When a patient with a suspected pancreas cancer comes to our multi-disciplinary clinic, to determine whether the disease is surgically resectable, we try to answer the following four questions:
What is the location of the pancreas cancer (head, body, or tail)?
The location of the pancreas cancer, as visualized by CT scan, will determine the type of the operation.
Cancers of the head of the pancreas may be surgically removable with a pancreaticoduodenectomy or Whipple operation.
Cancers of the body or tail of the pancreas may be surgically removable with a distal pancreatectomy. In removing the body and tail of the pancreas, we often also remove the spleen, because of the very close contact of the two organs, and to better remove the lymph nodes between the two organs. In selected cases tumors in the body or tail of the pancreas may be removed using minimally invasive approaches such as laparoscopic pancreatectomy.
Is the cancer growing into any of the major blood vessels running by the pancreas that would make the removal of the tumor dangerous or impossible?
Typically we use our high definition three-dimensional CT scan to determine whether the cancer is growing into any of the major blood vessels running by the pancreas. In many cases, it is extremely important that these images are obtained on 64 or 32 detector CT machines. These cutting-edge imaging machines are available at Johns Hopkins. Images obtained on 16 or 8 detector machines are significantly inferior in quality.
Specifically, the major blood vessels we examine are the portal vein/superior mesenteric vein (drains blood from the intestines to the liver), superior mesenteric artery (supplies blood from the heart to the intestines), and the hepatic artery (supplies blood from the heart to the liver). If there is significant involvement of any of these major blood vessels, the pancreas cancer may not be surgically removable (unresectable). In these instances the cancer is best treated medically.
Does the pancreas cancer show evidence of spread to other organs/areas?
We often determine whether the pancreas cancer has spread (metastasized) to other organs/areas by looking at the CT scan. The organs/areas that we sometimes see evidence of spread are the surrounding lymph nodes, liver, abdominal cavity, and lungs. These suspicious areas show up as abnormal spots that we do not normally see in those locations. If there is evidence of disease spread to surrounding lymph nodes, many times the disease can still be surgically removed.
However, if there is evidence of disease spread to the liver, abdominal cavity, and or lungs, then the disease is not surgically removable (unresectable).
Sometimes we order a PET/CT scan to help clarify whether there is evidence of metastasis. This test measures how much sugar each area of the body is using and tries to determine the likelihood of there being cancer in that location. If metastases are identified, the pancreas cancer may not be surgically removable (unresectable). In these instances the cancer is best treated medically.
Will the patient be able to tolerate the operation?
The decision of whether a patient will be able to tolerate an operation is very complex and best made by a very experienced team. Studies show that patient outcome is best at high volume surgical centers. Surgeons at Johns Hopkins have performed over 3,000 Whipple resections, more than any other institution in the world. Age by itself does not exclude anyone from an operation. We have successfully performed a Whipple operation on a patient over 100 years old. More important than age is the condition of the patient's body and how well their major organs are functioning. If the disease is determined to be resectable, the next step is to schedule surgery.