胰腺癌治療進(jìn)展英文課件

胰腺癌治療進(jìn)展英文ppt課件6、露凝無游氛，天高風(fēng)景澈。7、翩翩新來燕，雙雙入我廬，先巢故尚在，相將還舊居。8、吁嗟身后名，于我若浮煙。9、陶淵明（約365年—427年），字元亮，（又一說名潛，字淵明）號五柳先生，私謚“靖節(jié)”，東晉末期南朝宋初期詩人、文學(xué)家、辭賦家、散文家。漢族，東晉潯陽柴桑人（今江西九江）。曾做過幾年小官，后辭官回家，從此隱居，田園生活是陶淵明詩的主要題材，相關(guān)作品有《飲酒》、《歸園田居》、《桃花源記》、《五柳先生傳》、《歸去來兮辭》等。10、倚南窗以寄傲，審容膝之易安。胰腺癌治療進(jìn)展英文ppt課件胰腺癌治療進(jìn)展英文ppt課件6、露凝無游氛，天高風(fēng)景澈。7、翩翩新來燕，雙雙入我廬，先巢故尚在，相將還舊居。8、吁嗟身后名，于我若浮煙。9、陶淵明（約365年—427年），字元亮，（又一說名潛，字淵明）號五柳先生，私謚“靖節(jié)”，東晉末期南朝宋初期詩人、文學(xué)家、辭賦家、散文家。漢族，東晉潯陽柴桑人（今江西九江）。曾做過幾年小官，后辭官回家，從此隱居，田園生活是陶淵明詩的主要題材，相關(guān)作品有《飲酒》、《歸園田居》、《桃花源記》、《五柳先生傳》、《歸去來兮辭》等。10、倚南窗以寄傲，審容膝之易安。HowardA.Reber,MDProfessorofSurgeryUCLASchoolofMedicinePancreaticCancer

SurgicalApproachintheUSA-2014AgiHirshbergCenterforPancreaticDiseasesatUCLAPancreaticCancer

Epidemiology2014-46,420newcasesinUSA2014-39,590deaths4thmostcommoncancerkiller2ndmostcommonGIcancerkiller(colon#1)胰腺癌治療進(jìn)展英文ppt課件6、露凝無游氛，天高風(fēng)景澈。胰腺1胰腺癌治療進(jìn)展英文課件2胰腺癌治療進(jìn)展英文課件3胰腺癌治療進(jìn)展英文課件4胰腺癌治療進(jìn)展英文課件5PancreaticCancer

Epidemiology

85%ofnewcasesareadvancedLocallyadvanced:bloodvessels(StageIII)Distantspreadtoliver,lungs(StageIV)PancreaticCancer

Epidemiology6LatePresentation-PoorSurvivalHowlanderetal,SEERCancerStatisticsReview2012.AmericanCancerSociety,CancerFacts&Figures2013.StageIIIIIIIVPercentatdiagnosis60%45%30%15%0%LatePresentation-PoorSurvi7LatePresentation-PoorSurvivalHowlanderetal,SEERCancerStatisticsReview2012.AmericanCancerSociety,CancerFacts&Figures2013.24181260MedianSurvival(mos)StageIIIIIIIV0Even“early”stagediseaseisadvancedLatePresentation-PoorSurvi8NoSurgeryIf..Majorbloodvesselsinvolved(StageIII)Distantmetastases(StageIV)SomeStageIIImaybeexceptionsNoSurgeryIf..9PancreaticResectionDistalPancreatectomy(noAppleby)Whippleoperation(Pancreaticoduodenectomy)PancreaticResectionDistalPan10StandardWhipple

StandardWhipple11StandardWhippleRoux-en-YrarelydoneStandardWhippleRoux-en-Y12PylorusPreservingWhipple

Curerateissamewitheach..MostresectionsarePylorusPreservingWhipplesPylorusPreservingWhipple13PylorusPreservingWhipplePylorusPreservingWhipple14FactorsInfluencingSurvivalFactorsInfluencingSurvival15182consecutivepatientsunderwentaWhippleforpancreaticcancerbetween1987and2005.Patientsfrom1987-1995werecomparedwiththosefrom1996-2005.StudyDesign182consecutivepatientsunder16ResultsResults17SurvivalBiologicalfactorsrelatedtotumorDifferentiationNodalinvolvementPerineuralinvasionResectionmarginsSurvivalBiologicalfactorsrel18DegreeofTumorDifferentiationActuarialsurvivalestimateforpatientswithwell,moderately,andpoorlydifferentiatedadenocarcinomaofthepancreas(P<.001).

