5 4 3 2 1 9 step uh good morning everyone uh to all our participants and viewers as well as the panelists and the moderators on this morning's isg Master Class as you all know today we'll be having a panel discussion on the uh multimodality management of carcinoma of the pancreas this morning as you will have noticed uh we are missing Dr govind makaria on the panel as he is preoccupied with some urgent personal commitments well we are now completing about five months of these isg master classes which we began sometime in mid April and this is the 27th or the 28th session and uh for the last this is the third session that we are having as part of the isg GI oncology Series where we are discussing uh well is I think the fourth one that we are discussing about uh important uh in an area of gastroenterology where a lot is happening things are very rapidly moving but it is generally kind of off the Beaten Track for most gastroenterologists and you don't find a lot of attention to GI oncology topics except when we talk of palliation and civil interventions keeping this mind I thought in this day in mind we thought it would be a good idea to go through Uh current state of management of these common cancers today we will be talking about pancreatic cancer which all of you would agree is one of the most difficult cancers that gastroenterologists and GI oncologists have to deal with not only because of when it's setting can be quite diverse apart from a genetic background we also know that in chronic pancreatitis in calcific pancreatitis we may have cancer coming in it is one of those tumors that is difficult to detect early not only because it is in a part of the body that is difficult to access and image but also because it is very aggressive in its spread many of these tumors are chemo resistant radio resistant so they offer a challenge to the clinician who has to manage them and often radical and quite major surgical interventions are needed if cure is to be attempted while uh endoscopists Radiologists have to chip in with the palliative interventions now to take us through this whole gamut of management of carcinoma pancreas we have assembled a star panel of experts who will be moderated and in fact your driver and conductor for this journey will be Dr Gian Ramesh you all know Dr Ramesh he is the senior gastroenterologist and head of the Department of the gastroenterology at The Astor medicity in Kochi he's also a former president of the Society of gastrointestinal Endoscopy in India um we also have Dr Shelley Shri khande a professor of surgery and head of gin HPB surgical services at the Tata Memorial Hospital in Mumbai you are the most experienced surgeons to who dealing with this difficult humor in India uh for the nuances of diagnosis and interventions uh the role of the of Interventional Radiology for caracinoma pancreas we have Dr Raju Sharma a professor of radiology at the Olney Institute of Medical sciences and one of the leading radiologies experts in the country is a medical oncologist at the National Cancer Institute of aims at a judger in haryana and we hope to get insights into the new developments and Promises on the horizon for the oncology management of carcinoma pancreas and finally professor sudeep professor of gastroenterology at the Christian Medical College Vellore well uh chip in from the beginning to the end at places to talk about the role of the gastroenterologist who is often the first person on the scene when the diagnosis is made and who's offered the last to support the patient when palliation and reintervention so further palliation are required with these few words let us begin and I I hand over the Baton to Dr G and Ramesh to set the ball rolling for this afternoon thank you very much Professor Vivek um I'll start sharing my screen and that is where I start a warm very very warm good morning to you all um and if you could see my screen yes we can see your screen full screen mode yeah right so basically the the webinar is on carcinum of the pancreas a multi-disciplinary approach and I have a very rich panel with me you know as we all realize that approach and management of carcinoma of the pancreas has to be a team based approach which involves a gastroenterologist surgeon radiologist oncologist and maybe some more also we all realize that pdac um or pancreatic ductile had no carcinoma as it is known as a silent killer surgical resection is potentially Curative unfortunately even at this I may stand correct 15 to 20 percent are respectable and even after complete recession the prognosis does not seem to be too good with a five-year survival after surgery being 25 to 30 percent going by literature if no negative or 10 percent if not positive improve Imaging techniques have resulted in better detection better staging and palliative therapy and efforts to prolong good quality life are still the important goals our Focus today is going to be set on answering a few questions what are the best set of Investigations what is respectable what is non-receptable what is borderline receptive is tissue diagnosis always required and how best to do it the surgical results the choice of surgery and modifications thereof the role of new achievement and adjuvant therapy and of course we end up with the algorithms let me also be very clear about the fact that we are not going to be discussing any teas or the cystic leashes of the pancreas we start off with diagnosis and as Professor Vivek said the starting point is usually the gastroenterologist and most often this patient presence as a mass lesion in the head of the pancreas suspicion of malignancy as is there Dr sudiptop what questions do you ask yourself when you are faced with this clinical situation um thank you for the wonderful interaction just to take you uh briefly what Dr Ramesh was alluding to that with when you talk of mass nations in the pancreas the one thing that we have to always look out for is a pancreatic at no carcinoma but there are number of mimics which can confuse the picture and these include an inflammatory Smash in the setting of an underlying chronic pancreatitis which is more often in our scenario in India then of course we have the mass forming uh lesions in autoimmune pancreatitis and the group pancreatitis or the pancreatitis involving the pancake now if you look at the incidence of benign lesions that we have found out during Ripple surgery over a period of time within 1990s 2000 and 2014 there's significant number of lesions are still get operated for benign lesions having said this so if you ask us as a gas printers went to suspect malignancy one of the things that has been taught to us from the time we were medical students from the DM students was that if you have a patient with a new onset diabetes mellitus in a middle-aged person please suspect the pancreatic cancer in addition to that when there is a mass in the pancreas the other things that which point to us Point towards malignancy could include an older age of the individual a worsening abdominal pain presence of jaundice or gastric Outlet obstruction and significant loss of weight and of course if you have an elevated CA 99 it definitely is a pointer towards a possible magnification thank you um it's always said that we usually start with an ultrasound but we're not going to discuss much about ultrasound because we take it for granted that each of these patients has gone through an ultrasound but I'll ask I'd like to ask are Radiologists on the panel and and I know that he's a leader in Radiology in the country of all the Imaging modalities two amazing modalities that come to our mind are CT or MRI the question is CT or MRI or do they have a separate role by themselves and what is the role for contrast enhancement and what is the information that as a radiologist you would expect your Radiologists to provide to the clinician over to you Dr Raju thank you Dr Ramesh yes as you rightly pointed out ultrasound is essentially used as a screening modality just to detect the presence of a mass and the presence ability obstruction following that I think mdct is really where the money lies as far as Imaging the pancreas is concerned that is the Workhorse of pancreatic Imaging especially in the context of pdac it is useful both for detection for trying to characterize the lesion for distinguishing it from inflammatory pathologies that sudeep to alluded to earlier like Mass forming chronic pancreatitis or mass bombing uh AIP or the paradigodinal pancreatitis so it helps you in detection and characterization and more importantly in staging the Disease by a detailed analysis of the tumor vessel contact which is what the surgeon is interested in before he plans surgery having said that there is a problem solving role for Mr it's not the primary modality but we use it when the CT findings are equivocal it is very useful for detection of iso dance masses we know that about 10 percent of pancreatic cancers can be isotense on CT and they may not deform the Contour of the pancreas but just cause a ductal obstruction so those kind of lesions Mr is very useful and MRCP comes in handy it's also very good for small liver lesions for detecting distance spread of disease from a pancreatic cancer and for peritoneal metastatic disease there is an important sign that we use to distinguish between inflammatory masses and neoplastic masses and that is the duct penetration sign uh the duck the pancreatic duct tends to penetrate through an inflammatory Mass whereas it tends to get cut off by a uh adenocarcinoma and that is what is very easy to delineate using in MRCP so I would say the primary technique is a good contrast enhanced multiplayer CT and problem solving role for a contrast enhanced demo as far as what information we give to the clinician of course the presence of a pancreatic Mass try to characterize it whether it's inflammatory or neoplastic in nature if it is neoplastic is it a ductal adenocarcinoma or is it a new neuroendocrine tumor because they have a very different appearance on Imaging we then in an MDT setting sitting with the surgeon try and Stage the disease and assess the surgical resectibility of that lesion next the typical Imaging appearance of a pancreatic ductile cancer is that it's a hypovascular tumor it's a desmoplastic tumor so early in the course of disease