Peter W. T. Pisters

Quality management with the ability to benchmark quality metrics remains a cornerstone of the authors' overarching strategy to maintain consistent high-quality care throughout our national network.

293 Background: We previously introduced a novel classification system for assessing “operability” in patients with localized pancreatic adenocarcinoma (PDAC) that integrates cancer biology, patient physiology, and tumor anatomy. We sought to analyze resection rates, reasons for no resection, and outcomes after neoadjuvant therapy (NT) of patients with both resectable anatomy and either “operable” or “borderline” biology/physiology. Methods: We evaluated consecutive patients (2002-2007) with radiographically resectable cancers treated with NT prior to potential resection. Borderline resectable anatomy (BR-A) was excluded. We compared clinical factors and outcomes of 217 patients classified by established criteria as “potentially resectable-operable” (PR-OP, no evidence of extrapancreatic disease, performance status [PS] ≤1); “borderline resectable-B” (BR-B, findings suspicious for extrapancreatic disease); or “borderline resectable-C” (BR-C, severe but reversible comorbidities or marginal PS ≥2). Results: 138 PR-OP, 41 BR-B, and 38 BR-C patients began NT. 62.7% of all patients underwent subsequent pancreatectomy. Resection rates after NT for PR-OP, BR-B, and BR-C were 74.6%, 46.3%, and 36.8%, respectively (p Conclusions: Our operability classification system describes discrete clinical subgroups among PDAC patients with similar, resectable tumor anatomy but vastly heterogeneous physiology and cancer biology. It can be used with NT to predict outcomes, individualize treatment, and optimize survival rates.

289 Background: Fear of Cancer Recurrence (FCR) is well documented among survivors of breast, colon and prostate cancer. Incurable recurrence is common following resection of pancreatic and periampullary neoplasms. The incidence and significance of FCR in this population is unknown. We hypothesized that FCR represents an important source of psychosocial distress following resection of pancreatic neoplasms. Methods: We conducted a cross-sectional study of patients with non-recurrent pancreatic ductal (PDAC), periampullary adenocarcinoma or pancreatic neuroendocrine tumor (PNET) treated with potentially curative surgery 1991–2011. We assessed 7 discrete dimensions of FCR using the Fear of Recurrence Inventory (FCRI) and evaluated quality of life (QOL) and psychosocial distress using the Functional Assessment of Cancer Therapy-Hepatobiliary Questionnaire and Hospital Anxiety and Depression Scale. Participants completed these validated instruments by mail. Results: 188 (53%) of 355 eligible patients completed at least one instrument, a median of 49 months (range, 6–222 months) following potentially curative resection. Participants included 73 (39%) patients with PDAC, 55 (29%) with periampullary adenocarcinoma, and 60 (32%) with PNET. The median FCR severity score was higher than a previously established cutoff for clinical significance in 55%, 51% and 63% of patients with PDAC, periampullary adenocarcinoma and PNET, respectively. Older age, male gender, periampullary adenocarcinoma, negative lymph nodes, and longer interval since operation were clinical factors associated with lower total FCR score (all p Conclusions: Fear of cancer recurrence is pervasive following resection of pancreatic neoplasms, regardless of survivors’ histopathologic diagnosis, disease severity, or time since resection. Given its association with anxiety, depression and lower QOL, FCR represents a critical therapeutic target.

252 Background: Resection of recurrent disease in malignancies such as colorectal cancer has been shown to prolong survival but resection for recurrent pancreatic ductal adenocarcinoma (PDAC) is viewed as futile. We sought to identify factors that may be associated with prolonged survival following resection of recurrent PDAC. Methods: A retrospective review of a prospectively-maintained pancreatic tumor database was performed to identify all patients from 1992-2010 who developed recurrent PDAC after intended surgical cure. The group was screened for those who underwent a second operative procedure with curative intent. Clinicopathologic features were correlated with disease-free interval (DFI) and survival to identify factors that may be associated with prolonged survival in patients undergoing reoperation for PDAC. Results: Of 700 patients who underwent resection for PDAC, 426 (61%) recurred after a median of 8mo and 21 (5%) of those had a locoregional [pancreas (n=5), other (n=2)] or distant [lung (n=7), liver (n=6), brain (n=1)] recurrence that were selected for a second, potentially curative operation. Sixteen of 21 patients received chemotherapy prior to reoperation. Those selected had a single, technically resectable lesion, good performance status, and prolonged median DFI compared to patients not selected (22mo v. 8mo, p Conclusions: Patients who develop a solitary recurrence of PDAC in the lung after a long disease-free interval should be considered for reoperation. Those with recurrence in other sites are likely to re-recur relatively quickly after reoperation regardless of disease-free interval.

Surgery is the standard of care for primary resectable gastrointestinal stromal tumors (GISTs), but half of surgically treated patients relapse. Imatinib (IM) has been shown to prolong recurrence‐free survival after complete surgery and is now approved as adjuvant therapy (400 mg/day) for high‐risk GIST patients. IM is well tolerated, with mild to moderate side effects observed. Whether adjuvant IM prolongs overall survival is under evaluation in two ongoing clinical trials. J. Surg. Oncol. 2011; 104:896–900.

Learning Objectives: After completing this course, the reader will be able to: Explain the rationale for the use of adjuvant and neoadjuvant chemoradiation and/or chemotherapy in the treatment of patients with potentially resectable pancreatic cancer.Describe the limitations of prior prospective, randomized trials of adjuvant therapy strategies and the clinical implications of these limitations.Compare modern strategies for the multidisciplinary management of potentially resectable and borderline resectable pancreatic cancer. This article is available for continuing medical education credit at CME.TheOncologist.com. In this article, we review the rationale for and outcomes associated with the use of adjuvant and neoadjuvant therapy for resectable and borderline resectable cancer of the pancreatic head and uncinate process. Localized pancreatic cancer is a systemic disease that requires nonoperative therapies to minimize the local and systemic recurrences that almost invariably occur in the absence of such therapy, even following complete surgical resection. A well-defined role exists for the systemic administration of gemcitabine or 5-fluorouracil in the postoperative setting. Although the survival benefit associated with adjuvant chemoradiation has not been as rigorously defined, its use is supported by extensive historic experience; chemoradiation should be considered particularly for patients at high risk for local recurrence. Delivery of chemotherapy and/or chemoradiation prior to surgery has multiple potential advantages, although the superiority of neoadjuvant therapy over standard postoperative therapy has yet to be demonstrated. Neoadjuvant therapy may be particularly beneficial among patients with borderline resectable cancers. Although the existing literature is confusing, and indeed controversial, available evidence suggests that systemic chemotherapy and/or chemoradiation should be offered to all patients with pancreatic cancer who undergo potentially curative resection. Well-designed prospective trials are needed to define the optimal adjuvant or neoadjuvant therapy strategy for these patients.

Herein, we review the current management of localized and advanced gastrointestinal stromal tumors (GISTs). Although surgery remains the standard of care for patients with localized GIST, adjuvant imatinib can delay recurrence in some of these patients. In patients with advanced or metastatic disease, the standard of care is imatinib and surgery of residual masses is an option. Preoperative imatinib is an emerging treatment option for patients who require cytoreductive therapy. Sunitinib is a standard second‐line therapy. J. Surg. Oncol. 2010;102:530–538.