Primary Resectable Tumors
Primary resectable tumors are usually smaller lesions with no involvement of surrounding vital structures and are usually taken straight to surgery. These tumors are further staged after surgery by the surgeon and pathologist. Postoperative treatment is utilized after individual evaluation of each case following currently available treatment guidelines. This could include adjuvant chemotherapy radiation therapy or both. We let patients recover from surgery for a few weeks prior to starting adjuvant therapies. Determination of a tumor being primary resectable or locally advanced is done based on clinical staging following review of imaging/endoscopic studies in tumor board. Clinical staging is not as accurate as pathological staging, but patients can only have pathological staging after definitive surgery.
Locally Advanced Tumors
Locally advanced tumors are frequently more advanced in stage and they can be in close proximity or actually involve vital structures.
Following current trends and advancements in the treatment of locally advanced or marginally resectable GI malignancies, we frequently use a combination of various therapies together to achieve the best results and longest possible survival. This sometimes means the use of chemotherapy, radiation therapy or both prior to a surgical intervention. This is called neoadjuvant therapy that is well described in the surgical and oncologic literature.
Upfront treatment of certain larger tumors or locally advanced malignancies frequently results in downstaging of the tumor. Downstaging can convert inoperable tumors to operable tumors, or more extensive operations to less extensive surgeries. Neoadjuvant therapy is most commonly used in locally advanced pancreatic tumors and large primary or secondary liver malignancies. Specific indications are always discussed with the patient as part of the global treatment plan with all associated risk and benefits on an individual basis.
Occasionally additional interventions maybe necessary before a neoadjuvant treatment is started. For example, patient presenting with jaundice need the biliary tree adequately drained to make neoadjuvant therapy safer. Most of the time this can be accomplished via internal stenting of the bile duct. Sometimes percutaneous/external drainage of the biliary tree is necessary. All these decision are made on an individual basis.
Once a decision is made to use neoadjuvant therapy, treatment is started within days. After several weeks (8-12) of treatment, additional imaging studies are obtained to determine response of the tumor to the therapy used. This is called restaging. These restaging studies are reviewed in our multidisciplinary tumor board and decision is made about additional cycles of neoadjuvant therapy, possible radiation therapy, possible surgery, or switching to palliative intent chemo therapy.
Sometimes, patients need additional interventions prior to major liver surgery. This could be targeted treatment of the liver with chemotherapy particles (TACE or transarterial chemoembolization for primary liver cancer), or other intervention (portal vein embolization) to grow the side of the liver our surgeons are intending to leave behind. Our interventional radiologists have extensive experience with these procedures and are always part of the decision making process during multidisciplinary tumor boards.