as >180 degrees of contact. All CTs have a slice thickness of 3 mm.

Case 1

A 73-year-old female was diagnosed with locally advanced pancreatic head adenocarcinoma 6 months ago. CA 19-9 at diagnosis was 25 units/ml. She subsequently completed 4 months of gemcitabine and Abraxane, followed by Stereotactic Body Radiotherapy (SBRT), completed 2 weeks ago. She now presents to your clinic. Her repeat CA 19-9 is 31 units/ml. Restaging studies show no evidence of progression or metastatic disease, and a pancreatic protocol CT reveals a pancreatic head mass, slightly decreased in size, with encasement of the common and proper hepatic arteries, and abutment of the portal vein, with mild narrowing.

Imaging:

Venous:

(12)

Arterial:

Given these findings, would you offer this patient an exploration and possible resection at this time?

(13)

If No, what is your rationale (select all that apply)?

If No, what treatment would you recommend at this time?

Case 2

A 79-year-old male was diagnosed with locally advanced pancreatic head adenocarcinoma 10 months ago. His initial CA 19-9 was 55 units/ml. He subsequently received 4 cycles of FOLFIRINOX,

then SBRT, and completed treatment 1 month ago. He now presents to your clinic. His CA 19-9 is 21 units/ml. Restaging studies show no evidence of progression or metastatic disease, and pancreatic protocol CT reveals a pancreatic head/neck mass, significantly decreased in size, encasing the celiac

No

Concern about arterial involvement (R0 margin) Concern about venous involvement (R0 margin)

Concern about technical complexity (need for reconstruction)

Concern about tumor biology or disease response (doubt surgery will offer meaningful benefit)

Inadequate institutional resources for perioperative care/support Other

Additional chemotherapy (same regimen as previous) Additional chemotherapy (new regimen)

Explore clinical trial options

Directed referral for another surgical consultation

Observation with surveillance imaging and close follow-up Other

(14)

and common hepatic arteries, and the portal vein/SMV, with venous narrowing.

Imaging:

Venous:

Arterial:

(15)

Case 3

A 69-year-old female was diagnosed with locally advanced pancreatic head adenocarcinoma 8 months ago. Her initial CA 19-9 was 290 units/ml. She subsequently received 6 months of FOLFIRINOX,

Yes No

(16)

followed by SBRT, which was completed 1 week ago. She now presents to your clinic. Her most recent CA 19-9 is 85 units/ml. Restaging studies show no evidence of progression or metastatic disease, and a pancreatic protocol CT reveals a pancreatic head mass with encasement of the SMV and SMA, surrounded by significant stranding, and an enlarged necrotic lymph node at the root of the

mesentery.

Imaging:

Venous:

Arterial:

(17)

Yes No

(18)

Case 4

A 35-year-old male was diagnosed with a locally advanced pancreatic head adenocarcinoma 18

months ago. His initial CA 19-9 was 950 units/ml. He subsequently received 6 months of FOLFIRINOX chemotherapy, followed by chemoradiation to 50.4 Gy, and an additional 6 months of FOLFIRINOX. He is referred to your clinic for a second opinion. His most recent CA 19-9 is 250 units/ml. A PET/CT

shows an FDG-avid pancreatic head mass, and no evidence of progression or metastatic disease. His pancreatic protocol CT reveals a pancreatic uncinate mass with encasement of the celiac axis,

longitudinal encasement of the SMA, and PV/SMV abutment.

Imaging:

Venous:

(19)

Arterial:

(20)

Case 5

A 57-year-old male was diagnosed with locally advanced pancreatic head adenocarcinoma with SMA encasement and SMV occlusion 8 months ago. His initial CA19-9 was 2500 units/ml. He received 2 months of gemcitabine and Abraxane, followed by chemoradiation with Abraxane on protocol, and an additional 2 months of gemcitabine and Abraxane. He presents to your clinic for a second opinion. His most recent CA 19-9 is 12 units/ml. He has no evidence of progression or metastatic disease, and his

Yes No

(21)

SMA involvement (now just abutment), persistent long segment SMV encasement and occlusion, and prominent retroperitoneal and mesocolic collateral vessels.

Imaging:

Venous:

Venous 3D Reconstruction:

(22)

Arterial:

Given these findings, would you offer this patient an exploration and possible resection at this

(23)

Case 6

A 60-year-old female was initially diagnosed with metastatic pancreatic adenocarcinoma 7 months ago.

Her initial CA 19-9 was 23,500 units/ml, and imaging at that time showed a resectable head mass and 2 suspicious hepatic lesions, one biopsy confirmed. She subsequently completed 6 months of

gemcitabine and Abraxane. She is interested in surgical therapy and is referred to your clinic for Yes

No

(24)

consultation. Her most recent CA 19-9 is 80 units/ml. Recent imaging shows no evidence of

progression or new metastatic disease. Both hepatic lesions have decreased in size, from 16 mm to 6 mm in segment 8, and from 14 mm to 5 mm in segment 4. Her pancreatic head mass has decreased in size, from 4.0 x 3.3 cm, to 2.5 x 2.4 cm, and only shows slight abutment of the SMV without contour change, and an associated cystic lesion measuring 19 mm.

Imaging:

Venous:

Arterial:

(25)

Yes No

Concern about vessel involvement (R0 margin)

Concern about technical complexity (hepatic wedge resections)

(26)

Powered by Qualtrics Section 6

This is the conclusion of the survey. Thank you for your time.

Do you have any questions, comments or concerns?