it tends to produce ductal obstruction both of the common bile ducts when it's located in the head of the pancreas and of the main pancreatic duct producing the typical double duct sign which I'll show you in a little while it is an infiltrative tumor and therefore it infiltrates the surrounding mesentric vessels the SMA the smv the Celiac axis the Iota and the IDC as we know the commonest location of this tumor is in the head of the pancreas and therefore it produces biliary obstruction very early in the cause of the disease so important to remember that this is a hypovascular tumor so on CT will be seen as a hypo enhancing lesion in total contrast to the neuroendocrine tumors which appear as hyper-enhancing tumors because of that hypervascularity if I could go to the next line so typically we do a biphase x80 we want a pancreatic phase and a portal venous phase and for the purpose of postgraduates the pancreatic phase is acquired at 45 seconds from the beginning of injection and the portal venous phase at about 70 seconds from the beginning of injection use of contrast is absolutely mandatory there's no point doing a non-contrast ET at all if for any reason you cannot inject iodinated contrast in a CT because of a previous contrast reaction or something like that it's better to do an MR a non-contrast Mr is way Superior to a non-contra city I would say a non-contra city is absolutely useless and should not be done if for any reason contrast cannot be given because of deranged renal parameters or because of previous history of allergies then you would want to do a non-contrast Mr next please so these are some typical appearances of a pancreatic ductal adenocarcinoma and if my cursor is visible this is the lesion that I would like to show it's not really deforming the Contour of the pancreas but notice that it is causing an Abrupt cutoff of the main pancreatic duct in the body and tail of pancreas which is dilated there is atrophy of the distal body and Taylor pancreas and there is this subtle lesion sitting in the neck of the pancreas if you do a curved multiplanar reconstruction you can for your surgeon delineate the entire pancreatic duct in one image as has been done in this particular image this is an MRCP image showing you a double duct sign so this double duck sign is essentially a ductal obstruction of the common bile duct and the main pancreatic duct in closed vicinity and this also points to a feed act located the head of the pancreas I can please go to the next slide so this is again the typical hypovascular appearance of uh word located in the ansonate process of the pancreas behind the SMA and the smv and this is the post contrast Mr image showing you the same tumor producing a double dark time so the role of Mr is essentially in very small lesions which do not deform the Contour of the pancreas if you go by the literature as per the nccn guidelines both ZT and Mr are equally accurate in trying to Stage the disease however most Radiologists and surgeons are more comfortable looking at a good mdct for this purpose rather than an MR and therefore we reserve Mr for the problem-solving role and in those situations where CT contrast cannot be given in the western world where they screen some high-risk groups of attacks like patients with ipmn or reputation they use Mr for the purpose of screening in the interest of radiation protection next slide so this is the typical Mr appearance these are T2 weighted axial images showing you a hyper intense lesion G2 bright lesion located in the head of the pancreas these are some diffusion weighted images we find these very useful in the context of pancreatic cancer so this is a trace image from a diffusion weighted sequence and what you see here is a very bright lesion which shows you restriction or dark signal on the ADC map this is the typical appearance of a pancreatic ductal cancer I can go to the next slide please and these are again some more uh contrast enhanced images of a hypovascular tumor sitting in the region of the ansonate process behind the SMA and the SMB Tech space and that's the typical uh example of a double DOT sign you can see the dilated common bile duct and the suprapancreatic location and an Abrupt cutoff of a dilated main pancreatic duct as they approach the head of the pancreas and this double DOT sign because of her obstruction to the two ducts enclosed vicinity is produced by a pedac located in the head of the pancreas next please as I refer to Mr is very useful for picking up lesions small sub centimetric lesions in the liver are difficult to characterize on CT and when you want to characterize them better then Mr is the way to go and a diffusion weighted image is very useful in that context when you see these small lesions in the liver producing restricted diffusion you know you're likely dealing with liver metastatic disease next please so as far as the information given to the surgeon we've all switched to using a structured reporting template many articles published earlier have shown that a structured reporting template is more useful for the surgeon they find it easier to extract information from those next slide and these there are templates available and the useful template which we tend to follow is the NCC and template provided in 2019 which gives a detailed description of the tumor a very detailed analysis of the tumor in the context of the SMA whether the angle of contact is one less than 180 or more than 180 the angle of contact with the vein X please and we also then Define the presence of levolutions ascites the presence of lymph nodes and finally give out an impression of whether the tumor is resectable unresectable locally Advanced or as distant metastatic disease thank you thank you very much Dr Raju that was quite exhaustive and very very informative important thing of course is that contrast enhanced CT done with the pancreatic as per pancreatic protocol is probably the most important and if for some reason contrast cannot be given uh Mr would be the next best choice now we now shift our Focus to endoscopic ultrasound and that seems to be the end and I'd like to write how has EOS influenced the management of CA pancreas whatever Dr Raju mentioned about CT MRI what additional information does EOS give over and above these investigations was leaving to on on overall if you look at the comparable sensitivity and specificity of all these three modalities MRI CT scan in the U.S they are virtually all comparable except for that of pet City uh sensitivity MRI CT scan and the US is comparable we move to the next slide please now but what do you do in a situation where there's a multi-detector CT that leaves behind an indeterminate condition and you have a high suspicion for a pancreatic cancer now this is a meta-analysis of 206 patients they have four studies two and six patients the pancreatic masses were detected in uh about uh 144 patients of which is uh 40 were turning turned out to be neoplastic and the sensitivity of doing an EOS after an intermittent city was a very high almost 85 our specificity was low so there is a role for doing EOS when the lesion is indeterminate on in the city look to the next slide and most of the lesions as was identified in the previous study also showed that most relations were actually less than two centimeters and this is our Target area of interest because these are the lesions which would benefit best from from a surgical intervention done very early on next slide please an addition to the indeterminate lesions the other things which eus gives a very good information is the vessel involvement particularly Venus Invasion the three signs that we look for in venous invasions are whether there are Parent Portal uh peripancreatic or venous collaterals in the area of the mass that obliterates the normal and atomic location whether there's a tumor in the within the vessel Lumen or as in this particular image there's an abnormal vessel Contour with a loss of vessel parenchymal sonographic interface now all of these are good signs to say that there is a vessel invasion in this case our involvement now if you look at the overall sensitivity of this the sensitivity is around 72 percent per us and much higher than that of a CT scan if you nine studies with those comparison between EOS and CT scan the sensitivity of EOS to detect venous invasion was definitely higher than that of CT scan and so however the specificities were similar the area under the curve was higher for Eos as compared to that of CT scan so but as uh regards Venus that's because Venus Invasion but what about article Invasion the surgeons are nowadays not that concerned about Venus Invasion they're more interested to know whether the arterial invasion of a lesion and if you look at the artery Invasion now there are two recent studies which looked at this where the us could predict the presence of artill invasion and this they compared it against post-operative findings and the two things that stood out was if there's a loss of vessel color Integrity clear Invasion or a con contact with loss of hyper-equate vessel work these are very good sensitive criteria to identify arterial Invasion and and the first study the sensitivity to detect our Innovation was to the you know 70 specificity of 84 percent similarly for the seconds for the other study in 2019 the sensitivity was pretty high 83 and if you compare this particular criteria that is contact with loss of hyper-equate vessel wall then and in the post-operative findings and with contact without loss of hyper recognition vessel wall then there is a difference between the tumor and the vessel location by about 1000 micrometers now whether this is a useful information when the surgeon is trying to obtain an r0a section moving ahead so other Studies have looked at whether there's an incremental benefit of adding CSA EOS to the already available information on CT and MRI now this is of course a very uh this is a meta-analysis in published in 2017 but included a data from 1990 to onwards to 2007. so obviously the generations of CT scan have had a huge change the quality of CT scan images that we get have a significant change so probably the data may not be as relevant as it was at that point of time but having said this there is a benefit that when you add CEOs to lesions which were