Episode # 3 • 17 Jan 2025
Perioperative Management of Pancreatic Cancer
Most patients with localized pancreatic cancer already have disease the scans cannot see, which is why these GI oncologists treat chemotherapy before surgery as a test of tumor biology.
On this episode of the BackTable GI Oncology Creator Weekend™, medical oncologist Dr. Andrew Hendifar leads a tumor board with GI medical oncologists Dr. Arsen Osipov and Dr. Daniel Ahn on the perioperative management of pancreatic cancer. They explain why nearly every patient with localized disease now starts with chemotherapy rather than surgery, which red flags such as an elevated CA 19-9, enlarged lymph nodes, or profound weight loss point to hidden micrometastatic disease, and why an 80-year-old can still be a candidate for FOLFIRINOX when biological age outweighs chronological age.
Timestamps
00:00 - Introduction
01:11 - Workup and Resectability in Localized Pancreatic Cancer
05:14 - Upfront Surgery and Screening High-Risk Patients
09:04 - Choosing and Timing Neoadjuvant Chemotherapy
13:20 - Adjuvant Chemotherapy and Pathologic Response
17:32 - Supportive Care, Prehabilitation, and Community Practice
22:14 - RAS Inhibitors in the Adjuvant Setting
26:04 - Circulating Tumor DNA (ctDNA) Surveillance
28:56 - Case: Locally Advanced Pancreatic Cancer
34:32 - Closing Remarks
Resources
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More about this episode
The conversation moves through restaging every two months, why about four months of chemotherapy before surgery has become the norm with the rest of six months given afterward, and why a poor pathologic response rarely prompts a change in regimen. Dr. Osipov and Dr. Ahn make the case for early dietitian involvement, pancreatic enzyme replacement, and prehabilitation, share practical advice for community oncologists, and discuss the RASolute 304 trial of an adjuvant RAS inhibitor, the open question of resistance, and where circulating tumor DNA does and does not guide decisions. They close with a case of locally advanced disease encasing the superior mesenteric artery, treated with modified FOLFIRINOX and then radiation, in a patient now about a year and a half past radiation and doing well.
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