The Latest in Pancreatic Surgery

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals exploring the latest innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase I and Sarcoma Programs. Today, I'm happy to be joined by Dr. Terence Jackson, surgeon at Cleveland Clinic Akron General. He's here today to talk to us about the latest advances in pancreatic surgery. Welcome. Thanks for joining us today.

Terence Jackson, MD: Thank you so much for having me, Dr. Shepard.

Dale Shepard, MD, PhD: Maybe you can start by just telling us a little bit about what you do at Akron General and what your role is as a surgeon.

Terence Jackson, MD: Yes, absolutely. I'm a hepatobiliary, pancreatic and foregut surgeon, and I've been here at Akron General for the last year. I've had the privilege of taking care of patients with pancreas cancer, cholangiocarcinoma, bile duct cancers, liver cancers of various kind. At the same time, gastric, GE junction and esophageal adenocarcinoma, and squamous cell cancers. These are all difficult diseases to take care of. And we have a wonderful team here that helps me be a part of their team and take care of them. And it's been just a privilege.

Dale Shepard, MD, PhD: Well, certainly it has been helpful to have surgeons like yourself at Akron General to help manage patients. When you think about surgery, particularly as we're talking about the pancreas, let's just start off. And what's most exciting and that field of pancreas surgery right now? So certainly, some of the techniques have been around for a really long time. What are we thinking about in terms of new things?

Terence Jackson, MD: You're right. Techniques and operations have been around for a very long time. And the new developments that we are seeing right now are more directed therapy, targeted therapy, immune mediated therapies that are up and coming for treatment of pancreas cancer.

And also, we have several trials and studies that are in place to not just treat pancreas adenocarcinoma, but also to try and prevent them. Because we see hundreds and hundreds of patients with pancreas cysts every year. Resect or surgically treat so many of them and really, not all of them end up being cancer, but we do it because we want to prevent adenocarcinoma.

There are studies coming out to try and identify those patients that are specifically at higher risk for developing adenocarcinoma. There are also great studies coming out to tell us whether truly minimally invasive, robotic, or open pancreatectomy is make any difference to patients. A lot of exciting stuff. I mean, I think this is a great age to be in. There was a time when chemotherapy wasn't as good and we truly struggled with pancreas cancer. And to be honest, we still struggle, but I think we're making great strides. And this is an exciting time to be in.

Dale Shepard, MD, PhD: Well, prevention is always something that's good to hear about because I guess, I had a mentor once pointed out the easiest cancer to treat is the one the patient doesn't have.

Terence Jackson, MD: That is correct.

Dale Shepard, MD, PhD: Tell me a little bit about how you're thinking through cysts. And who to take to surgery and what characteristics that those patients might have that would drive those decisions.

Terence Jackson, MD: Excellent question. This is a hot debated topic, just because of the sheer number of pancreas cysts we see. As our imaging studies have slowly improved in quality, we start to see more and more of these cysts. And the baseline understanding that needs to be inculcated in all of our educational systems is that most of these cysts do not turn out to be cancer.

We try to assess the risks of these cysts turning into cancer based on some specific factors. For example, the presence of a nodule within a cyst, or the dilation of the main pancreatic duct. Or if the patient has symptoms like pancreatitis or jaundice. Now, these are not perfect. And still, more than 50% of the cysts that we resect either end up being completely benign or are low risk cysts that may or may not have turned into cancer at all.

On the flip side, you do often see cysts in the form of IPMNs, intraductal papillary mucinous neoplasms, or mucinous cystic neoplasms that you resect and it comes back as a lesion with high-grade dysplasia. Which is the most satisfying operation of all, because you know that you've caught it just in time. It's not turned into cancer yet, and you essentially prevented pancreas adenocarcinoma.

The goal behind deciding whether to resect or not is really dependent on balancing the morbidity of the operation and the risk of cancer. And this is where the new molecular markers and genetic markers in terms of Caris testing, BRACA testing, fluid analysis, really help and tell us how much of a risk of cancer this patient has. And hopefully, guide us in performing the right operation for the right patient.

Dale Shepard, MD, PhD: When we think about resection of these cysts and taking them out, to just in case, how have newer techniques, like robotic surgery or minimally invasive surgery, made that less of an issue for patients? Or are we still understandably trying to avoid that?

Terence Jackson, MD: Oh no, absolutely. Minimally invasive surgery is definitely a boon, a blessing in this age, specifically for tail and body lesions. We have multiple studies, multiple meta analysis, which have looked at minimally invasive distal pancreatectomy, or laparoscopic, or robotic. Here at Akron General, we perform them laparoscopically and robotically. And have clearly shown an improvement in opiate requirements, pain, length of stay and morbidity from the operation.

We are still trying to decide whether a right-sided pancreatic tumor would benefit from a minimally invasive approach or not. A Whipple operation is a big operation. And regardless of whether we tend to perform it laparoscopically, robotically, or in an open fashion, patient tends to have a recovery that is not dominated by the incision. The recovery is really dominated by what's happening inside of them. And that remains the same whether you do it minimally invasively or in an open fashion.