deemed resectable at CTR MRI then at least 19 of them were performed to be unreceptable when you did that EOS and if you only if you move on to the next question so we've gone through the gamut of investigative modalities the Imaging techniques which will give us a lot of information now we are left with making a decision as to what is to be done and I understand that Central to this decision making is the staging and staging is basically done best by the Radiologists in association with the U.S findings whatever it is so may I request Dr Raju to tell us how do we stage pancreatic cancer there are so many systems you go into the literature which is a staging which is most relevant and useful so firstly for the purpose of staging you need a good quality City an Embry setting in a high volume Center I think that is where an appropriate stage can be assigned to a lesion and it's not just the surgical receptability that we are talking about we're trying to predict an r0 rejection or trying to predict oncological curability as you mentioned there are different systems there is the tnm staging system given by the ajcc which is more useful for prognostication there is an ASCO staging system a staging system from the MD Anderson Group and the nccn staging uh in our institution and I think most oncology institutions it is the nccn staging that is more universally followed in trying to classify the disease into resectable borderline resectable and locally Advanced or unresactivable disease you could go to the next slide so basically you need a high quality pancreatic protocol CT not more than four weeks before surgery if only a standard um single phase CT is available it's a better idea to repeat that CT do a good quality CT and sit on a workstation with your surgeon and evaluate multi-planar reconstructions as well as mips or maximum intensity projections and then you stage the disease appropriately next please so the T M station is more useful for prognostication and is based on the size the T stage is based on the size of the tumor the end stage on the number of lymph nodes but this is not something that helps you decide the management for that particular patient that is based on using the nccn staging system next please next so this is really where this is the more important slide for the staging purpose uh the resectable disease is when there is no arterial tumor contact and on the venous side either there is no contact or there is a contact of less than 180 degrees which means it's only abutting the vein but not invading the vein borderline resectible is the category where the arterial contact is there but is less than 180 degrees on the venous side the contact can be greater than 180 degrees but you should be able to show to a surgeon that there is a reconstructible vein both above and below the site of involvement unresuctible disease on the other hand is when the arterial con the contact with the SMA or the Celiac axis is greater than 180 degrees and on the venous side you do not have a reconstructible vein available the vein is occluded by tumor or by a thrombus and there is no possibility of a safe resection and reconstruction of a surgeon next please the accuracy of staging is in the range of about 90 Imaging does a much better job of deciding unresactable tumors than it does as far as resectability is concerned and many state Studies have shown that when Imaging says that the tumor is resectible only about 70 to 80 percent of those tumors are actually found to be deductible at surgery there is some role for PET CT although it is not something that is routinely done and it has been advocated in patients who have uh who are at high risk those with very large tumors those with large lymph nodes or in borderline resectable tumors to pick up distant peristatic disease and which would then preclude surgery next please well uh thank you this is about the conventional seat the Imaging with respect to respectability I am going to Dr sudipta once again uh you did mention about U.S Now by how much does EOS improve on assessment of resectability as compared to ctmri just for the sake of our residents if you could just give a figure before we go on to this question uh so as uh Dr Raju was mentioning with the current generation of mdcts you can get a very good information as regards the degree of vessel involvement whether it's more than 180 or less than 180 degrees and the and the uh whether there is a vein that can be reconstructed after after surgery or at surgery unfortunately at EOS with the current generation of EOS the degree of vessel involvement will probably not be available with a condition we can say there is a contact the amount of contact but whether there's a 180 degrees or less than 180 degrees that will probably is unable to say okay yeah uh now we now go on to this cup issue of tissue acquisition now radiologist tells us this is a pancreatic malignancy or CA pancreas or sometimes it says Mass lesion maybe CA pancreas now my question to you Dr sudipta is tissue acquisition uh is it always essential when not when yes and I also would like you to address this question and this is a bit debatable is percutaneous tissue acquisition a procedure of the past thank you the thing uh as regards the surgeon is concerned I think that their uh their criteria and the guidelines are very clear that when the Imaging is consistent with a cancer pancreatic cancer and it's a resectable disease we better not wait for a tissue accusation and there's an Associated complications related to tissue Acquisitions And Delay the surgery and upfront surgery may be a wise however there are certain situations where a tissue acquisition is necessary especially when you have an atypical mass in the air Imaging which is not consistent with a pancreatic cancer where or where there is no Mass but there is just like not up of the pancretic duct and we are not sure unsure whether that's actually a mass producing a cutoff or whether there is a structure of the pancreatic duct in borderline recyclable cases and patients who are planned for near juvenile chemotherapy there is definitely a role for Eos guided tissue acquisition because before chemotherapy it's always good to know that we are giving chemotherapy to an individual who has a cancer and of course there is a role in palliative cancer I said this to address the next question this is like one of our standard cases where particular fnac was done and then which was negative and then you move ahead to use guided fnac on in the endoscopy room itself just using a mobile camera you can get a picture of this uh lesion which is a picture of the histology and showing pancreatically so very quick thing having said this overall there is no difference in as because the accuracy is concerned when you compare forgiveness at Tennessee versus EOS data dependency and there's two studies of course Very Old 2002 and 2030. we showed that overall there is no difference in accuracy however the complications are much lower when you do EOS guided and at U.S guided smaller lesions can be targeted having said this we are a resource limited country and we have to understand where judiciously we can use it the U.S has certain advantages that is it decreases the risk of needle track seeding can be used to Target small lesions for lower risk of complications however is not widely available it's uh it involves higher costs and of course if negative needs sedation on the other hand per Keepers fnacs always lose cost with a lower cost wider availability no need for sedition so in my mind if you have a borderline resectable lesion small lesions or atypical lesions Evas guided fnacies is the way to go however in the setting of a metastatic disease or unrestrictable low PE Advanced application either one of this is a good option my question to you based on this is is this risk of needle track seeding real or perceived there are documented case reports where there has been needle track seeding and U.S guided thing having said this there was a very power paper and got published a few years ago we showed that there was no risk of recurrence in the patients who undergoing usfnac versus those who did not undergo USA Tennessee thank you thank you yeah anything that you wanted to say before I was always a concern about it and so therefore we would try to avoid doing this okay now uh Dr Raju coming back to you uh as I said The crucial to decision making is resectability so if you could just tell us what are the definitions of a resectable CA pancreas unresectability and borderline receptivity before we go on to the surgeon so one important concept is the differentiation of abutment from encasement when we talk of angle of contact of 180 degrees we're essentially talking about 50 of the circumference so uh this is a schematic diagram showing you Apartments to the smv where the angle of contact is less than half the circumference whereas this shows you angle of contact greater than 180 it involves about 80 percent of the uh circumference of the vein and this is encasement and the other thing that we look at is the deformity of the Contour of the vein and that is also very important if you have this kind of a teardrop deformity of the vein that also suggests Venus involvement and this is showing with respect to the superior mesenteric artery so a lot of what we do on Imaging is assessing the contact of the tumor with the vessel I already talked about the definitions of resectability and borderline receptibility earlier and in the interest of time I'll just show you some examples so this is a resectable tumor in the consonate process of the pancreas I hope my cursor is visible that's that it's not it is okay and this is the superior mesenteric vein this is the superior mesenteric artery and there is almost no contact with the of the tumor with the two vessels with the two vital vessels and this is the kind of patient that the surgeon is looking for where the tumor is rejectable up front a biopsy is not required uh probably and because the findings are fairly certain in favor of a tdac next slide please the definition of borderline resectable unfortunately is far more ambiguous and it tends to differ from one Center to another and this is best done in a multi-disciplinary group with your surgeon you need to the radiologist then helps