Pancreatic Cancer and Its Treatment

Pancreatic cancer is one of the most common and difficult-to-treat types of cancer in our time. Professor Dr. Süleyman Yedibela, General Surgery Specialist at Anadolu Health Center, explained the treatment methods for pancreatic cancer...

Pancreatic Cancer Statistics
Pancreatic cancer ranks fourth in terms of cancer-related deaths in both men and women. In pancreatic carcinoma, precursors with different genetic profiles can be distinguished (PanIN 1 - 3 and IPMN = intraductal papillary-mucinous neoplasm of the pancreas). The microscopic diagnosis of pancreatic cancer is made within the framework of the classification of all pancreatic tumors, as defined by the World Health Organization (WHO).

Exocrine Pancreatic Cancer
The most common type of pancreatic cancer originates from the cells of the pancreatic ducts, which secrete pancreatic juice and help break down the smallest molecules of the food we consume (exocrine function of the pancreas).

Location of Pancreatic Tumors
Tumors can develop in three sections of the pancreas: the head, body, and tail. Approximately 60-70% of pancreatic carcinomas originating from cells that secrete pancreatic fluid are found in the head of the pancreas, 10-15% in the body, and the remainder in the tail of the pancreas.

Surgical Approach in Pancreatic Cancer

The only potentially curative treatment for exocrine pancreatic cancer is surgery.

In patients with pancreatic carcinoma who are considered operable, special chemotherapy, chemoradiotherapy, or radiation treatment is not applied. If distant metastases (organ metastases, peritoneal spread, or lymph node metastases considered distant) are detected, surgery is not performed for pancreatic cancer.

Surgical procedures are a part of the treatment strategy defined in weekly tumor board meetings with the pancreas oncology specialists at Anadolu Health Center, where we collaborate with gastroenterology, radiation therapy, and interventional radiology experts. Based on national/international guidelines and research findings, we offer the best possible treatment option for you. You can also seek a second opinion from us.

We place great importance on providing the latest oncological surgical techniques and comprehensive, innovative treatment options (chemotherapy, immunotherapy, radiation therapy).

Determining Surgical Operability (Resectability)

The assessment of surgical operability requires comprehensive and high-quality staging diagnosis (environmental diagnosis) through computed tomography (CT), magnetic resonance (MR), and, if necessary, positron emission tomography (PET)-CT, especially in suspected cases.

Only about 15-20% of patients with pancreatic cancer are operable. Approximately 5-10% of patients have borderline operability.

Resectability Criteria for Pancreatic Cancer (Borderline)

If the primary tumor involves the celiac region or arteries that supply the entire small and large intestines (superior mesenteric artery), surgery should not be performed. If veins that drain blood from the small and large intestines to the liver (portal vein and/or superior mesenteric vein) or the splenic vein, which carries blood from the spleen to the liver, are involved by the tumor, this should not be considered as a criterion for not performing surgery.

The criteria determining operability (resectability) are typically (I) involvement of veins leading to the liver (superior mesenteric vein/portal vein) that cannot be surgically repaired, (II) tumor-vascular contact greater than 180° with the artery supplying the intestines (superior mesenteric artery), (III) tumor-vascular contact with the artery supplying the liver (hepatic artery) that cannot be surgically repaired, and (IV) tumor-vascular contact with the celiac trunk greater than 180° (see the table above).

Pancreatic Head Resection

The surgical treatment of pancreatic carcinoma aims for complete tumor removal. In cases of locally limited tumors, standard resections such as partial pancreatic head resection (pancreaticoduodenectomy), resection of the pancreatic tail (distal pancreatectomy), total pancreatectomy (complete removal of the pancreas), and removal of necessary lymph nodes can be performed. In cases of involvement of veins leading to the liver (mesenteric-portal veins) or adjacent organ involvement, it is often possible to perform a surgery that completely eradicates the disease, with a slight increase in complication rates but comparable oncological outcomes. The surgical treatment plan for pancreatic carcinoma should also include adjuvant chemotherapy postoperatively, as determined by the tumor board decision.

The pancreatic head resection can be performed in the classical Kausch-Whipple method (removal of the lower third of the stomach, duodenum, bile duct, gallbladder, and pancreatic head) or in the Traverso-Longmire method, which protects the pylorus (in this variant, the stomach is preserved) (see the images below).

Pancreatic Head Resection Reconstruction

The upper small intestine is connected to the remaining left pancreas, allowing the flow of pancreatic juice into the intestines. Additionally, through the connection of the main bile duct to the small intestine, bile flow into the intestine is ensured.

The final connection is between the stomach (here, classical surgery according to Kausch-Whipple) and the upper small intestine.

Left Pancreatic Resection

Tumors in the body and tail of the pancreas require splenectomy (removal of the spleen) and, if the surgery is due to cancer, removal of the pancreatic tail and lymph nodes in that region (distal pancreatectomy).

Research results have shown that laparoscopic (minimally invasive) left pancreatic resections are as successful as open surgeries in completely removing the tumor and in removing similar amounts of lymph nodes. However, most studies cannot determine how much benefit patients gain from laparoscopic surgery and its associated advantages. The main reason is strong patient selection and the treatment of these patients through open surgery.

Total Pancreatectomy (Total Duodenopancreatectomy)

In cases of widespread tumor involvement or tumors located centrally in the pancreas, where resection is not possible using the above methods, removal of the pancreas, duodenum, spleen, and all lymph nodes in this region (lymphadenectomy) may be required.

Extended Pancreatic Surgery Strategies

If a good oncological result can be achieved for the patient, surgery should aim at removing not only the pancreas but also adjacent organs or tissues. Extended procedures involve the removal of blood vessels affected by the tumor and their reconstruction with artificial vessels, as well as complete removal of neighboring organs involved by the tumor. Recent studies have shown that surgeries involving the removal of blood vessels, performed by experienced surgeons, do not increase surgical complications, and long-term survival is equivalent to surgeries without vascular involvement. In the case of a single metastasis (e.g., in the liver) or recurrence, the removal of metastases is evaluated individually, and the best outcome is discussed in an interdisciplinary tumor board, where doctors from different specialties participate.