50%(1987-2005)DegreeofTumorDifferentiatio19LymphNodesNegativePositive28%22%Actuarialsurvivalfornode-negative(solidline)andnode-positive(dottedline)patientswithadenocarcinomaofthepancreasundergoingapancreaticoduodenectomy(P<.001).38%(1987-2005)LymphNodesNegativePositive28%20PerineuralInvasionNegativePositive36%13%Actuarialsurvivalforpatientswithadenocarcinomaofthepancreasundergoingpancreaticoduodenectomy(P<.001).36%(1987-2005)PerineuralInvasionNegativePos21ResectionMarginsNegativePositive27%Biologicfeaturesofthetumorsthemselvesaretheprimarydeterminantsofprognosis!

27%157pts(1987-2005)R0R1ResectionMarginsNegativePosit2227.4%40.9%76.4%All182PtsSurvivalforEntireCohortAll182Pts(1987-2005)27.4%40.9%76.4%All182PtsSurv23胰腺癌治療進(jìn)展英文課件24350mlEBL475mlEBL35.5%15.8%BloodLossInfluencesSurvival350mlEBL475mlEBL35.5%15.8%25AdjuvantTherapyTreatmentgivenafterresectionEfforttoeradicateanyremainingmicroscopictumorAllptsinUSAreceivechemotherapyafterresection!SomeinUSAalsogetradiationAdjuvantTherapyTreatmentgive26CancermayinvolveHA,PV,superiormesentericveinorarteryUNRESECTABLECancermayUNRESECTABLE27CriteriaforResectionWhynotresecttheinvolvedbloodvessels?CriteriaforResectionWhynot28CriteriaforResectionThosewithvesselinvasionhaveextensivetumorwithmicroscopicspreadthatcannotberemovedcompletelyNotseenonpreopscans,butexperiencetellsusit’sthereIfweresectStageIIItumors,thecancercomesbackquicklyCriteriaforResectionThosewi29“Downstaging”ofPaCa

Ptsgivenchemotherapy6-12mosWetrytokillthemicroscopictumor firstRe-evaluationbyCT,CA19-9ResectionthenpossibleinsomeFirstreportedbyourgroup(1998)NowmorewidelydoneinUSA…So..“Downstaging”ofPaCaSo..30EffectofChemotherapyonTumorTumor:4.4x3.8cmPVinvasion(+)Tumor:2.8x2.5cm(57%reduction)PVinvasion(-)BeforeAfterEffectofChemotherapyonTumo31InitialscanshowsSMAinvolvement6mosscanlookssimilarButpatientfeltwellandCA19-9fellfrom840tonormal..ArchSurg.2011;146(7):836-843.DonahueTR,ReberHAetalWhen/WhethertoOperate?

CTImagingInitialscanshowsSMAinvolve32PVSMASVSMVIMVLRVLGASAHAPancreasAdrenalPVSMASVSMVIMVLRVLGASAHAPancrea33DownstagingofPaCa

Survival25+survivors5-17yearsObservedfive-yearsurvivalrate:28%13morecloseto5yrswithnorecurrencePossiblefiveyearsurvivalrate:53%DownstagingofPaCa25+survivo34AdjuvantTherapyTreatmentgivenaftersurgery(Whipple/distal)EfforttoeradicateanyremainingmicroscopictumorStandardapproachAdjuvantTherapyTreatmentgive35NeoadjuvantTherapyTreatmentgivenbeforesurgeryinptswithresectabledisease(StageIandII)SomeinUSArecommendthisinsteadofsurgeryfirstAdvantagesanddisadvantagesNeoadjuvantTherapyTreatmentg36TheoreticalAdvantagesAlmostallptshavemicrometastaticdiseaseatdiagnosis… 1cm-28%havemetastases 2cm-73% 3cm-94% Soalmostallptscouldbenefit..