you to decide what is the length of the vein involved and whether there is reconstructible brain above and below but different centers follow different definitions so essentially we would look at coronal reformatted images along with the surgeon because this definition is a little ambiguous and tends to vary from one Center to another next piece now this is a tumor where there's a large tumor sitting in the head and neck of the pancreas and there is a thrombus in the superior mesenteric vein which I'm showing with my cursor again the smv is thrombosed so if this is over A short segment and there's a vein above and below which can be reconstructed this could again fall in the category of borderline resectible in the hands of a competent surgeon like uh challenge next please so this on the other hand is a patient where there is a tumor which has a contact with the SMA unfortunately I can't control the video at my end so it's showing you dilated bile ducts there is a tumor in the ansonate process the head of pancreas which has a contact with the Supreme mesentric artery less than 180 degrees and this again would fall in the category of borderline resectible next please this is a image again showing you the contact with the superior mesenteric artery this is the tumor that's the superior mesenteric artery here and you have angle of contact which is again less than 50 percent of the circumference of the aorta again falling into the category of borderline resectable next piece unfortunately majority of the patients that we encounter in our practice are ones who have advanced locally Advanced disease you can see this large tumor which is causing a teardrop deformity over a very long segment of the vein and there was no reconstructible brain above and below and this was an unresectable tumor next please this is another example of an advanced locally Advanced tumor where you have a tumor sitting in the body of the pancreas which has invaded the Celiac axis it also has a broad area of contact with the aorta and this would render the disease unresectable next please and then of course if you have focal lesions in the liver with a Target morphology and a T2 weighted image this is a metastatic disease and this patient could then go in for chemotherapy if you have a dual energy CT you can then generate fancy images like this do an iodine map this is a patient who had a replaced right hepatic artery arising from the superior mesenteric artery and so you can also tell your surgeon about variant anatomy in this case the replaced right hepatic had a broad area of contact with the tumor next piece this is an example again of a tumor sitting in the region of the neck and body of the pancreas which is which has an area of contact with the SMA which is larger than half the circumference or more than 180 degrees again rendering the tumor unresectable there's a lot of awareness amongst Radiologists today about perineural Invasion and we look for soft tissue traversing along the blood vessels which then suggests that there is likely to be better neutral Invasion this is a tumor located in the tail of the pancreas which is involving this splenic artery and that is resectable unless it goes and extends right up to the origin of the Celiac axis from the aorta next slide please this is essentially uh showing you if you could just click on this video uh Dr Ramesh this will run this is a patient who has uh four collisions in the liver bulky nodal disease remember peripancreatic nodal disease is still resectable whatever nodes are removed as a part of the Whipple's rejection that is still considered resectable disease unless it goes to the root of the misentry or to the periodic location which then becomes a metastatic node if I could go to the next slide so essentially what I want to say is that the job of the radiologist is not to just say whether the rejection is going to be technically possible or not but also go into details and try and sit with a surgeon and analyze whether an RZ road is action is going to be possible or not next please thank you well we now move on to the this this uh Dr Shailesh you've heard a lot about the Imaging the role of endoscopy I'd like to first of all start with a very pointed question uh would you take up a patient for surgery without a tissue diagnosis I'll also add on one more thing to this would you take up a patient for surgery without an eus over to your side dish right so I think it's very clear that if you have a solid tumor and the solid tumor is localized and resectable and not just definitively a hypoechoic area which is telling you clearly it's pancreatic cancer if you are reasonably sure sure that you are dealing with a mass lesion which is in the head of the pancreas which is localized you are justified in going ahead with a radical resection without a pre-operative tissue diagnosis notwithstanding the fact that we would still document about 6 to 15 percent of patients who on the final pathology May reveal something other than pancreatic ductal adenocarcinoma I've been a part of this international study group for pancreatic surgery and you can see that that's the conclusion are 26 high volume surgeons came together that in the presence of a solid Mass suspicious for malignancy consensus was reached that biopsy proof is not required before proceeding with resection confirmation of malignancy however is mandatory for patients with borderline resectable disease because that disease is nowadays treated with neoadjuvant treatment options like good chemotherapy and then about 70 percent of these patients would get a worthwhile surgical resection which will give them a chance of long-term survival so yes the answer is that we would go ahead uh when in doubt we would take it out this is our own data of 446 resections and you will see that we turned out to be having benign diagnosis in 29 out of these 446 but out of these 29 we had 17 patients with focal chronic pancreatitis and even for focal chronic pancreatitis a head resection or a ripple resection continues to be a transatlantic divide as to whether you should do pancreas preserving head Corine or whether you should be doing a ripple resection which is what they would earn on the side of doing in the Americas this is important because in the conundrum of uncertainty we must also make sure that we do not lose out on the chance of offering a Curative resection if you get a patient with retroperitoneal lymph nodes and with a mass Etc which is more than four centimeters in size you already lost the battle much later even though you might diagnose it as pancreatic cancer so when in doubt we would take it out is is my first answer and in this slide you will see that we had a number of cases where we have done a variety of Investigations and a combination of Investigations and even then in about six percent or seven percent of cases we will fall short and end up offering them a major surgery now there is some other areas and both my speakers earlier on have alluded to so they have made my job very easier would I go ahead with surgery for something like this you can see obviously from the Radiology that there is a dilated gallbladder and you have a situation where you have a dilated common bile duct which is coming right down you have a clear idea that there is going to be some block at the terminal end because you have got an excellent dilated system but the city has not conclusively told me that there is a mass lesion in such a situation I clearly need my gastroenterologist to answer the latter part of your first question that do I need an U.S in every case in fact I need an U.S in very few cases which are resectable but in this particular situation this is resectable a triphasic CT scan is done vein artery all free but we need to confirm that I see a mass leisure we will of course discuss this perhaps later if we get the time but for very small lesions if it's a solid lesion we may or may not do a biopsy via EOS depending on what we are thinking radiologically and clinically for a patient so sometimes my endosonographist would just do an endosonography and tell me this is no stone this is no worry some structure or benign structure you clearly have a solid Mass lesion and do you need a biopsy and I would say sometimes yes and many a times I would say no as long as it's a lesion this is good enough for me to take the patient to the operation table to offer radical Curative surgery we've heard such excellent update from Dr Raju Sharma who's an expert that he's made our surgeon's job easy but in every Center you don't have a Raju Sharma so I think I would also urge the younger member especially that when you evaluate your patients do not look only at the Radiology printed report every clinician interested in management of pancreatic cancer he or she must be able to study the CT scans on their own in great detail so this is what we looked at that we would prefer mdct triphasic as the first Imaging modality in the era where you have got confusion about chronic pancreatitis and ipmn we would also add an MR or an MRCP as a complementary test not as a competitive test otherwise I am happy with only one CT scan EOS sudipta has very nicely highlighted but we would recommend it for assessing lesions not clearly detected but suspected in borderline resectable as I told you and in some cases to assess vascular involvement but as our experience in surgery has grown we have realized that we actually don't depend on any U.S for vascular involvement I depend on a high quality triphasic CT scan and I get all the information that I need thank you very much sales now we go on to surgery and Beyond I think I I'll stay with you uh Dr Shailesh and my first question to you would be uh we I had mentioned the beginning if at all you're looking for a Curative solution it is the role of surgery in CA pancreas what are the major issues and recession that you would like the gastroenterologists to be mindful of and whether there will be any difference between your approach to borderline resectable cancer or locally Advanced cancer right so again my job has been made easy and it's flowing very well the way you have designed this session again for a surgeon I want both my Radiologists and gastroenterologists to be aware that this is the way I think Beyond nccn and is GPS my