Pancreatic Cancer Surgery Q&A July 21-25 w/ Dr. Poruk, Mayo Clinic

Thanks to moderators for setting this up and to all the docs for participating!

For Dr. Poruk:

Same question I posed to Dr. Stauffer in his discussion ( https://connect.mayoclinic.org/discussion/pancreatic-cancer-qa-with-dr-stauffer-mayo-surgeon-may-29/ ) which was inspired by a paper you co-authored in 2016 ( https://pubmed.ncbi.nlm.nih.gov/27215900/ ):

"Given the high rate of recurrence after Whipple, what are your latest thoughts on total pancreatectomy, especially for younger PDAC patients or patients with mutations predisposing them to more PDAC development?"

What are the other major concerns beyond lifetime enzyme and insulin dependence, which a patient may already have?

Also, how difficult is it to preserve a spleen when doing a distal or total pancreatectomy?

Can you describe how the intraoperative pathology is performed during a Whipple procedure to determine if margins are clear or if another cut is needed?

e.g., is it purely microscope-driven, human examination of cells, or is there any kind of machine/scanner assistance? What advancements are being made to help surgeons know when they've made enough cuts to eliminate recurrence?

Are recurrences at the surgical site typically the result of overlooked cancer cells at the boundary, cancer cells that were already present deeper in the remnant pancreas, cancer stem cells that later developed or differentiated their way into mature cancer cells, or something else?

Can you please elaborate on the differences between a pylorus-preserving Whipple and a traditional Whipple?

Perspectives of interest are on difficulty getting clean margins vs chance of recurrence, and patient outcome regarding a return to normal digestion and bowel function.

Thank you again for addressing any of the above and for all your work and dedication fighting this disease!

Recently discovered the largest of my peritoneal nodules, 1.5cm is abutting the appendix. Does it make sense to do a very noninvasive removal of appendix or portion of the appendix to get rid of that nodule to avoid it actually invading the appendix given the risk of potential "seeding"?

When/where will the answers to our questions be posted? I hope I haven’t missed a webinar or zoom!

Maybe sometime after 9am, today. That's the posted deadline to get your questions in. That's ET time.

Th risk to benefit far outweighs a total pancreatectomy. The vast majority of progression is not from a new primary developing in the remnant pancreas or not having an RO margin, it is because there is micrometastatic disease that has already occurred and undetectable by conventional imaging methods. Doing a complete pancreatectomy will do nothing about micrometastatic disease. I cases where there is certain germline mutations that are associated with repeated development of new primary cancers making a family member diagnosed with pancreatic cancer an extreme risk to develop a new primary, then a surgeon would entertain that possibility of removing the entire pancreas vs waiting and frequent surveillance.

Hello doctor, I was diagnosed in August 2023 and underwent 12 cycles of Folfirinox and 3 months of gemcitabine chemotherapy. The liver metastases were eliminated with ablation surgery.
Today, the cancer has metastasized to the liver again.
I have no pain, I haven't lost weight, and my daily life continues as usual. My doctor said that your pancreatic cancer does not follow the textbook. The tumor in the pancreas and liver will be removed through surgery. What is your opinion on this? Is it worth trying?

Translated with DeepL.com (free version)

The best treatment for any pancreas adenocarcinoma that has spread is chemotherapy. This is because chemotherapy will treat all the sites of disease. This is true for liver metastases, lung metastases, and peritoneal disease. Surgery is rarely an option, and for a highly specialized center to consider it, there must be stability of the disease after at least 9 to 12 months of chemotherapy. Rarely, a patient may be considered for surgery with peritoneal disease, but this is in the setting of a clinical trial currently offered at the Mayo Clinic, based on specific guidelines and very little metastatic disease.

I am sorry to hear about your wife's diagnosis. The best treatment for any pancreas cancer that has spread is chemotherapy. We rarely offer surgery to patients with disease outside of the pancreas, although we will consider this in selected patients. This is usually a patient who has very small volume liver disease (1 - 3 small lesions that can also be treated) that has been stable or has disappeared on 9-12 months of chemotherapy. I would encourage your wife to continue with chemotherapy and, depending on how she responds, she could be evaluated in the future to see if surgery may be an option.