Iacobuzio-Donahueetal2011CellTheoreticalAdvantagesAlmosta37TheoreticalAdvantagesIfgivenaftersurgery,upto25%maynotbetreatedatall..Ifgivenbefore,morelikelytobephysicallyfitandabletotoleratetreatmentOrtreatmentmaystartlateiftherewerecomplicationsTheoreticalAdvantagesIfgiven38EffectofAdjuvantTreatmentDelayonSurvivalIacobuzio-Donahueetal2011CellAvoidTreatmentDelayAfterSurgery70%40%EffectofAdjuvantTreatmentD39TheoreticalAdvantagesofNeoadjuvantTherapyIdentifyptsunlikelytobenefitfromsurgery…

During2-3motreatment,upto 20%ptsshowmetastases.. ..ordeveloppoorperformance statusTheoreticalAdvantagesofNeoa40IsThisanAdvantage?Isthisgoodorbad?

Good..Theyaresparedsurgerythatwouldnothavehelped.. orBad..Theymissedtheirchanceforresectionandpossiblecure..IsThisanAdvantage?Isthisg41NeoadjuvantTherapySowhyhasitnotbecomethestandardapproach?SeveralreasonsaregivenChemotherapytodayhaslittleeffectinmostptsNeoadjuvantTherapySowhyhas42NeoadjuvantTherapyAtmost,1/3ofptsrespondtoneoadjuvanttreatment..So2/3woulddelayresectionby2-3months,withouteffectivetreatmentduringthattime..DiseasecouldprogressNeoadjuvantTherapyAtmost,43NeoadjuvantTherapyAlthoughtodayChemotherapyhaslittleeffectinmostpts..Thiscouldchangewithmoreeffectiveneoadjuvantregimens..

OrwiththeabilitytoselectivelychoosearegimenspecificforthemolecularfeaturesofeachtumorNeoadjuvantTherapyAlthought44NeoadjuvantRadioTherapyRadiationTherapy(RTx)ofunclearvalueinmostptsRTxdefinitelydecreaseslocal

recurrenceofcancerButitdoesnotincreasesurvivalinmost..Mostptsdieofdistantdisease(liver,lung,peritoneal)evenwhenlocalrecurrenceislowSoneoadjuvantRTxalsoisnotdonebymostUSAsurgeonsNeoadjuvantRadioTherapyRadi45SurgeryinUSA-2014FurthermajorsurgicaladvancesunlikelyMortalityrate<1%;morbiditystillhighImprovedoutcomeslikelytocomefrommoreeffectivedrugsincombinationwithsurgeryNeoadjuvanttherapywillbeusedmoreMoredownstagingwithbetterdrugsSurgeryinUSA-2014Furtherma46DavidGeffenSchoolofMedicine

atUCLA1955-2014DavidGeffenSchoolofMedicin47RonaldReaganUCLAMedicalCenterOpenedJune2008RonaldReaganUCLAMedicalCen48HowardA.Reber,MDProfessorofSurgeryUCLASchoolofMedicinePancreaticCancer

SurgicalApproachintheUSA-2014AgiHirshbergCenterforPancreaticDiseasesatUCLAHowardA.Reber,MDPancreatic4941、學(xué)問是異常珍貴的東西，從任何源泉吸收都不可恥?！⒉贰と铡しɡ?/p>

42、只有在人群中間，才能認(rèn)識自己?！聡?/p>

43、重復(fù)別人所說的話，只需要教育；而要挑戰(zhàn)別人所說的話，則需要頭腦?！旣悺づ宓俨┒鳌て諣?/p>

44、卓越的人一大優(yōu)點(diǎn)是：在不利與艱難的遭遇里百折不饒?！惗喾?/p>

45、自己的飯量自己知道?！K聯(lián)41、學(xué)問是異常珍貴的東西，從任何源泉吸收都不可恥。——阿卜50胰腺癌治療進(jìn)展英文ppt課件6、露凝無游氛，天高風(fēng)景澈。7、翩翩新來燕，雙雙入我廬，先巢故尚在，相將還舊居。8、吁嗟身后名，于我若浮煙。9、陶淵明（約365年—427年），字元亮，（又一說名潛，字淵明）號五柳先生，私謚“靖節(jié)”，東晉末期南朝宋初期詩人、文學(xué)家、辭賦家、散文家。漢族，東晉潯陽柴桑人（今江西九江）。曾做過幾年小官，后辭官回家，從此隱居，田園生活是陶淵明詩的主要題材，相關(guān)作品有《飲酒》、《歸園田居》、《桃花源記》、《五柳先生傳》、《歸去來兮辭》等。10、倚南窗以寄傲，審容膝之易安。胰腺癌治療進(jìn)展英文ppt課件胰腺癌治療進(jìn)展英文ppt課件6、露凝無游氛，天高風(fēng)景澈。7、翩翩新來燕，雙雙入我廬，先巢故尚在，相將還舊居。8、吁嗟身后名，于我若浮煙。9、陶淵明（約365年—427年），字元亮，（又一說名潛，字淵明）號五柳先生，私謚“靖節(jié)”，東晉末期南朝宋初期詩人、文學(xué)家、辭賦家、散文家。漢族，東晉潯陽柴桑人（今江西九江）。曾做過幾年小官，后辭官回家，從此隱居，田園生活是陶淵明詩的主要題材，相關(guān)作品有《飲酒》、《歸園田居》、《桃花源記》、《五柳先生傳》、《歸去來兮辭》等。10、倚南窗以寄傲，審容膝之易安。HowardA.Reber,MDProfessorofSurgeryUCLASchoolofMedicinePancreaticCancer

