Improving Patient Centered Outcomes in Pancreatic Cancer

1. 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

2. 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

3. 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

4. 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?

5. Why develop a minimally invasive approach to Pancreas? • “prophylactic” pancreatectomy • IPMN=polyp of the pancreas

6. 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

7. 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—its 3D like Avatar!

8. 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

9. UPMC Robotic Pancreas Program9/17/2011 N=195 RAPD N=85 RACP N=43 RATP N=5 RADP N=60 RAF N=2

10. ROBOT-ASSISTED MINIMALLY-INVASIVE DISTAL PANCREATECTOMY IS SUPERIOR TO THE LAPAROSCOPIC TECHNIQUE

11. 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 RADPto 94 consecutive historical control LDP.

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17. 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

18. UPMC Robotic Pancreas Program9/17/2011 N=195 RAPD N=85 RACP N=43 RATP N=5 RADP N=60 RAF N=2

25. 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

26. 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

27. UPMC Pancreatic Cancer Program zehh@upmc.edu moseraj@upmc.edu

28. RAPD Set up

29. Tying it all together…

30. 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

31. Case Presentation

32. Case Presentation

33. Case Presentation IMPN of main duct • Uncomplicated Robotic Assisted Pancreaticoduoenectomy • Discharged POD #10 • Final Pathology • IPMN with dysplasia

34. 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

36. Case Presentation : #2 • Received six cycles of modified FOLFOX • Repeat Staging demonstrated partial response in tumor and no metastatic disease

38. Case Presentation : #2 • Uncomplicated Robotic Assisted Pancreaticoduoenectomy • Discharged POD 5 • Final Pathology • Acinar Cell Carcinoma with significant Rx effect • Negative margins

39. Case Presentation : #2 • Received additional three cycles of modified FOLFOX • Alive and disease free at 24 months