Advances in the Management of Hepatic and Pancreatic Malignancies

Perry Shen, MD, FACS

Clancy Clark, MD

Wake Forest Baptist Health Comprehensive Cancer Center

Despite an overall decline in cancer death rates during the last decade, hepatic and pancreatic cancer death rates are on the rise. Pancreatic cancer is now a leading cause of cancer death. Due to a dramatic increase in the incidence of hepatitis C, the incidence and death rate from primary hepatic malignancies are on the rise. The only opportunity for cure for hepatic and pancreatic malignancies is surgical resection. Therefore, Wake Forest Baptist Health Comprehensive Cancer Center has introduced a multidisciplinary, multifaceted approach to the surgical management of hepatic and pancreatic malignancies.

As a high-volume center for hepatobiliary and pancreatic procedures, Wake Forest Baptist Health provides a broad spectrum of services from dedicated specialists in hepatopancreaticobiliary (HPB) surgery, interventional radiology, advanced gastrointestinal endoscopy, radiation oncology, cytology/ pathology, and medical oncology. The care of hepatic and pancreatic cancer patients begins with a coordinated 1-day evaluation that includes surgical assessment, diagnostic imaging, laboratory studies, and diagnostic procedures, such as endoscopic ultrasound and fine-needle aspiration. Since 2003, a multidisciplinary HPB committee has then reviewed each case and a care plan has been developed based on the best available clinical evidence. A full spectrum of standard and investigational therapeutic interventions is available for patients of all stages and presentations, depending on specific patient comorbidities and previous treatments.

One area that represents the latest development in the treatment of localized tumors of the liver is minimally invasive hepatic surgery. This approach has been popularized for gallbladder, hernia, and bariatric surgery, but remains relatively new in this disease site. We have been performing laparoscopic hepatic resection since 2004 for a variety of primary and secondary malignancies of the liver, with the most common being colorectal hepatic metastases and hepatocellular carcinoma.

More recently, we have also begun performing robotic-assisted liver resections (Figure). Both major and minor hepatic operations are done in this fashion using smaller incisions with a blood transfusion rate of only 9% and median hospital stay of 4 days, compared with a 5- to 7-day stay for open liver resections. This approach allows patients to return to normal activities sooner. With decreased recovery time, patients are more likely to receive adjuvant chemotherapy in a timely fashion.

In addition to using the latest surgical techniques, the HPB team at Wake Forest is introducing evidence-based care pathways for the perioperative care of complex pancreatic operations, such as pancreaticoduodenectomy. Our approach to perioperative care includes preoperative patient education, a dedicated pain service, standardized laboratory studies, routine use of deep vein thrombosis prophylaxis, and standardized postoperative orders. These systems-level changes have been implemented to decrease perioperative complications, improve quality of care, and reduce healthcare delivery costs.

Figure. Robot-assisted hepatic resection.

Safe, high-quality care is a priority of the HPB team at Wake Forest. Not only do we apply the strongest clinical evidence in the care of our patients, we also conduct clinical trials to improve the clinical outcomes. For example, we have recently reported our experience with negative-pressure dressings in the prevention of surgical site infections (Blackham AU. Am J Surg. 2013. doi: 10.1016/j.amjsurg.2012.06.007). In this study of 191 high-risk surgical oncology patients, the use of negative-pressure dressings was associated with a lower rate of superficial wound infection (6.7% vs 19.5%; P = .015).

The optimal use of perioperative chemotherapy for patients with colorectal hepatic metastases has been the subject of extensive research and our group recently published our experience on this topic (Ihemelandu C, et al. Am Surg. In press). There is no consensus on the best time to administer systemic chemotherapy for resectable colorectal hepatic metastases. We reviewed our experience in 210 patients treated from 1996 to 2010. Patients were classified into four groups based on when their chemotherapy was given: neoadjuvant only, adjuvant only, perioperative (neoadjuvant/adjuvant), and surgery alone. Various treatment regimens were used. Treatment groups showed no difference in clinicopathologic presentation except for a higher incidence of metachronous tumors in the neoadjuvant and perioperative groups (P = .01). Patients receiving only adjuvant chemotherapy had a significantly higher median overall survival (P = .04) compared with the other groups. Research such as this helps us better define management strategies that will result in the best clinical outcomes.

Not only are we focused on improving short- and long-term clinical outcomes for our patients with hepatic and pancreatic malignancies, we are also actively investigating how these disease processes and our interventions impact a patient’s overall quality of life. Our researchers have utilized national cancer registry data along with SF-36 quality-of- life survey data to understand the physical and mental health of patients with pancreatic cancer before and after their diagnosis, as compared with patients without a history of cancer. This research is shedding light on how patients adapt to their diagnosis and are impacted by surgical intervention. These investigations into quality of life form the building blocks for designing patient-centered clinical services that address the needs of our patients and their families.