I'm not a doctor, but I'm voting on surgery first at MSKCC as long as you are committed to doing adjuvant chemo (and radiation if recommended) afterward.

There are a lot of nuances to consider, but in a nutshell, I look at it this way: Surgical removal is the only reliable cure for pancreatic cancer, but the catch is that you have to remove 100% of it, or remove enough that chemotherapy has a chance to kill the rest. However, chemo rarely kills 100% of whatever cancer remains in your body, even if it's at undetectable microscopic levels.

I vote for treating the cancer you KNOW exists first with a method that you KNOW "cures" it it over treating cancer that MIGHT be there (elsewhere) with a method (chemo) that MIGHT cure it.

There's a definite chance your cancer could spread while you're doing chemo before surgery. Surgeons want you off chemo (another chance for cancer to spread) for 4 weeks before surgery, and this is already longer than the 3 weeks your MSKCC surgeon has you scheduled to wait. After surgery, you may have to wait 4-8 weeks to heal before starting chemo, which is still another chance for anything that remains to spread.

You also mentioned the inconclusive biopsy. That means they don't know specifically what type of cancer it is (if any) and thus don't know what the most appropriate chemo regimen for it would be.

You are young, fit, and going to a reputable center of excellence, so that odds are that you will survive the surgery just fine and recover well enough soon enough to tolerate and benefit from adjuvant chemo.

Your relatively low CA19-9 level is a good indicator the cancer is not yet advanced. It may be of limited benefit, but you could consider requesting a PET scan prior to your surgery. On the plus side, it might reveal any disqualifying metastases, possibly give the surgeon new anatomical insights, and maybe resolve some of the ambiguity from your biopsy. A potential negative is that any remaining inflammation from your biopsy might register false positive uptake on the PET.

For background education, I always recommend these two 10-minute videos debating the subject of chemo first or surgery first:

There's some more recent follow-up out there, including this longer one with Dr. Katz moderating (and quizzing the other participants):

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Context for my comments:

I was also healthy (casual triathlete) and fairly young (58) at diagnosis of stage-2 PDAC in the pancreas head. My team (at a center of excellence) recommended TNT ("Total Neoadjuvant Therapy) which consisted of 6 months (12 bi-weekly infusions of Folfirinox) before Whipple, and no therapy afterward. Cancer returned in the original surgical bed less than 4 months after Whipple, and had turned into Stage-4 before I was able to begin treatment. I was not happy or impressed with this approach.

The six months of pre-op chemo did nothing for the size of my tumor or my CA19-9, and seems to have been a waste of time. I'm just a sample of one, but that's my experience and rationale for my comments.

Wishing you all the best.