practical working table is this particular one that the red box highlights to you what I as a surgeon am clearly able to see as resectable disease But it includes two distinct categories you have the major vasculature like the veins and the arteries and resectable is easy there is no vein no artery involvement patient is fit for surgery best thing is to do a radical r0 Curative resection and give the best possible chance of long-term cure borderline resectable Superior mesenteric artery Celiac axis should be less than 180 degrees affected if the vein is more than 180 degrees affected it is still resectable disease in experienced hands as long as the disease does not progress under neoagulant chemotherapy and the locally Advanced and unresectable disease is when there is encasement around the artery in the retroperitoneum OR there is no encasement but the length of the vein involved is such that you don't have a superior mesenteric pain inferiorly that is available for the surgeons to join back and send the blood supply back to the liver so these are my broad Concepts when I look at what is resectable versus borderline resectable versus locally Advanced Point number two in borderline resectable it's not only about good Radiology by Dr Raju Sharma or eus by Dr sudipta I think it's important that you first look at your patient and that's where the ABC classification is important and I would urge the younger members to study this very well that b is biological definition of what is borderline resectable a is of course the anatomical definition which we all discussed in great detail so far in biology you have ca199 but I would add a caveat to that that a high CA 99 in the absence of obstructive jaundice is important if you have a high CA 99 in the presence of obstructive jaundice I would rather have the obstructive jaundice trained and reassess what is the true Baseline CA 99 which would contribute both as a baseline marker for monitoring response to treatment or influence the surgeon's decision to do a pre-operative laproscopy to rule out a high chance of metastatic disease especially if the ca 99 is 300 400 Etc the other part is that you see number of lymph nodes the minute you see lymph nodes even in resectable disease in the vast majority of times you are dealing uh with grade two or stage three pancreatic cancer even if they have got a good surgical resection and then of course it is the conditional definition as well so I might have a favorable a and I might have a favorable B but I might have an unfavorable C and then the surgeon needs to decide that am I trying to play God or should I just stop and look at palliative options giving good quality of life give chemotherapy radiotherapy and not subject them to a high risk surgery that's one part looking at the other parts were surgical perspective again where the gastroenterologist would help us in a multi-disciplinary treatment board is that if I have abutment in scenario a and even in scenario as I get a more and more confident surgeon even if there is partial encasement of the vein I great get a great surgical plane which is there between the superior miocentric artery and Superior eccentric vein so I completely Safeguard both the arteries in both the scenarios and get the tumor out will make me a very happy surgeon and in this situation if I am a competent surgeon even with complete encasement I would still be able to take it out because of superior mesentric artery first technique which is a surgical approach which I'm not going to discuss now in detail but while doing this it's good to look back what has been published more than 13 years ago by a very well-known vascular surgeon from Japan by Macau that if you start getting collateral formation if you have complete encasement or you have a severe venous deformity these group of patients don't do very well in the long run even if you do a great surgical section in pancreas cancer and it is this group where the surgeons actually need the gastroenterologist because I need a tissue diagnosis from them because I want to confirm suspected diagnosis of pancreatic cancer and then get in my medical oncologist to treat what is essentially a systemic cancer and then consider surgery rather than a big technical exercise um there is another area which is coming back a little bit to the pre-operative phase when you ask me what can a gastroenterologist do and what surgeons want gastroenterologist to know of course we can go on and have a debate on this subject for an hour but just now the brief for me to share with you is that we would have problems if the endoscopic procedure has been a complicated one we would have problems if there is associated pancreatitis and these problems is not just a surgical this is what a direct impact on the patient's post-operative recovery and outcome this is an old study from our team of 144 resections and if it was a smooth well done ercp with a stint there was no problems but if there was a complicated ercp there were big problems Point number one point number two if the patient needs real good optimization [Music] on a Wednesday or the following Monday the stenting has been in my opinion for three most important reasons one is that the patient is nutritionally not good two ways patient has got colangitis and or coagulopathy that's no rocket science they all must give it three if they are going to get Neo actual treatment which is going to go on for two or three months I want them expandable metal stems I don't want them to get a plastic strength there is enough data I don't want the chemotherapy to get interrupted with cholangitis and other problems I want good consistent safe lineage of jaundice bilirubin of less than three and then chemotherapy is possible so I think that's important for my gastroenterologist to go when I want a plastic and then I want a little extent and then I would wait for them and then I would go ahead with surgery uh since the disclaimer was no neuroendocrine and no cystic tumors we can discard this slide and go ahead as to when I need and even this one can be discarded and we can reach um yeah so what are the program is after a good I mean generally there is an air of you know a defeatist attitude or you know desperation as far as is concerned yeah prognosis we know that you are a large volume Center yeah uh and what message is emerge from these data yeah so what I can share with you is that we have got very good perioperative outcomes on par with the best in the world you can see that we have developed and we continue to develop into a very high volume Center for ripple resections across the country um and we are confident of our perioperative outcomes but speaking of long-term outcomes you clearly have to differentiate between pancreatic cancer and periapillary cancer with periampillary Cancers we clearly have a five-year survival which is now going up to 40 to 50 percent even with no positive disease for stage one stage two stage three taken together but when it comes to pancreatic head cancer I'll bring your attention to the landmark study by John Cameron from Johns Hopkins where if the pancreatic cancer was node negative you would have more than 40 percent patients alive at the end of five years so is it a bad cancer it is a bad cancer and for all stages together if you do a radical surgery are you going to have a situation where 20 people will live and the remaining 80 will die within the next five years for pancreatic ductal adenocarcinoma yes the answer is true but if you get node negative the figure improves and more importantly uh with chemotherapy adjuvant chemotherapy we now have reached a situation where the number of patients who are living for up to five years has now gone up to somewhere between 30 to 40 percent because if they get good safe surgery and then they get good chemotherapy and it is finished in a particular span of time then you will have about 30 to 40 percent patients who are alive the same group of patients two decades ago we were looking at data of 15 to 20 percent five-year survival this is born out by studies uh by the conco study by the espac group right from the turn of the century to the most latest aspect five which clearly shows that chemotherapy has made progress on the background of good quality safe surgery this is our own data from Tata Memorial and now we've got a series of more than 1600 people resections and it's obvious that whatever is the World experience we are able to have about two years survival of 78 percent of patients uh of course it tapers down to 20 for pancreatic head cancer but it's about 40 percent for periampillary tumors even if they are not positive after a ripple resection we do get 57 patients who are R1 resection on pathology it's more because of specialized pathology and not due to poor surgery that you will still get about for pancreatic head cancer close to 60 patients who are R1 but even that group of patients with adjuven chemotherapy can expect a better meaningful length of life than just a decade ago that's uh that's a large volume of day yeah and it and the box that in the right right corner I think is important for us all to understand as medical gas control just that we are now looking at probably better uh outcomes as far as surgery is concerned and this is something that all of us must realize as as the medical gas to launch its fraternity thank you very much uh Dr Shailesh thank you could you just do me a favor by deleting those marks that on the screen is it possible from your side yeah I don't know how do I delete them I'm struggling now Raju may help anyway we just go on with the discussion but we also want to delete them what can I do to delete them I could annotate them and then clear clear yeah press clear now uh sudiptop uh let's just click on view options okay thank you it's there yeah now uh sudiptop before I go on to our oncology colleague who's been waiting in the wings and eyes we know that oncology has got a very very important role to play in this different or emerging change in outcome I just like you to address this particular issue once again about routine tree of bellary drainage now is it routine number one number two is if so what is your preferred mode of drainage when and why so I'll just uh take you back to what Dr Shailesh was also alluding to in his presentation