After Neoadjuvant Therapy, Imaging No Longer Provides a Clear Answer

The following summary comes the article by Dr. Cristina Ferrone and was published in the International Journal of Radiation Oncology, Biology, Physics. The full article can be found here.

Image credit: Ferrone CR, Marchegiani G, Hong TS, et al. Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer. Ann Surg. 2015;261(1):12-7.

Patients with a presumed diagnosis of pancreatic cancer are initially evaluated by radiological imaging (Pancreas protocol CT-scan). Imaging provides a great deal of information regarding the tumor including tumor size, involvement of nearby blood vessels and organs, and distant spread of disease. Patients with tumors that involve nearby blood vessels may not be a candidate for a surgery-first approach and have been shown to benefit from upfront chemotherapy followed by potential surgical resection (see October blog post, Outcome of Patients with Borderline Resectable Pancreatic Cancer in the Contemporary Era of Neoadjuvant Chemotherapy for more information on vessel involvement).

Given the improvements in chemotherapy a majority of patients with pancreatic cancer are now managed via a neoadjuvant-first approach even when diagnosed at a resectable stage, given that systemic disease dictates long term outcomes. With this change in practice, a majority of patients initially receive chemo/chemoradiation therapy followed by a repeat scan (re-staging scan), and a potential surgical resection. Recently, it has become evident that post-neoadjuvant CT scans might not provide accurate assessment of disease. At Massachusetts General Hospital in Boston, MA, researchers have theorized that preoperative chemoradiation may cause tumors to appear worse on CT scans than before therapy. With this in mind, this group sought to find patients who received neoadjuvant therapy and had unfavorable imaging after the neoadjuvant therapy, but did have a good performance status and a decrease in pancreatic cancer tumor markers (CA19-9). These patients were taken to the operating room for surgical exploration to evaluate the true extent of disease. Promisingly, 92% of the first 40 patients underwent R0 resection margins, meaning there was no tumor seen at the resection plane (see August blog post, “The Importance of Resection Margin Status in Pancreatic Surgery” for more information on resection margins). What was observed on the CT-scans of these patients was most likely dead tissue with scarring that was mimicking living tumor.

In conclusion, patients with good performance status and decreasing tumor markers after neoadjuvant therapy should be considered for surgical exploration, even if CT scans demonstrate persistent tumor.

A special thanks for this summary by Michael Wright, Department of Surgery, Johns Hopkins School of Medicine and to Dr. Ammar Javed for his support.

Outcome of Patients with Borderline Resectable Pancreatic Cancer in the Contemporary Era of Neoadjuvant Chemotherapy

Image credit: Zaky, AM, Wolfgang, CL, Weiss, MJ, et al. (2016). Tumor-vessel relationships in pancreatic ductal adenocarcinoma at multidetector CT: different classification systems and their influence on treatment planning. RadioGraphics; 37(1):93-112

The following study was recently published in the Journal of Gastrointestinal Surgery by Ammar A. Javed and colleagues in September 2018. Below is a summary of the article.

Localized pancreatic cancer can be classified into resectable, borderline resectable and locally advanced lesions based on the degree of involvement of adjacent blood vessels (portal vein, superior mesenteric artery and celiac artery). Borderline resectable tumors are those that have limited invasion of the vessels and, while surgically resectable, carry a high risk of positive margins at the time of resection (see prior Nikki Mitchell Foundation article on margin status). Chemotherapy available for pancreatic cancer has improved significantly over the last decade. With effective therapies now available, a majority of patients with borderline resectable disease now receive preoperative chemotherapy. The authors sought to evaluate the outcomes of patients undergoing surgery for borderline resectable pancreatic cancer at a single high-volume center.

The authors identified 151 patients from their multidisciplinary clinic who were diagnosed with borderline resectable pancreatic cancer. 142 (94.0%) patients received chemotherapy and 78 (51.7%) received radiation therapy. Ninety-six (63.6%) were able to undergo surgery, while 12 (7.9%) patients were taken to the operating room but their procedure was aborted due to extensive disease. 47 (31.1%) of patients unfortunately had progression of disease and were deemed to be unresectable at follow up. Patients who underwent surgery had a median overall survival of 28.8 months as compared to 13.5 months in those who did not receive surgery.

Take home points:

  • Multidisciplinary management is vital for borderline resectable pancreatic cancer.
  • Resection of borderline resectable pancreatic cancer is safe when performed by experienced surgeons at a high volume institution.
  • The rate of resection in patients with borderline pancreatic cancer is approximately 65%.
  • Surgical resection of borderline resectable pancreatic cancer is associated with improved overall survival.
  • Disease progression while receiving chemotherapy is the most frequent reason for unresectability.

