facing a pancreatic tumour: when / how / whatcase presentation laura mans 8 sbrt may 2018: sbrt with...

BGDO Annual Meeting 2020Advances in Pancreaticobiliary Cancers

Borderline resectable vs locally advanced pancreatic cancer | Case presentation Laura Mans

1

Facing a pancreatic tumour: when / how / what ?

Laura MANS, MD

January 11, 2020

73 YEARS-OLD MAN – JULY 2017

Clinical features:

Abdominal pain

Loss of weight – 6Kg

Medical history:

High blood pressure

Hyperuricemia

Home-based treatment:

Lisinopril 10mg

Allopurinol 300mg



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BASELINE EVALUATION – AUGUST 2017

Abdominal CE-CT scan:

Tumoral lesion of the pancreas isthmus with double duct sign upstream the lesion Contact with the SMV < 180° Contact with the SMA < 180° Coeliac LN : 11 mm short axis


Abdominal MRI:

Tumoral lesion of the pancreas isthmus: DWI restriction Coeliac LN : 11 mm short axis



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Abdominal MRI:

Tumoral lesion of the pancreas isthmus: DWI restriction Coeliac LN : 11 mm short axis Contact with the SMV < 180° and with the SMA < 180° Absence of liver metastasis


Abdominal MRI:

Tumoral lesion of the pancreas isthmus: DWI restriction Coeliac LN : 11 mm short axis Contact with the SMV < 180° and with the SMA < 180° Absence of liver metastasisMRCP: double duct sign upstream the lesion



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Pancreatic EUS: lesion of the isthmus with contact to porto-mesenteric confluence and involvement of the gastro-duodenal artery.

FNA: adenocarcinoma

Chest CT scan: negative

CA19.9: 430 kU/l


FDG PET/CT: tumoral lesion of the pancreas isthmuswithout loco-regional extension or distant metastasis.



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MULTIDISCIPLINARY BOARD

Pancreatic adenocarcinoma cT2N1M0 borderline resectable

Multidisciplinary board decision:

Induction chemotherapy FOLFIRINOX-based (NEOPAC protocol)

EARLY EVALUATION (AFTER 2 CYCLES)

CA 19.9: 430 kU/l 120 kU/l (72% decrease)

FDG PET/CT: Excellent metabolic response to ChT



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ONGOING CHEMOTHERAPY…

Evaluation after 5 cycles (November 2017)

CA 19.9: 430 kU/l 120 kU/l 99 kU/l

Thoraco-abdominal CT scan: stable disease

Continuation of chemotherapy for 7 cycles in total

DECEMBER 2017

Exploratory surgery: contact with the anterior and the right lateral face of the superior mesenteric vein at the level of the Henle trunk: risk of R1 resection.

Restart chemotherapy (4 cycles)



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MARCH 2018: EVALUATION AFTER 4 MORE CYCLES

CA 19.9: 430 kU/l 120 kU/l 99 kU/l 20 kU/l

Thoraco-abdominal CT scan: decrease in size of the pancreatic lesion

MARCH 2018: EVALUATION AFTER 4 MORE CYCLES

FDG PET/CT: Complete metabolic response



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SBRT

May 2018: SBRT with 35 Gy + boost (40 Gy) at the contact area with the SMV (11/05 to 17/05)

June 2018: evaluation post SBRT

FDG PET/CT: persistence of a complete metabolic response

JUNE 2018: POST SBRT EVALUATION

Fiducials in relation to the pancreatic tumor. The tumor was stable in size, running along the upper mesenteric vein upstream of the spleno‐mesaraic confluence

Thoraco‐abdominal CT scan:



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JULY 2018 : SURGERY

Duodenopancreatectomy:

Pathology: 15 mm well differentiated adenocarcinoma. No lymphovascular or neural invasion. N1 (1/17). R0. ypT1cN1

Due to post op frailty: no adjuvant therapy

No disease recurrence in october 2019

KEY MESSAGES

Accurate staging (vascular) mandatory for decision making

Emerging place for neoadjuvant therapy

Place and role of adding (SB)RT to NChT

Need for prospective RCT.



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NEOPAC - TREATMENT PLAN

w11 w12 w13w14w15w16w17w18Diagnosis

w1 w7 w8w5 w9w6 w10w2 w3 w4

PETCTCA19.9, CEA

BS

Work‐upCT‐scan C+PETCTBlood test CA19.9, CEAEUS‐FNA

FOLFIRINOX 1 cycle/ 2 weekss

Radiochemotherapy or SBRT (5x6Gy) optional after vascular restagingRadiochemotherapy : 50.4 Gy (1.8 Gy x 28 fr) + capecitabine 1650 mg/m2/j

PETCTCT‐scan C+CA19.9, CEA

BS

PETCTCT‐scan C+CA19.9, CEA

BS

Surgical resection if no progression

facing a pancreatic tumour: when / how / whatcase presentation laura mans 8 sbrt may 2018: sbrt with...

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