that basically uh there is a very limited role for Billy re drainage but if you look at the data which has been there in literature very old data from 1985 also showed this is probably the only random style we showed that pure surgical complications happened when they did the ptb however when they included the ptbt complications this advantage of also decreases overall most of the Studies have shown that their complication rates are definitely higher when we do a biliary intervention but however there is no difference in the overall survival length of Hospital stay or the morbidity of the uh or morbidity however the complications do go up this is again a meta-analysis of the three randomized control trials and 22 retrospective studies and what is more important to note here is that the bilirubin level that was recruited for the randomized control trials including the which is a large randomized control trial I was less than 15 milligrams per deciliter so patients were having bilirubins less than 15 milligrams per deciliter when we do ercp versus surgery ercp increases posterior overall complication rates increases the risk of wound infection and there is no difference in the early perioperative mortality in trapdamental abscesses or pancreatic fistula formation what it goes on to show that pre-op ercp in patients who have bilirubins less than 15 milligrams per deciliter is probably not of Great Value and only adds to complications and delaying surgery so when should we know if you ask then the question answers would be if there is underlying cholangitis in an individual if the person is a candidate for near driven chemotherapy and the patient or the patient has intractable providers and there is a delay in Surge anticipated delay in surgery for more than two weeks and impatience of course this can this number is controversial can be variable between different things but for us if the bilirubin is more than 15 million per deciliter we have more evidence to justify not doing stenting and so therefore we can say that in patients with bilirubin more than 15 million per deciliter we should go ahead and do a village standing when you put in a stent it will be a metal stent or a plastic stent even the patient is a candidate for a surgery as a borderline recyclable plan for a new human chemotherapy we usually prefer a plastic stain the goal here is to put a plastic stem below the cystic duct origin and uh just to attain biliary drainage we do not put a metal stand because of the complications related to surgery everyone has a different skill sets and so considering keeping that in mind we stick to putting in early plastic stance but our surgeon I presume is happier with metal still being put in because he feels that probably the quality of palliation or or whatever say the Improvement is much better with metals and isn't it turned out to stylish yes I was just raising my hand up to make a comment that I understand that cost is a major concern and cost will drive treatment and should drive treatment because this is practical reality but in an ideal world if I am discussing science where there is a patient who has an eminent 70 chance of getting a good resection after chemotherapy then I don't want complicated as it is chemotherapy causes complications with immunity and other challenges so we don't want to tent getting blocked and if I'm to understand the data coming from gastroenterologists and endoscopies a plastic stent would have a 30 percent chance of blocking while the Sims would have a less than five percent chance of blocking statement number one and statement number two um you know uh I have no problems dealing with any kind of stent even a metal stent can be extracted out during surgery and even a plastic stain can be extracted so I think it should be a decision looking at socio-economic status intent of treatment performance status of the patient and then do what is best for the patient thank you very much childish we now go on to the oncologists and I'll request Dr Akash jar to unmute himself uh two questions to you in succession first is what is the role and mode of new achievement therapy for CA pancreas we all understand that borderline resectable there is a role for new adjuven therapy uh what is your advice as far as new adjuven therapy is concerned thank you sir uh so so before we start I want to share few things that is different in CA pancreas in comparison to other solid tumors for our colleagues Junior colleagues first thing is in pancreas even if after so many years of research and improvements r0 is not the main thing that we want to achieve there are many trials that all larger trials they have accepted R1 it's not because that we want to do that it's because we are getting that and if the patient is going for an upfront surgery R1 is an acceptable around 50 percent of all the cases in all major Trials of adjuvant chemotherapy R1 has been accepted in those cases and chemotherapy it does make a difference although the amount of increase in survival is not as good as in r0 so that is one thing that we want to tell besides coming to my own topic this new adjuven chemotherapy there are two things that is very important Raju sir has already mentioned the in MDT you have to decide but we at our Center are more comfortable work surgeons are comfortable with if they think if their their surgeons are okay that they most of the time they take the first hand and decide it is borderline deceptible because it depends on the expertise that we have at our Center or at any Center because at times the different institutions worldwide have adopted different uh criterias for borderline receptive so that is one thing besides we have to understand that there is no high level trial robust data that only answers near adjuven therapy so all the data that has come up has come up from the adjuvant setting or metastatic setting so that the drugs that have been or the combinations that have been used in metastatic setting that have been used in newer German setting so that is these are the chemo drugs that are the the five six two the whole gametes of these five six tracks it is five a few keeps it again this is gems Latins and ironautigans the whole idea is the combination or a single uh uh agent so that is one thing that we need to know more that if the patient has to be fit enough or near given chemotherapy Because unless you give a proper combination chemotherapy like falkirinox the patient will not convert into completely respectable status so first thing is biology of the uh I mean performance status of the patient the age and the ability to tolerate these regimens definitely after the Advent of fall fair enough it has every other combination this is a combination of 5fu ionotechin and oxalate platin with liquid besides gem gems is another regimen that has been effective in poor PS patients mostly PS2 0 to 2 and knocks in zero to one if the patient is a breaka or germline Carrier there is a pal V2 mutation carriers platins do act well in these cases so maybe all three knocks or jumpsuit against a splatin combination would act besides the role of RT is still blurred in this setting there are multiple large styles are ongoing who are looking at the subsequent first chemotherapy followed by chemo radiation and then the effect but till now the data is very blurred we are not very sure not many good data is there so RT is dark right now next slide this is the classical fulfurinox regimen just for new uh junior colleagues these are the recombination this is two weekly uh you don't need to remember the doses but across two weekly uh Paul Theory Knox generally in your given setting we go for two to three Cycles before surgery one thing that I want to uh add right now that is very important after new adjuven chemotherapy we generally go for a repeat Imaging and see a 19.9 and symptom and assessment there are three important things that we are just need to know so after either gems vitamin epic Excel all fall fairy knocks if you feel that there is a significant clinical Improvement there is a significant decrease in CA 99 but on Imaging if you feel that the tumor Remains the Same you should not worry at that time you should not blame it as unreceptable at that time you should go for a diagnostic laparoscopy and see most of the in retrospective series they have shown that although not visible on repeat CT scan or repeat Imaging so post neogen chemotherapy usage you should ask your surgeon or you request them to go for a diagnostic laparoscopy and see for receptability because Imaging is not a uh good modality at that time well I have already mentioned role of radiotherapy is very debatable let's see okay okay um uh I I'll share with you uh uh we were talking about new adjuvant now I'm going I want to ask you about uh the the role of chemotherapy and radiotherapy in unresectable cancer pancreas you're talking about new achievement but is the outcome really bad because many of us when we are faced with this situation we say Okay God nothing else to be done is it really that bad so uh right now in present scenario there as Sir has already mentioned the outcome has improved significantly right now in adjuvant setting the faulty knocks that has just recently published few months back that shows that the overall survival has ranged up to 54 months in comparison to only single agent gems that have been so definitely the survival has improved significantly and that trial also included around 40 50 percent of R1 resections so we are talking about the whole uh this upfront resectable thing even if there is R1 it is okay for now unless we get something bigger this is these are the slides that I have taken from uh for adjuven setting if the patient is up and resected either R1 or r0 as you can see the the previous slide this is the aspect trial uh this is the evolution of aspectral this European group that had compared multiple up to aspect 4 and this is as you can see the curve has consistently improving over the years so we are doing something we are achieving something so it's improving significantly last expect four was gem cap this is the same thing that we are seeing the median overall survival has changed after various trials that is this is the past trials that we can see next slide this is the game changer so Valkyrie knocks