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Aimee: Welcome to the Oncology Sound Byte, a podcast produced by the Seattle Cancer Care Alliance designed to offer bite-sized audible oncology education from one of the top cancer treatment centers in the nation. I'm your host, Aimee Martin, a senior physician liaison at the Seattle Cancer Care Alliance.

During this episode, we will focus on a new cutting-edge procedure for pancreatic cancer patients. With us is the SCCA pancreatic surgeon who performed the very first Appleby procedure at UW Medicine earlier this year, Dr. Jonathan Sham. Welcome to the show.

Dr Jonathan Sham: Thanks so much for having me,  

Aimee: It's great to have you with us. I wanted to jump right in with my first question. Really just to start us off, what is the state of pancreatic cancer therapy?

Dr Jonathan Sham: You know, obviously, when people hear the term pancreas cancer, it sends a chill up their spine, because it's a scary diagnosis. but the good news is we have made a lot of headway, over the past five to 10 years. You know, I can remember, when I was in training during my residency, we would always talk to patients about survival, after surgery, somewhere in the 10 to 20% range at five years. And now we're talking to patients about, survivals in the 40 to 50% range after surgery, when it's combined with modern chemotherapies.

So while it is a scary diagnosis, and we still have, a lot of room improve, things are getting better and that, is because our chemotherapies are getting better. We're doing a better job at selecting which patients will benefit from aggressive therapies. And quite frankly, our surgeries are getting better. we're able to perform surgeries, more safely, with fewer complications, getting patients out of the hospital more quickly, and really improving their quality of life much more rapidly. And so, I'd say, while, there are still challenges and hurdles ahead, I'd say this is one of the most exciting times to be, practicing in this space.

Aimee: That's fantastic to hear. Really promising. And in that regard, I know that one of those latest advancements to the field is the Appleby procedure. And I'm curious if you could shed light on that and also let us know who can benefit from it.

Dr Jonathan Sham: Absolutely. So the Appleby procedure was actually a, surgery devised by Dr. Lyon Appleby, who was a Canadian surgeon, back in the fifties, who devised it for actually locally advanced gastric cancer. These were tumors that had grown out of the back of the stomach, into the pancreas, and into the celiac access to the main blood supply into the upper abdomen.

And essentially this involves, a total gastrectomy, so we're moving the entire stomach; distal pancreatectomy and splenectomy and removal of that celiac axis. and was almost, kind of like a procedure before its time because, while it, successfully could remove many tumors, obviously chemotherapies were not advanced enough at the time to really support, long-term survival, by treating the micrometastatic disease. And so it really fell to the wayside, for decades.

and so probably, you know, in the last. 10 years or so, pancreas surgeons have kind of, adopted this and perform what's called a modified Appleby procedure. So we leave the stomach alone, but we do remove, half of the pancreas, the spleen and the, celiac axis, which again, supplies blood to the stomach and liver, primarily, in a way to remove, cancers.

And again, early on, even 10 years ago, when our chemotherapies weren't quite as good for pancreas cancer, this didn't really make much sense because we might be able to remove, the tumor, but the cancer would come right back in six months or a year or two years. Now that we're having more and more effective chemotherapies, it really justifies a more aggressive surgical approach and, justifies us taking out the celiac and putting patients through a big operation because we're seeing, pretty impressive survivals long-term.

now you might ask, "Well, how does the liver and other organs, how do they receive their blood, after this procedure if we're taking out the celiac? Because you know, we're taught in anatomy class that it's a really important blood vessel." Well, it turns out that in the pancreatic head, there's a lot of collateralized blood flow. And so we have small vessels from the SMA or superior mesenteric artery that create collaterals naturally, through the pancreatic head into the GDA or gastroduodenal artery.

And so it's pretty amazing. during surgery, we'll clamp the celiac and we'll clamp the distal common hepatic artery. And we'll wait for just a couple of seconds and pretty universally, we'll see blood flow switch directions. And so instead of going, from cranial to caudal in the GDA, it'll switch and the blood flow will go from caudal to cranial, from the SMA through the GDA and then up into the liver. And this also supplies the stomach through either the right gastric or right gastroepiploic artery depending on the situation.