SurgicalApproachintheUSA-2014AgiHirshbergCenterforPancreaticDiseasesatUCLAPancreaticCancer

Epidemiology2014-46,420newcasesinUSA2014-39,590deaths4thmostcommoncancerkiller2ndmostcommonGIcancerkiller(colon#1)胰腺癌治療進(jìn)展英文ppt課件6、露凝無游氛，天高風(fēng)景澈。胰腺51胰腺癌治療進(jìn)展英文課件52胰腺癌治療進(jìn)展英文課件53胰腺癌治療進(jìn)展英文課件54胰腺癌治療進(jìn)展英文課件55PancreaticCancer

Epidemiology

85%ofnewcasesareadvancedLocallyadvanced:bloodvessels(StageIII)Distantspreadtoliver,lungs(StageIV)PancreaticCancer

Epidemiology56LatePresentation-PoorSurvivalHowlanderetal,SEERCancerStatisticsReview2012.AmericanCancerSociety,CancerFacts&Figures2013.StageIIIIIIIVPercentatdiagnosis60%45%30%15%0%LatePresentation-PoorSurvi57LatePresentation-PoorSurvivalHowlanderetal,SEERCancerStatisticsReview2012.AmericanCancerSociety,CancerFacts&Figures2013.24181260MedianSurvival(mos)StageIIIIIIIV0Even“early”stagediseaseisadvancedLatePresentation-PoorSurvi58NoSurgeryIf..Majorbloodvesselsinvolved(StageIII)Distantmetastases(StageIV)SomeStageIIImaybeexceptionsNoSurgeryIf..59PancreaticResectionDistalPancreatectomy(noAppleby)Whippleoperation(Pancreaticoduodenectomy)PancreaticResectionDistalPan60StandardWhipple

StandardWhipple61StandardWhippleRoux-en-YrarelydoneStandardWhippleRoux-en-Y62PylorusPreservingWhipple

Curerateissamewitheach..MostresectionsarePylorusPreservingWhipplesPylorusPreservingWhipple63PylorusPreservingWhipplePylorusPreservingWhipple64FactorsInfluencingSurvivalFactorsInfluencingSurvival65182consecutivepatientsunderwentaWhippleforpancreaticcancerbetween1987and2005.Patientsfrom1987-1995werecomparedwiththosefrom1996-2005.StudyDesign182consecutivepatientsunder66ResultsResults67SurvivalBiologicalfactorsrelatedtotumorDifferentiationNodalinvolvementPerineuralinvasionResectionmarginsSurvivalBiologicalfactorsrel68DegreeofTumorDifferentiationActuarialsurvivalestimateforpatientswithwell,moderately,andpoorlydifferentiatedadenocarcinomaofthepancreas(P<.001).

50%(1987-2005)DegreeofTumorDifferentiatio69LymphNodesNegativePositive28%22%Actuarialsurvivalfornode-negative(solidline)andnode-positive(dottedline)patientswithadenocarcinomaofthepancreasundergoingapancreaticoduodenectomy(P<.001).38%(1987-2005)LymphNodesNegativePositive28%70PerineuralInvasionNegativePositive36%13%Actuarialsurvivalforpatientswithadenocarcinomaofthepancreasundergoingpancreaticoduodenectomy(P<.001).36%(1987-2005)PerineuralInvasionNegativePos71ResectionMarginsNegativePositive27%Biologicfeaturesofthetumorsthemselvesaretheprimarydeterminantsofprognosis!