that has been effective in metastatic setting the most active regimen we have right now the survival has ended up ranged up to 54 months and you can see the three-year overall survival is around 63 percent in uh if the patient can be is fit enough to tolerate all forms of uh I mean fall Ferry knocks in that so we are improving a lot in that sense now for the unresectable metastatic setting the outcome is bad definitely it is bad but here again the uh the chemotherapy has made some changes the most effective is Paul fairy knocks that is the combination of three major drugs most importantly the problem with Paul perinox is high toxicity one so the performance status the patient acceptable is zero to one you cannot go above one and it has led to a significant Improvement in survival I can see 11.1 months versus 16 months next slide the second most active drug combination isitabin you can see the survival has increased from 8.5 to 6.7 months it is almost two months survival benefit but we have to remember these are poor risk patients who are performance status PS2 so it is still we can give in even those patients who are all the more more uh poorest patients we can give even single engine setup inwards thank you very much uh now uh I think we've run out of time it's ten past one and uh I had promised that I will wind up the panel but I know that I have not been able to tackle that issue of patients with carcinoma of the body and tail so I'd like to Dr shellage to just tell us briefly without the help of individuals uh what would be your approach to a patient who's got a mass in the body of the pancreas or the tail of the pancreas before we go on to the concluding slides yeah so I think you can have the same approach that you have for a pancreatic head cancer uh pancreatic cancer is a bad cancer is accepted whether you are dealing with body head or neck or tail and the clear answer is that if it is resectable disease resected with a radical modular pancreatic or splenectomy with an adequate and a complete lymphadenectomy and you will still get the same figures for five years survival as you get with pancreatic head cancer the problem with pancreatic body tumors is that many of them are in close contact with the Celiac axis and a number of them would be considered to be unresectable because of the fact that there is arterial involvement but that is not always the case thanks to better chemo therapy that we are getting and if you can show me just one of my slides of the intra-operative picture and a CT scan I can wind up in less than a minute that's the one yeah so here just the one before so this just to show you is the hepatic artery the splenic artery a tumor going right down pancreatic body cancer and unresectable locally Advanced but good chemotherapy good fall free knocks good response to treatment and then Radiology telling us that the gastroduodenal was also supplying the liver well next slide what we have done here is that we have divided the pancreatic neck to the right of the portal vein we've resected the Celiac axis that's the crust of the diaphragm the superior mesentric arteries here the divided common hepatic arteries here but the gastroduodenal artery supplied the blood to the liver we were prepared to replace a hepatic artery here so a body tumor which responded well to chemotherapy with good performance status you are able to do a Celiac axis infection so formerly something considered as unreceptable is clearly resectable and the last bit pancreatic tail tumors we have documented our work with ramps and you will get a three year overall survival of 56 and a disease-free survival of about 38 that's all that I would like to say thank you very much thank you very much so we come to the concluding aspect of this webinar where we just deal with a few algorithms and few messages that have emerged from our presentation the first and very important present a message that has emerged is if we are going for an Imaging contrast good contrast and hand CT done with the pancreatic protocol is extremely important in assessing and uh for a decision regarding resectability and receptability is basically a radiological diagnosis and which will be given to us by the Radiologists and this would probably be the algor I'm sure there is no difference of opinion as far as this is concerned starts with the clinical manifestations the dynamic city done with the pancreatic protocol the role of ercp dwindling absolutely the role of psychological and histological diagnosis we have already diagnosed and once we have the stage then of course we need to classify them into resectable or initially unresectable or borderline resectable and then tailor our modality of treatment appropriately all these things we have actually discussed in detail the role of new adjuven therapy and the algorithm for onco therapy in conclusions I would like to say be the pancreatic ductal adenocarcinoma is best managed as an mdp multi-disciplinary team and Dr Raju put it right up front it is important that there should be a open discussion between the Radiologists the surgeon and the gastrologist but the best way forward and also the oncologist advances in imaging have led to Accurate diagnosis and staging when needed endoscope is provide tissue diagnosis and further staging through U.S surgical resection even now is the only chance of cure improved surgical techniques with respect to venous reconstruction has resulted in increased resectability newer chemotherapy protocols with or without radiation have resulted in better survival the strategy however remains palliative new adjuvant therapy in the pre-operative setting is very promising effective pain management and that's something that we could not discuss is very crucial and that's done both by the gastroenterologist as well as the pain and palliative person or the oncologists despite all this bank credit no carcinoma remains a silent killer and we await a biomarker for early detection which is desperately needed thank you very much to all the panelists it was wonderful having been associated with you all of you have been great all of you have been very very clear as far as your messages are concerned very crisp thank you very much ISD for having given us this opportunity and with this it's over to Dr Vivek saraswat to conduct the Q a session uh and as promised the time 1 15. thank you thank you very much Gian could you please uh stop sharing your screen now so that I think I will do that yeah uh I think uh GN has led this whole discussion in an exemplary manner all the focus and the clarity comes if you ask a clear question you get a nice and clear answer thank you GM so I I think we'll uh there have been a few questions and uh some of them probably have been covered but there is no harm reiterating these very important messages so my doctor Anand Gupta from Jaipur wants to know I think repeatedly uh we have talked about a pancreatic protocol City and versus a triple phase City so especially when you're trying to look for second reason the liver and also assess the pancreatic Sol Professor Raju Sharma uh I mean what do you suggest there should be a triple phase or a pancreatic protocol or how should the clinician go about it so sorry you are muted if you could unmute please I think in my view of pancreatic protocol suffices we do a pancreatic phase at 45 seconds and a portal venous phase which is good for liver metastases at 70 seconds from the beginning of injection all the information about the arteries is available on the uh the pancreatic phase as well so there's really no major difference between a triple phase versus a two-phase CT which is taken in the pancreatic phase and the portal venous phase a lot of literature supports this and this is what we follow in our Institute so a pancreatic protocol CT generally will suffice and obviously if there are indeterminate areas and other questions to be answered you've already covered that in your presentation thank you Dr radhushan regarding um CA 99 I think the non-jaundice and jaundice patients its value was mentioned a question was which patients should every patient have it and what should be the timing before or after drainage or before [Music] um taking the patient for surgery it's maybe a quick answer to that one of you yeah so I would just say that uh just before starting off treatment whether it's surgery or chemotherapy a baseline serum ca19-9 hopefully after resolution of jaundice would be reasonably specific and sensitive though it's essentially a non-specific and a non-sensitive marker but it can help both the surgeons and and the medical oncologists to monitor response to treatment in case it is elevated because it's not elevated in all patients right and it helps you in follow-up after resection also oh yes because if it is high in the beginning and then we've done chemotherapy surgery chemotherapy and there is a nice decline you can clearly follow up your patients every four monthly SOS with additional scans and even give them second line of chemotherapy Etc because it can help you in detecting a relapse and so it's good to have a baseline before you start treatment all right um Dr sudeep I think there are a few questions regarding stenting so Dr Bilal Mohammed from Cochin and Dr Avinash tiwadi from Srinagar and a couple of others wanted to know you were emphasizing plastic stents but I think repeatedly I mean there have been mentioned about if people are able to afford uh which Sims covered or bear would be preferable um in case a metal stent is to be used don't uh so we are talking of stenting in two scenarios so one is when we are doing uh standing for the palliative intent and standing for a bridging intent for the person this questions over the pre-operative uh drainage first instance when you're doing it for a pre-operative uh stenting uh for our Center our surgeons prefer there that we provide the plastic stand considering that there are two reasons one basically some surgeons obviously have a difficulty it depends on the exercise saying expertise some people have difficulty doing a surgery when there's already a metal stent in place and there's a reaction around the bile duct and the difficulty as associated with the surgery surgery involved and second most important thing is that if the surgery is planned within a period