And so, yeah, this is essentially giving patients who previously have been told that either surgery wasn't possible, or would be too dangerous, other options. and again, as evidenced by our first patient that we performed at the SCCA UW, who's now, eight months out, with no evidence of disease, and doing great.

Aimee: Oh, that's so great to hear. How promising. That's really exciting. And Dr. Sham, for those providers that have a pancreatic cancer patient, how do they know who qualifies for this procedure?

Dr Jonathan Sham: Sure. Well, I'll be very clear that this, is a clinical decision made in the context of a really specialized multidisciplinary team at the SCCA. So this is not something that just surgeons decide alone or, you know, a medical oncologists decide alone. It really is we team approach. And so, at the SSCA, we have, really experienced multidisciplinary team comprised of medical oncologists, surgeons, radiation-oncologists, and then pathologists and radiologists who participate in the conference as well. And so obviously, we're happy to see anyone, who, you might think, could benefit, from this advanced care.

With that being said, sometimes I realize particularly for patients who aren't in the immediate Seattle area, or perhaps don't want to go through the hassle of kind of getting a more formal, evaluation, we actually have a mechanism where we can perform a rapid review of cases. And so, group has actually rolled out a rapid eConsult program where if you send us an email, I think it's HPBconsult@uw.com. And there's a phone number that I don't remember off the top of my head, but I'm sure we can post that. if you just email that or call that number, one of our surgeons, so not a scheduler, not a nurse, one of our actual surgeons will look at and look at the case, look at the images if available, even zoom with you if you'd like, over the computer. And within 24 hours, we'll get back to you, to let you know whether or not we think that it's even worth sending a formal referral obviously we know that, sometimes it's just a lot of work and effort, both on the part of the physician, but also the patient to go through that formal consultation process. So we wanted to make sure that we offered kind of a quick, rapid and easy way to get in touch with us. Kind of like just calling us up on our cell phone. And again, we'll happily give our cell phone numbers out to anyone who'd like it, to see, again if we can get patients where they need to be for the appropriate care.

Aimee: That's fantastic. That's really great. That is a great service that you offer for those that are looking to explore their options. So really appreciate that information. I'm just curious, because I know that you'd mentioned you have performed the procedure on one patient, do you have any immediate plans for future procedures?

Dr Jonathan Sham: Yeah, to clarify, a little bit more about the process. So all of these patients who undergo or candidates for Appleby procedure, they need chemotherapy first. And that usually looks like four to six months of a multimodal chemotherapy prior to the operation. And the reason for this is we really want to test the biology of the tumor. So we know that, tumors that progress on chemotherapy, those patients aren't great candidates for the procedure, because if they progressed on chemotherapy, even if we can get it out, the tumor that is, it's much more likely that those patients recur after surgery.

And so we kind of perform this biologic test by giving the patients again, four to six months of neoadjuvant chemotherapy. And then at that point, we make a determination. "Okay, how do they look? What's their physical status? How are their tumor markers doing? What does the imaging look like?" And then come to a consensus as a group whether or not we think they are a good candidate. And so we actually have three or four patients right now who are in that pre-surgery chemotherapy process. over the next one to three months, they'll be ending that, and then we'll kind of reevaluate and, see if it's the right thing for those patients. And so, I wouldn't say this is a super common procedure only because oftentimes, these cancers just can't be resected because they're either involving too many, blood vessels or more commonly they've spread to distant sites.

So if a patient has a locally advanced tumor, and then during chemotherapy, develops some metastasis say in the liver or the lungs, we know that surgery is probably not going to help that patient either. And so again, it's all about selecting the right patients who can benefit from this aggressive surgical approach.

Aimee: Wow! Really promising news on the pancreatic cancer front. Dr. Sham, thank you so much for joining me today and thanks to our listeners for tuning in to the Oncology Sound Byte. To hear more, subscribe to the Oncology Sound Byte in your favorite podcast app, and to updates on our future podcast episodes along with other news out of SCCA, go to SeattleCCA.org/providerblog and click subscribe. Until next time. Thanks for listening and take good care.