You can read the entire article here.

A special thanks for this summary by Michael Wright, Department of Surgery, Johns Hopkins School of Medicine and Dr. Ammar Javed for his support.

The Importance of Resection Margin Status in Pancreatic Surgery

The following study was recently published in the British Journal of Surgery and below is a summary of the article.

Validation of at least 1 mm as cutoff for resection margins for pancreatic adenocarcinoma of the body and tail.

Hank, T., Hinz, U., Tarantino, I., et al.

One of the major goals of surgical resection of a pancreatic tumor is to clear the body of all local disease. A resection margin is the outer edge of the tissue that was removed. The margins of the resected specimen are reviewed by the pathologists and should ideally be free of disease. Traditionally, R0 represents no cancer at the margins, while R1 represents microscopic disease at the margin, and R2 is representative of gross disease at the margins (seen by naked eye). In recent times, the topic of an R0 resection with disease located within 1mm of the margin has gained interest in the surgical community.

Using an institutional database, the authors identified 455 patients and classified resection status as either R0, R1 less than 1 mm, and R1 direct.

Median survival (time from surgery to death)

  • R0: 62.4 months
  • R1< 1mm from margin: 24.6 months
  • R1 direct: 17.2 months

Postoperative chemotherapy group median survival

  • R0: 68.6 months
  • R1< 1mm from margin: 32.8 months
  • R1 direct: 21.4 months

An important aspect of the study was that the authors not only analyzed the survival rates of all patients but also studied trends of survival in patients who received postoperative chemotherapy. Since postoperative chemotherapy is known to be related with survival, the authors wanted to demonstrate that margin status was independently associated with improved survival.

The results of the study confirm the importance of resection margin as they independently predicted survival in these patients regardless of their postoperative chemotherapy status. In particular, the survival benefit of clean resection margins beyond 1mm are highlighted. The differences observed in all reported median survivals were statistically significant.

Note: published data suggests that the same findings hold true for Whipple procedures. In short, R0 resections are associated with improved survival of all pancreatic adenocarcinomas, regardless of pancreatic surgery type.

You can read the entire article here.

Summary by: Michael J. Wright, Department of Surgery, Johns Hopkins School of Medicine

An Activist and Survivor Shares Her Story

Lisa Eidelberg has been integral in raising funds for Nikki Mitchell Foundation’s “Country Boots Cancer” show, which is donating 100% of the proceeds to the future Pancreatic Cancer Precision Medicine Program at Johns Hopkins Medicine.

The pancreatic cancer activist and survivor shares her story: 

Lisa and her sons

“Peace Out Johns Hopkins”

Rhonda Miles, Jamey Johnson, Lisa Eidelberg









I am a very lucky four-year pancreatic cancer survivor!!

This journey began on Saturday June 7, 2014 when I woke up, looked in the mirror and thought, “Mmm, I look a little yellow!”  A friend had stopped by, looked at me and confirmed what I didn’t want to believe; I was indeed yellow!  My husband Marc and I went to the emergency room of a local hospital where I was told I would simply need my gall bladder out, even as I was becoming increasingly yellow! Fortunately, the doctors in my family had me moved to another hospital where I would have an ERCP the next day.  Coming out of anesthesia, Marc had the most difficult task of delivering the bad news……I had pancreatic cancer.  We were all shocked!  I was 54 at the time, healthy, had no family history of it, was active and had two 19-year-old sons who still needed me!  In the four months prior to diagnosis, I had an endoscopy, colonoscopy, two ultrasounds and blood work (just six weeks before diagnosis) which were all normal!

Luckily for me, I got an appointment with Dr. Wolfgang and team at Johns Hopkins Hospital, which I was told was the premiere pancreatic cancer team. Boy is that true!  On Saturday June 14, 2014, I had a successful Whipple surgery.  Recovery was so much more pleasant because of the caring staff at JHH!  Aftercare with this surgery is almost as important as the surgery itself!   Following recovery, I had 10 rounds of Folfirinox and radiation at Overlook Hospital in Summit, NJ where again, I was fortunate to receive compassionate, quality care.

At a post-surgical visit with Dr. Wolfgang and Lindsey Manos, they urged me to reach out to the Nikki Mitchell Foundation founder Rhonda Miles.  Somehow, they got a vibe that I resembled Nikki in spirit and attitude, although we were completely different people in the way we lived our lives.  My attitude was always positive, but I made it my business NOT to read the sad stories of this dreaded disease, so why would I reach out to Rhonda? Nikki had sadly and bravely lost her battle with this demon.  However, I’m so glad I did!  It’s enlightened me to the fact that this disease does not discriminate.  There is no “stereotypical” person who is affected by this many time fatal disease.  It’s brought about a renewed outlook on life and others.  Just as pancreatic cancer doesn’t judge, I don’t either.