27%157pts(1987-2005)R0R1ResectionMarginsNegativePosit7227.4%40.9%76.4%All182PtsSurvivalforEntireCohortAll182Pts(1987-2005)27.4%40.9%76.4%All182PtsSurv73胰腺癌治療進(jìn)展英文課件74350mlEBL475mlEBL35.5%15.8%BloodLossInfluencesSurvival350mlEBL475mlEBL35.5%15.8%75AdjuvantTherapyTreatmentgivenafterresectionEfforttoeradicateanyremainingmicroscopictumorAllptsinUSAreceivechemotherapyafterresection!SomeinUSAalsogetradiationAdjuvantTherapyTreatmentgive76CancermayinvolveHA,PV,superiormesentericveinorarteryUNRESECTABLECancermayUNRESECTABLE77CriteriaforResectionWhynotresecttheinvolvedbloodvessels?CriteriaforResectionWhynot78CriteriaforResectionThosewithvesselinvasionhaveextensivetumorwithmicroscopicspreadthatcannotberemovedcompletelyNotseenonpreopscans,butexperiencetellsusit’sthereIfweresectStageIIItumors,thecancercomesbackquicklyCriteriaforResectionThosewi79“Downstaging”ofPaCa

Ptsgivenchemotherapy6-12mosWetrytokillthemicroscopictumor firstRe-evaluationbyCT,CA19-9ResectionthenpossibleinsomeFirstreportedbyourgroup(1998)NowmorewidelydoneinUSA…So..“Downstaging”ofPaCaSo..80EffectofChemotherapyonTumorTumor:4.4x3.8cmPVinvasion(+)Tumor:2.8x2.5cm(57%reduction)PVinvasion(-)BeforeAfterEffectofChemotherapyonTumo81InitialscanshowsSMAinvolvement6mosscanlookssimilarButpatientfeltwellandCA19-9fellfrom840tonormal..ArchSurg.2011;146(7):836-843.DonahueTR,ReberHAetalWhen/WhethertoOperate?

CTImagingInitialscanshowsSMAinvolve82PVSMASVSMVIMVLRVLGASAHAPancreasAdrenalPVSMASVSMVIMVLRVLGASAHAPancrea83DownstagingofPaCa

Survival25+survivors5-17yearsObservedfive-yearsurvivalrate:28%13morecloseto5yrswithnorecurrencePossiblefiveyearsurvivalrate:53%DownstagingofPaCa25+survivo84AdjuvantTherapyTreatmentgivenaftersurgery(Whipple/distal)EfforttoeradicateanyremainingmicroscopictumorStandardapproachAdjuvantTherapyTreatmentgive85NeoadjuvantTherapyTreatmentgivenbeforesurgeryinptswithresectabledisease(StageIandII)SomeinUSArecommendthisinsteadofsurgeryfirstAdvantagesanddisadvantagesNeoadjuvantTherapyTreatmentg86TheoreticalAdvantagesAlmostallptshavemicrometastaticdiseaseatdiagnosis… 1cm-28%havemetastases 2cm-73% 3cm-94% Soalmostallptscouldbenefit..

Iacobuzio-Donahueetal2011CellTheoreticalAdvantagesAlmosta87TheoreticalAdvantagesIfgivenaftersurgery,upto25%maynotbetreatedatall..Ifgivenbefore,morelikelytobephysicallyfitandabletotoleratetreatmentOrtreatmentmaystartlateiftherewerecomplicationsTheoreticalAdvantagesIfgiven88EffectofAdjuvantTreatmentDelayonSurvivalIacobuzio-Donahueetal2011CellAvoidTreatmentDelayAfterSurgery70%40%EffectofAdjuvantTreatmentD89TheoreticalAdvantagesofNeoadjuvantTherapyIdentifyptsunlikelytobenefitfromsurgery…

During2-3motreatment,upto 20%ptsshowmetastases.. ..ordeveloppoorperformance statusTheoreticalAdvantagesofNeoa90IsThisanAdvantage?Isthisgoodorbad?

Good..Theyaresparedsurgerythatwouldnothavehelped.. orBad..Theymissedtheirchanceforresectionandpossiblecure..IsThisanAdvantage?Isthisg91NeoadjuvantTherapySowhyhasitnotbecomethestandardapproach?SeveralreasonsaregivenChemotherapytodayhaslittleeffectinmostpts