Again, here at Akron General, we do it robotically. We offer patients robotic Whipples, laparoscopic Whipples and open Whipples. And we select our patients very carefully. I believe morbidly obese patients, those who suffer from visceral or peripheral obesity, really do benefit from minimally invasive approaches in either case. And that's been a development of the past five to 10 years or so, where this has really started to pick up. And I think we are proud to be part of the team, even including Main Campus Cleveland Clinic to be one of the few centers around the country and the world to offer robotic pancreas surgery.

Dale Shepard, MD, PhD: Just thinking back to these IPMNs because they certainly are things, as we scan more often, we find these things more often. And understandably, they cause concern to patients and providers. And as we develop ways to manage those, what does that conversation look like? I mean, I can imagine that there are patients who just want it out. They know pancreas cancer is bad. At what level are we able to educate that some of these new ways to observe might work?

Terence Jackson, MD: We do have some broad data to help guide these conversations, but you're right. These conversations are extremely challenging. And even if I present to the patient a very low risk, a less than 3% risk of a malignancy in a side branch IPMN, which has had minimal change over so many years. Sometimes it causes the patients so much mental anguish that they request an operation.

And we try to put it off for months and months. And eventually, we get to a point where they're either going to get an operation with us, or they're going to go somewhere else and try and do the same thing. This is challenging. The best thing I think we can do is to try and counsel the patients and have an informed discussion with them and their family members about the morbidity of the operation and balancing it with the risk of an upcoming or a progressive malignancy. And of course, we never turn a blind eye on any of these patients. They're always followed very closely with high quality imaging. And that helps reassure them that even if something does develop, we would not miss it to a point where it gets too late.

Dale Shepard, MD, PhD: Moving a little bit further down the spectrum. No cancer, IPMN to early stage pancreas cancer. Within your practice at Akron General, how are you thinking about small nodules in the pancreas suspected to be a pancreatic cancer? Everyone's had the frustrations of someone going to surgery and then developing metastatic disease.

Terence Jackson, MD: Yes.

Dale Shepard, MD, PhD: And how are we thinking about adjutant therapies prior to even resection of apparently resectable disease?

Terence Jackson, MD: Excellent question. Every time I see someone who has a suspicion for a pancreatic ductal adenocarcinoma, or has a diagnosis of pancreatic adenocarcinoma, the conversation is very different. We sit with the patient and the family. And one of the first things we say is that this is truly a systemic disease, not just a disease of the pancreas.

And the treatment and standard of care for them is surgery and chemotherapy. Even though I do not have evidence to prove that surgery first or chemotherapy first is better right now, I tell them upfront, that they need both in totality to have the best longevity, to have the best disease-free survival. And in all, we have several pieces of evidence to suggest that more than 40% of patients that undergo surgery first never get to complete chemotherapy, so that doesn't serve our purpose.

I try to convince my patients to get chemotherapy upfront. If we are able to give them totally neoadjuvant chemotherapy, as in all 12 cycles of FOLFIRINOX upfront, if possible, I will do it. Sometimes patients are not able to tolerate FOLFIRINOX for that long, and then they end up wanting surgery beforehand. But the goal is to give them all the chemotherapy and all of surgery in the best way possible through our treatment. And not all of such a high quality operations with good outcomes. And that's what provides them the best outcomes.

Dale Shepard, MD, PhD: You're in Akron General for those listening. And you're about an hour or so south of our main campus. What works well in terms of engagement? We're a health system. We provide good quality of care at our main campus and our regional sites. And the thought is, if you walk into a regional site, you're going to get really good care and we value you guys as a resource. But how do you coordinate that care and keep in touch with colleagues and what works? So maybe you can help people might be listening and they were working within these kinds of systems. What's the secret to success?

Terence Jackson, MD: Great question. I love this question because one of the biggest problems we're facing right now is not just the fact that we struggle to provide high quality care. It's also the fact that we struggled to provide quality access to high quality care. In that aspect, I think the Cleveland Clinic Foundation and the heads of our cancer department, including our chairman at the Cleveland Clinic, Main Campus, Dr. Walsh, they do a great job in establishing and helping these centers, which are not just within the main campus. Aiding us in providing high quality cancer care.

Because even though we are technically a community center so far out from the main city, we are heading towards being a high volume esophageal cancer center, high volume rectal cancer center. And we are a high volume pancreas cancer center. And we've been able to do this through close collaboration with the Main Campus Cleveland Clinic. And we've established the same standards of care that they have there. We have the same multidisciplinary board meetings, which are held several times a week. We have interdisciplinary meetings between Cleveland Main Campus and ourselves.

I think it is, at the end of the day, communication and a support for everyone around you has really helped us grow. And of course, I have to speak volumes of the team that we have here. And not just as physicians. Our practice leads, our nurses, our radiologists pathologists, oncologists, radiation oncology. Everybody here, they just do an amazing job taking care of these patients before and after their operations and their therapy. And I think together we can provide great high quality care and access to high quality care close to home. And that's just a true blessing for all of our patients.

