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

Thank you for your questions. I would defer your question regarding systemic therapy and NED to one of our medical oncologists, as there are many factors they consider as to whether to continue chemotherapy or switch to surveillance imaging. With regards to radiation therapy, we tend to use this both as a treatment for unresectable tumors as well as a way to kill tumors and ensure a negative margin at surgery. I have not seen any research that shows it may awaken dormant cancer cells.

I am glad you are doing well after surgery. In general, every patient is different, and each tumor has its own biology that requires individualized treatment. I usually recommend to my patients with tumors in the pancreas, bile duct, or ampulla that surgery alone is not curative; treatment usually requires a combination of surgery (to remove the tumor where it is and sample lymph nodes) and chemotherapy to prevent the tumor from coming back. Patients with the best survival are mainly those treated with both chemotherapy and surgery. While I cannot speak to the exact reason that radiation was recommended after your operation, we tend to reserve these for patients with tumor that has been left behind (a positive margin). However, this also requires an individualized discussion with a radiation oncologist. If there is any uncertainty about the plan, I never hesitate to have a patient get a second opinion (whether it is about surgery, chemotherapy, or radiation).

There are many factors that go into a decision to remove the entire pancreas. In general, it is rarely done for pancreas adenocarcinoma when we are able to do a Whipple or a distal pancreatectomy. Mainly, this is because the vast majority of recurrences are not within the pancreas, but are to distant organs such as the liver or lungs. Removing the whole pancreas does not seem to prevent this. For cases of cancer, we do not preserve the spleen, as there are important lymph nodes near the spleen that need to be removed to properly "stage" the cancer. We will rarely preserve the spleen for pre-cancerous lesions or certain types of neuroendocrine cancers, but this also depends on many patient factors.

It is important to understand that surgical margins are not always assessed at the time of surgery at many cancer centers; there are studies that are often debated in the surgical community which do not show a difference in recurrence due to a positive margin. It is very surgeon-specific. At Mayo Clinic, we do assess margins in the operating room as we feel it is important to ensure all the cancer has been removed. This is done as a frozen assessment, and it is done by review by a trained pathologist looking at the margins. This is highly accurate but not always perfect and may change when the final pathology is determined 3-5 days after surgery. This has also been looked at extensively in the literature. However, as previously mentioned, most patients recur with disease outside of the pancreas, likely due to small cancer cells that had already been released into the blood stream before surgery. This is why chemotherapy is such an important part of treatment for pancreatic adenocarcinoma, whether or not a patient has surgery. This is also why some centers do not check intraoperative margins – it is not clearly known if disease that is left behind contributes to distant recurrence.

I tell all of my patients that the best chance of cure and long-term survival is with a combination of surgery and chemotherapy. Surgery is needed to remove all of the tumor with clear margins, and chemotherapy to treat microscopic disease that may be in the blood stream and prevent it from coming back. The difficult thing about pancreas cancer is that it is often the biology of a specific tumor that drives its aggressiveness; a patient can have a clean operation (all margins negative), and it can still come back in a distant organ. This is why chemotherapy is so important – it is not a local recurrence that tends to lead to low survival, but disease that goes to the liver or other organs. With regards to digestion after surgery, it depends on the type of operation. Tumors that are removed with a distal pancreatectomy or splenectomy do not involve any bowel resection, and I expect my patients to have normal eating habits 2-3 months after surgery. With a Whipple, there is a re-plumbing of the bowel. For this reason, some patients may lose weight after surgery, but after 2-3 months I expect patients to get back to normal with eating and maintain their weight. However, most may need to stay on small, frequent meals throughout the day.

I am sorry to hear about your disease. I unfortunately am unable to comment on this, given there are many factors that go into a surgeon's decision to operate for peritoneal tumors.

I'm sorry to learn of your diagnosis. Unfortunately, we're not able to provide personalized medical advice in this type of public forum. All patients and tumors are different with respect to their response to chemotherapy, and thus how we may or may not approach them surgically. However, we wish you the best in your care journey.

A pylorus-preserving Whipple preserves the entire stomach, while the traditional Whipple takes a small piece of the stomach. There are different reasons why each are performed, and it is often related to the location of your tumor and other factors. It is a good discussion to have with your surgeon if you are discussing a possible Whipple operation.

And if for some reason I needed an emergency appendectomy, I would not get one?

I understand.