(Locally Advanced and Borderline Resectable Pancreatic Cancers)
Pancreatic Cancers often grow into the tissues adjacent to the pancreas. The location of the pancreas deep within the abdomen places the pancreas close to major blood vessels (see “Where is the pancreas?” post). Pancreatic cancers that invade into these blood vessels pose a significant surgical problem and in some cases may even preclude surgery. Pancreatic cancers that invade these nearby vessels (called the celiac artery, the portal vein, and the superior mesenteric artery and vein) are referred to as either “border-line resectable” or “locally advanced”. Pancreatic cancers in these categories are challenging to treat. Despite this aggressive feature, some patients in this situation will be able to undergo surgery and have their cancer removed, while others will be treated with chemotherapy or chemoradiotherapy (“radiation therapy”). To complicate matters, other patients will have surgery, but only after undergoing chemoradiotherapy first. The bottom line is that in order to deliver the most effective treatment for these patients with pancreatic cancer a cooperative effort of a team of cancer experts is required. We have found that this is best accomplished through a multidisciplinary clinic where patients are evaluated by all of the specialists in a single day. As a result, the first-ever and most successful Pancreatic Cancer Multidisciplinary Clinic was developed at Johns Hopkins. If you would like to learn more about this clinic please feel free to contact us at 410-933-PANC. We will be able to answer your questions and schedule a clinic appointment for you at your request.
One of the most important steps in determining the best treatment for someone with locally invasive pancreatic cancer is a high quality imaging study. At Johns Hopkins we perform a computerized tomography scan (aka “CT scan”) using a cutting edge 64 or 128 slice CT scanner. Information obtained from this CT scanner allows us to view the cancer and its relationship to nearby blood vessels from numerous angles and even in three-dimensions. These images are reviewed in our multidisciplinary conference. This portion of the discussion is lead by the world’s leading expert on pancreatic CT imaging, Dr. Elliot Fishman.
The CT images are reviewed by the team in order to determine if surgery is possible. In the absence of metastatic disease this is determined by assessing the relationship of the tumor to vessels as follows. There are two main arteries and one main venous system near the head, neck and body of the pancreas. The main arteries are called the celiac artery and the superior mesenteric artery. The venous system is the portal vein and its tributaries (superior mesenteric vein, splenic vein). Cancer invasion into arteries and veins is handled differently. Cancers that are found to significantly involve the artery on CT scan (“encasement”) are typically not operable. Although it may be technically possible to remove these cancers, the complications of doing so and the side effects of this procedure outweigh any potential benefits. Moreover, removal of such cancers under these circumstances often leaves a portion of the cancer behind (R2 resection) and thus the surgery may confer no survival benefit while potentially subjecting the person to debilitating side effects.
Unlike arteries, isolated involvement of the portal and/or superior mesenteric vein does not rule out tumor removal – although it does make the operation more complex. If the cancer involves the vein but not the artery, and it is technically possible to reconstruct the vein, these cancers can be surgically removed with long-term survival similar to pancreatic cancer not involving vessels. There are numerous exceptions to this general algorithm based on the individual patient and their cancer. In addition, select patients may benefit from chemoradiotherapy (“radiation therapy”) prior to surgery. The complexity of the many treatment options underscores the need to be evaluated by an experienced team of specialists.
Surgery for the removal of cancers that involve main vessels should only be attempted by surgeons experienced in pancreatic resections. The team of surgeons at Johns Hopkins perform more pancreatic resections than any other group in the country. Our team has extensive experience in performing vein resection and reconstruction for the removal of locally aggressive pancreatic cancers. We are confident in our ability to perform these operations and have recently published our results (PMID: 19394156). We reported that patients undergoing vein resection and reconstruction for the removal of locally aggressive pancreatic cancers here at Johns Hopkins had a very low risk of operative-related death and a similar rate of complications to a pancreatic operation without a vein resection. Most importantly the long-term survival of patients undergoing a portal vein or superior mesenteric vein resection with reconstruction was no different than those who did not require this procedure and underwent a standard operation.
Our team has four surgeons with expertise in pancreatic surgery for patients in whom their cancer involves the portal veins and/or superior mesenteric vein: John L. Cameron, MD, FACS, Barish H. Edil, MD, FACS, Richard D. Schulick, MD, FACS and Christopher L. Wolfgang, MD, PhD, FACS. If you have been told you have a pancreatic cancer that involves blood vessels and would like to be evaluated by the Johns Hopkins Multidisciplinary Team please call our schedulers at 410-933-PANC.