It is my privilege to work with both the Nikki Mitchell Foundation and Johns Hopkins Hospital to raise funds for the new Pancreatic Cancer Precision Medicine program which will enhance the patient’s experience.  This will be THE place, for competent, caring, compassionate and cohesive treatment for those afflicted by this ugly disease!

I personally look forward to celebrating many more survival anniversaries but look forward to having a lot more company in the future!!

Donations for this event can be made HERE and select the campaign “Country Boots Cancer.”

David’s Story

In August of 2017, at age 55, I was diagnosed with pancreatic cancer. Five years earlier my mom passed away from the disease so I knew what lay ahead of me.

When I met with my oncologist he said, “We’re talking cure, not life extension.” My surgeon at Johns Hopkins said, “We got this.” I knew the statistics but after hearing how optimistic my care team was…how could I not be?!

Over the next few months, as I went through the chemo, radiation and all the side effects, I remained absolutely optimistic and positive. I refused to allow negativity, anger or sorrow into my thought process….as these were counter-productive to my desired outcome. Along with a great care team, and just as essential, I had amazing support from my wife, kids and community (near and far), providing me with a lot of comfort.

March 16, 2018 I had my Whipple surgery. Everything went smoothly and as of now I’ve made a rapid recovery. I take great pride in saying that I am a survivor of pancreatic cancer….something too few people get to say.

What has become abundantly clear is that the past is past. The future is not here yet and all we have this moment. I am very much living in the moment and every day find something to appreciate or amaze me.

By, David Sokoloff

Palliative Care: Myths vs. Facts

I just returned from the Pancreas Club 2018 conference in Washington D.C., where I listened to 63 oral abstracts regarding ongoing research. It was a lot to sit through! The final presentation on the second and last day was titled “Utilization of palliative care services among patients with pancreatic cancer.”

I find it ironic that palliative care was recommended to Nikki very near the end of her life and the conference pushed this presentation to the very end as well. Nikki and I spoke many times about the need for palliative care early in a cancer diagnosis. Why not utilize all avenues to strengthen and improve your quality of life and build up a support system? I believe doctors and patients lack education on this extremely important and helpful type of care.

So, what is Palliative Care?  PALLIATIVE CARE IS “NOT” HOSPICE CARE.

Palliative care is specialized medical care for people with serious illness. This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a specially-trained team of doctors, nurses and other specialists who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness, and it can be provided along with curative treatment.

5 Myths and Facts of Palliative Care

  1. Myth: Palliative care hastens death. 
     Palliative care does not hasten death. It provides comfort and the best quality of life from diagnosis of an advanced illness until end of life.
  2. Myth:Palliative care is only for people dying of cancer.
    Fact: Palliative care can benefit patients and their families from the time of diagnosis of any illness that may shorten life.
  3. Myth: Palliative care is only provided in a hospital.
    Fact:Palliative care can be provided wherever the patient lives: home, long-term care facility, hospice or hospital. 
  4. Myth:Taking pain medications in palliative care leads to addiction. 
    Keeping people comfortable often requires increased doses of pain medication. This is a result of tolerance to medication as the body adjusts, not addiction. 
  5. Myth:Palliative care means my doctor has given up and there is no hope for me.
    Fact: Palliative care ensures the best quality of life for those who have been diagnosed with an advanced illness.

The last myth is a big pet peeve of mine. I have heard people comment, “If your doctor mentions palliative care, then get a new doctor.” They think this means the doctor has given up on them, but this is flat out incorrect. If a doctor recommends palliative care, then you have a progressive doctor seeking to treat the whole person and ultimately, their loved ones. That is the kind of forward-thinking doctor I’d want for myself.

This type of care treats pain, depression, shortness of breath, fatigue, constipation, nausea, loss of appetite, difficulty sleeping, anxiety and any other symptoms that may be causing distress. The doctor will help you gain the strength to carry on with daily life and improve your quality of life.

Nikki’s first visit with her palliative care doctor was amazing! He sat and listened to her for a very long time, asked many questions and listened to her answers. He then formulated a plan specifically for her and gave her the tools she needed to move forward. When she felt better, physically and mentally, she wasn’t a cancer patient, she was just Nikki…

For more information on palliative care, click HERE (scroll to the end) and HERE.

Post by Rhonda Miles