Pruett Professor of Surgery, Section of Hepatobiliary-Pancreatic and Gastrointestinal Surgery, Washington University School of Medicine.
University Of Toronto
University Of Toronto
Toronto General Hospital
Areas of expertise: Biliary Surgery Hepatobiliary Pancreatic Cancer General Surgery Gallbladder Surgery Hepatobiliary Surgery Pancreatic Cancer Gastrointestinal Surgery Pancreatic Surgery Liver Surgery Gastrointestinal Oncology Hepatobiliary Pancreatic (HPB) Surgery
Washington University School of Medicine
GI Center 4921 Parkview Place, C, 8
St. Louis, MO
In a patient who has not had any imaging studies the clinical stage of the cancer will be established by a specialized CT scan or MRI of the abdomen which provides very detailed images of the pancreas at various phases of blood flow. Xrays of the chest will also be obtained as well as standard blood chemistry and a tumor marker for pancreas cancer called CA19-9. In some cases that is all that is needed to proceed to surgical resection of the tumor. When there is doubt about the diagnosis a biopsy may be needed. This is done by endoscopic ultrasound which is performed by a biliary endoscopist. An endoscope will be placed into the stomach and using ultrasound the whole pancreas may be seen and biopsied with a fine needle. The EUS will also provide useful imaging which may help surgical decision making. The surgeon will be using all of these tests to answer the questions described under point 3. In some patients who have become jaundiced it may be advisable to place a stent (a little tube) in the bile duct so the jaundice recedes prior to surgery. This is also done by endoscopy and is called ERCP.
In addition to these pancreatic cancer specific tests the surgeon may wish to do tests which are related to assessing co-morbidities such as heart or lung disease. For example a patient may be asked to undergo a cardiac stress test. This type of testing is done in conjunction with anesthesiologists who will be in charge of the anesthesia during the operation and also in conjunction with the patient’s own doctors
It is common for pancreatic cancer to spread to the lymph nodes around the pancreas. These nodes are removed as part of the surgical procedure. In some cases nodes are involved that are beyond the extent of the usual surgical procedures. When such lymph nodes become enlarged they may often be seen on imaging tests such as CT, MRI or endoscopic ultrasound and biopsies of such nodes may be performed. If cancer showed up in such distant nodes then surgical resection of the pancreas would not usually be performed at the present time. Biopsies are not usually done when the lymph nodes are within the scope of the surgical procedure as they will be removed with the procedure. However, after the cancer is removed each node is studied under the microscope to determine if there is cancer in the lymph node. This information is used to determine the pathological stage of the disease.
There are several things that help both the patient and the surgeon. First the patient should eat a healthy diet. In some cases pancreatic enzyme replacement may help with this. Next the patient should exercise daily. Walking is the best exercise and should be done for at least 20 minutes daily if possible. We also teach patients how to do breathing exercises using an Incentive Spirometer. This provides them will familiarity with this equipment, which they will also use in the postoperative period to expand their lungs and prevent pneumonia. Smokers should stop smoking immediately and completely and receive drugs to help with this is necessary.
It’s really the surgeon’s job to look for complications. All patients are on a care path and are followed carefully for deviations from the path. Patients are seen 2-3 times per day in the postoperative period by the surgeon, his colleagues or assistants. Very serious complications are unusual these days if the surgery is performed in high volume centers by experienced surgeons. When they occur they are usually related to infection, leakage from places that the intestine has been sewn to the pancreas, or bleeding.
Palliative surgery is performed in some cases for jaundice or intestinal obstruction. Jaundice is usually treated by a stent – surgery is not usually needed for this problem. Intestinal obstruction can sometimes also be treated with an intestinal stent. Sometimes cancer spread beyond the scope of the cancer operation is found only after the operation is started. Fortunately this is much less common today than it was in the past. However when this occurs a palliative operation to eliminate jaundice and intestinal obstruction will usually be done.
Pancreatic cancer is a very specialized area and patients are best treated at a high volume tertiary care center. These are usually NIH Designated Comprehensive Cancer Centers of which there are more than 20 in the USA such as the Siteman Cancer Center at Washington University in St Louis. These centers are highly experienced in treatment of all phases of this disease. Once the management plan is formulated it may be possible to administer some parts of the treatment closer to home for those patients who live distant from the cancer center. It is wise to remember that there are several types of pancreatic cancer and the management and outcome is dependent on the type. The subsequent responses will be in regard to the common type of pancreatic cancer called Adenocarcinoma of the Pancreas or Ductal Adenocarcinoma of the pancreas.
At the cancer center the patient will be evaluated by a multidisciplinary team consisting of surgeon, medical oncologist, gastroenterologist and radiologist. Diagnosis and the clinical stage of the disease will be determined and an appropriate management plan will be initiated.
Pancreatic cancers may be divided into those that are local, regional or systemic.
Patients who have local cancers are in the best situation for surgical excision of the cancer by standard surgical procedures such as the Whipple procedure (cancers of the head of the pancreas) or the RAMPS procedure (cancer of the body and tail of the pancreas. Cancers which are local can be removed by these procedures without any prior chemotherapy of radiation.
Regional spread of cancer may occur in the tissues around the pancreas. Depending on the site of spread the cancers may be immediately resectable or not. Those which are not are often referred to as borderline. Such cancers may sometimes be converted into a resectable type (meaning one which can be removed by surgery) by the use of chemotherapy with or without radiation therapy. This is often referred to as downsizing the cancer. Downsizing has become more successful in recent years.
Cancers which have become systemic have spread to sites distant form the pancreas such as the liver and the lung. Such patient are rarely eligible for surgical treatments aimed at cure although on occasion may be helped by palliative procedures.
Patients will see a surgeon early on when the disease is local or regional.
The patient and family will meet the surgeon and establish a working relationship. The surgeon will go over the history of the disease and examine the patient as well as the record of tests and X-rays a review the X-rays that have been done before coming to the Comprehensive Cancer center. The surgeon is seeking to answer several questions. Is the diagnosis correct? Is the clinical stage of the cancer such that it can be removed presently? If the answer to the last question is in the negative then the surgeon will ask what aspect of the spread of the cancer needs to be treated so that the cancer can be removed at a later date. Based upon the answers to these questions the surgeon will initiate testing or advise the patient to proceed to surgery.
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