or within a month then obviously it obvious the need for a re-intervention because plastic stance as we know uh plastic stance can last at least for two months or two plastic stents can be uh can cover the uh can take care of the job when you're talking for palliative intent then obviously it's an uncovered metal stain that you're talking about and in if you're talking about pre-operative if you plan to put a metal stain then should be a fully covered metal stand in any circumstances in a pre-operative setting we would try to put the stand below the cystic duct origin all right and I think my in the setting when you are headed for new adjuven therapy and uh biliary drainage may be required for a longer period of time would be another case before a metal stand yeah that that may be worthwhile we are considering a metal strain at that point but that should be in consultation with the surgical unit concern right thank you uh Dr bhavesh from Lucknow and Dr avinashi from Srinagar uh have a question on new adjuvant chemotherapy which patient should be offered how do you choose patients for new adjuvant and should every resectable patient or only selected patients be offer new adjuvant therapy uh so for new adjuvate chemotherapy the most important thing is the discussion in mdtt if the surgeons are completely comfortable and we classify after discussion with a radiologist and surges that it is borderline deceptible and things are clear then we chemotherapy and the regimens the intensity of that is also dependent on the on the general condition of the patient if the patient is young the general condition is really good because giving half-hearted chemotherapy never helps so you give combination good chemotherapies like quality knocks and some other chemotherapy that is the high efficacy but then that it takes it has high side effects also so the patient has to be young fed individuals the case has to be the on Imaging and on surgical assessment it is this borderline resectable then only we choose that we can go for a new achievement service thank you so basically what you're saying there are two things that have to be seen number one that it is a borderline resectable as discussed between the surgeon and the radiologist for complete evaluation and two the patient has to be fit to tolerate a full dose aggressive new adjuvant therapy course right very true uh well I think maybe um you might want to take this Dr tayu manavan from Chennai wants to know what is the protocol for screening for cancer pancreas in chronic calcific pancreatitis in idiopathic pancreatitis and how do we go about it a very naughty question but well with once you admit that there is a slightly and there is an increased risk we have to suggest ways to tackle it so um the problem uh particularly this is a very relevant question sir because this is the scenario that we face in India patients with early onset idiopathic chronic pancreatitis go on so for a long time and we do not have a particular screening protocol in place primarily because of two reasons there is no very well defined pre-neoplastic lesion that we can identify with the current generation of Imaging Technologies are not a very well validated tumor markers that are available in practice having said this uh a number of Studies have evaluated both ca199 as a tumor marker for uh for chronic for uh pancreatic cancer in the setting of chronic pancreas in fact one study from Chennai in fact had looked at it and showed that if we have a pancreatic head mask whether tumor levels or cn99 levels or more than 127 in the presence of a elevated bilirubin or ductal that's a high probability that the person might be offering a neoplasm other studies also from India have looked at different levels of CA 99 from 300 to 1370 of all these Studies have not been done in a systematic manner having said said this there's a new uh monoclonal antibody which has now uh come in work this is the pam4 and this monoclonal antibody has been shown to be elevated in patients with pancreatic cancer and not in patients with chronic pancreatitis so maybe the future lies in using a combination of cn99 along with Pam 4 to identify neoplastic or prionary plastic lesions in the setting of chronic pancreatitis as because Imaging is concerned we in our Center we keep on doing ultrasounds at six monthly or thing but we know the sensitivity of ultrasound to pick up early lesions is very poor doing an endoscopic ultrasound every year is kind of uh difficult and not feasible so probably we are looking at only using CA 99 and future lies in Tampa make a point size the only comment that I would like to make is yes it's a gray Zone and we know that it's a field defect in chronic pancreatitis Suresh Charis showed us long time ago about the high risk of pancreatic cancer in long-standing chronic pancreatitis I've done some work on this before comparing tropical idiopathic and alcoholic chronic pancreatitis and their progress the only thing which concerns me more in the clinic even now in a place like Tata which is obviously a referral place is a number of patients who have had a head mass in chronic pancreatitis they've been asymptomatic and then they have been treated conservatively because pain has not been there and then a number of these patients have had pancreatic cancer many times a florid situation over which we have had no control so I think Whenever there is a patient of chronic pancreatitis showing signs of developing complications I.E obstruction to the bile duct uh the ductal morphology Etc I would feel that it's important to integrate a surgeon at an early stage in a multi-disciplinary clinic so that we will try and get some patients who can be operated in time or rather than be missing out on long-standing chronic pancreatitis who are dying of pancreatic cancer in the head especially right thank you very much I think is it and does my professor Raju Sharma or maybe GM you would like to have any other comments on this because I would like to ask Dr Raju Sharma in fact uh with the present technology available uh a good pancreatic protocol CT gives us a very good idea and so a good pancreatic protocol CT plus human intelligence should sort out the problem in virtually 95 96 percent of cases do you think do you see any role for artificial intelligence in the near future so there are a lot of Publications that have come in the last one year on AI and pancreatic cancer and people are working on all kinds of things they're working on texture analysis there's a whole new emerging field of radionics which now looks at images as quantitative data rather than just qualitative image for the analysis of the radiologist because there are many things which computer algorithms can pick up in the image which uh which the Radiologists cannot see so there are empty number of studies going on all across the world which are looking at texture analysis of pancreatic cancers to predict prognosis to pick up association with genetic mutations in the Keras gene or in the brca1 and also trying to predict response to chemotherapy so these are interesting times and hopefully in a year or two we'll have data to discuss it's half past one I think we've we've reached the time limit uh so it's back to you Dr Vivek for the final words and where I must I think um Jane has already said it and I cannot uh say in very many different or better words that this has been an outstanding session and each one of the panelists has uh provided very clear and Lucid insights into the areas of therapy or Diagnostics that they were requested to do and I think Ramesh has structured this whole panel discussion very well by articulating very clear and distinct questions so in about 90 minutes we have managed to cover a vast area given you and given all our audience and insight into what is going on and where they may be new developments in the near future although still pancreatic cancer remains one of the most challenging conditions to for the clinician and the entire multimodality team to manage so I'd like to thank each one of you very sincerely for all the hard work put in and for putting this panel discussion together thank you now I think before we close a few as usual a quick couple of housekeeping uh announcements as well as uh to tell you that next Sunday we will be having a panel discussion on the multi-modality management of carcinoma of the esophagus and again we have a very distinguished uh Panel LED by Dr Bhaskar nandi who will be the moderator Dr Amit mayadev will talk to us about and the role of the therapeutic endoscopist and Dr Amit Agarwal medical oncology at the BL Kapoor Hospital Delhi will talk about the role of the oncologist while Dr b k mohanti who's the director of the Kim's Cancer Center in bhubaneswar Orissa will talk to us about radiotherapy we will also have Dr swagata sen and Dr C.S promise for Imaging and Surgical Oncology from the Tata Medical Center as well as startup Medical hospital so another exciting panel discussion to look forward to next Sunday now as you all know the isg annual conference is uh uh coming up in November and abstracts we are happy to announce that a very large number about 390 almost 400 abstracts have been received this year which is in excess of what we actually used to get in non-lockdown years so in a way I think lockdown has helped more people to get their work together and to submitted for ISD so we look forward to a very um good uh meeting in Pune in December also the isg elections have been announced then all of those of you who are interested are requested to uh look at the announcement and send in your papers to Dr Rakesh kocher at PGI Chandigarh so um with these few announcements I'd also like to thank the sponsors who have helped us to bring this session Lupine Pharmaceuticals as well as our facilitators in the background whom you don't see you don't hear but they make this happen Mr Dinesh who's been providing technical assistance for this transmission and uh yogita from the isg Secretariat who does all the coordination work thank you all very much thank you once again to all the panelists and especially to ugn and with this I'd like to uh say bye bye till the next Sunday when hopefully we'll all uh get to participate in the next panel discussion thank you bye-bye thank you very much thank you very much