Dale Shepard, MD, PhD: Yeah, no. You guys do a really good job of having the same cohesive group and support and things as we have here. You maintain your own tumor board. Do you participate in our main campus tumor boards or is it a case by case basis? How does that work?

Terence Jackson, MD: We do. We have at least two multidisciplinary tumor boards of our own here every week. And then on a case by case basis, we do discuss things with a multi-disciplinary boards at Cleveland Clinic Main Campus, as well.

Just this last week, I was discussing with Dr. Berber and some of our oncologists and gastroenterologists at main campus, about a gentleman with a colon cancer liver metastasis. And it was a challenging case. Something that we are still growing and developing in terms of management. This is a big lesion, will need a major hepatectomy.

And it was a wonderful discussion. We made great plans. I think we're taking the best steps. Collaboration has just been amazing. I think the lack of political agendas and things like that influencing patient care, is something that it has to be spoken about because all the physicians that participate in the care of the patients no matter where they are, really put in their best effort. And put all of their personal agendas aside and take care of them with us. That's just amazing.

Dale Shepard, MD, PhD: Yeah. Well, we've mostly talked about pancreas at this point, but you do also treat cholangiocarcinoma and liver and gastric and things that you've mentioned.

Terence Jackson, MD: Yes.

Dale Shepard, MD, PhD: What's exciting in those areas. Are there things that you're doing procedurally, surgically in those areas?

Terence Jackson, MD: Yes.

Dale Shepard, MD, PhD: What excites you in those areas?

Terence Jackson, MD: Yes. So again, robotic hepatobilliary and pancreatic surgery is something that's just starting throughout the world and here as well. We've been doing more and more robotic esophagectomies, gastrectomies, major hepatectomy. That really excites me because even though these are big operations on the inside, some of their covering is definitely incision-driven. And I think by minimizing the morbidity of a major open incision, it helps the patients.

In terms of various types of liver malignancies, we have seen significant development in liver directed therapy over the past several years and that's really exciting. Particularly intraarterial therapy, intraarterial radiation therapy, intraarterial chemoembolization. These are all excellent, excellent devices and methods to take care of these really challenging patients.

We've also, I think recently started offering PRRT for metastatic neuroendocrine tumors, which is really exciting. I use that in my training programs down in Dallas. And we were missing that and sending patients away for that treatment. But I think we started offering that now, and that's also very exciting and hopefully offers our patients a lot of benefit.

Dale Shepard, MD, PhD: Yeah. We certainly are doing PRRT here on main campus as well. And I can only imagine the large number of new systemic therapies for HCC for instance, has changed how we approach surgery in that disease as well.

Terence Jackson, MD: That is correct. That's correct. So now, HCC has always been a challenge in its treatment. And we have multiple options available, both surgically and systemically. Thankfully, systemic therapy has improved really significantly over the past several years. And now, we also have second and third line therapies, including immunotherapy for metastatic HCC.

And all of this is very exciting. We do have the ability to refer to our transplant team at Main Campus Cleveland Clinic too, who've been wonderful collaborators in their care. And yeah, we do see a lot of patients with HCC. And thankfully, they've all been doing pretty well.

Dale Shepard, MD, PhD: Within pancreas, within hepatic biliary surgeries, what do you think are the biggest gaps? Is it techniques? Is it when we stage various modalities? What do you think are the biggest hurdles we're going to need to overcome to make more progress?

Terence Jackson, MD: Yes. Particularly in terms of pancreas cancer. I think in terms of technique, even though we are moving towards minimally invasive surgery, the surgery itself has been very stable for a good few decades now. What can we improve in terms of surgery? I think not so much. But there's lots of exciting things coming up in terms of improvement in chemotherapy and various systemic agents.

I think the next frontier will be selecting the right patient for surgery. We still see a lot of operations that are performed and patients have early recurrences. That should tell us that we are not selecting our patients properly and allowing our patients to undergo the morbidity of the operation with very little benefit. I think the next frontier will be selecting the right patient, identifying which patients are going to have that several year, 10 year survival after surgery. Hopefully, disease-free survival. And targeting those patients for surgery and try and identify patients that will benefit from systemic therapy alone.

This is still a challenge. We still do not have an equivalence in terms of the delivery of care for pancreas cancer. Across the country, not everyone would agree that systemic therapy neoadjuvantly is the right thing to do for resectable pancreas cancer. We don't have equivalence throughout the country. And that's something that needs to be addressed as well.

Hopefully, over the next decade or so we see more targeted therapy and better patient selection. And I think that will help us improve outcomes in pancreas surgery. Because in all honesty, we still struggle. Our survival and disease-free survival rates are not as good as it is for colon cancer.

Dale Shepard, MD, PhD: Yeah. Very good. Well, I certainly appreciate you being there as a regional colleague. And I appreciate your insights today. And thank you for being with us.

Terence Jackson, MD: Thank you so much for having me. It's a privilege.

Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google Play, Spotify SoundCloud, or wherever you listen to podcasts. And don't forget you can access real-time updates from Cleveland Clinic’s Cancer Center experts on our Consult QD website at consultqd.clevelandclinic.org/cancer. Thank you for listening. Please join us again soon.