I was refused surgery because of the vessels. Is there still a chance?

For some patients, yes. If the tumor involves a limited segment of a vein, the vein can often be removed and reconstructed; with arterial involvement, chemotherapy comes first and the possibility of surgery is then reassessed. To tell, the CT discs are needed, not just the report.

Why can’t I be operated on straight away?

Tumors involving the vessels carry a high risk of hidden micrometastases. Chemotherapy before surgery acts on them and reveals the tumor’s biology: if metastases appear during treatment, surgery would not have helped. If the disease is stable, the MDT assesses whether the tumor can be removed completely.

After chemotherapy the CT shows the tumor has not shrunk. Is that the end?

Not necessarily. After chemotherapy, scar tissue often remains where the tumor was, and CT cannot distinguish it from live tumor. The decision takes into account CA 19-9, the absence of new lesions and general condition.

How much riskier is surgery with vascular resection?

The risk of resecting and reconstructing a vein depends on the length of involvement and the reconstruction method; in experienced hands it is moderate. We do not perform arterial resections.

How long does preparation for surgery take?

Usually 4–6 months of chemotherapy, sometimes longer, with follow-up CT and CA 19-9 every 2–3 months. Surgery is performed a few weeks after the last cycle.

Pancreatic cancer involving blood vessels: after surgery was declined

When a pancreatic tumor touches major blood vessels — the portal or superior mesenteric vein, the hepatic artery, the celiac trunk — patients are often told that surgery is not possible. For some of these tumors, however, that is not the final word. Borderline resectable and some locally advanced tumors become operable in some patients after several months of chemotherapy: the tumor is removed together with the affected segment of the vein, and the vein is reconstructed. Such a decision requires careful selection, experience in vascular reconstruction and close MDT teamwork.

Kateryna Valikhnovska, MD, surgical oncologist, during a laparoscopic operation — The laparoscopic stage of an operation: the lights in the operating room are dimmed because the surgeon works from the camera image on the monitor.

What “borderline resectable” means

The pancreas lies against the main blood vessels of the upper abdomen. Depending on how much the tumor touches them, three groups are distinguished. A resectable tumor does not touch the arteries, and contact with the veins is minimal. A borderline resectable tumor encases more than half of a vein or narrows it, but the vein can be removed and reconstructed, or it touches the arteries over no more than half their circumference. A locally advanced tumor encases more than half of the superior mesenteric artery or celiac trunk, or involves a vein so that it cannot be reconstructed.

Besides anatomy, tumor biology is taken into account — a very high CA 19-9 or suspicious nodes suggest occult spread — as well as the patient’s general condition. That is why the decision is not based on CT alone.

Are there symptoms

The symptoms are the same as in pancreatic cancer in general: jaundice, upper abdominal pain radiating to the back, weight loss, loss of appetite. When the vessels and the nerve plexuses around them are involved, back pain can be more severe and constant.

How severe the symptoms are does not show whether surgery is possible: that is decided by CT and the response to treatment.

Examinations needed

Pancreatic protocol CT — it should be reviewed by a radiologist and a surgeon who work with the pancreas every day: the plan depends on the details of the tumor’s contact with each vessel.
Endoscopic ultrasound with biopsy — confirmation of the diagnosis is mandatory before chemotherapy.
Liver MRI and, when indicated, PET-CT — so as not to miss distant metastases.
CA 19-9 — before treatment and over time: a fall during chemotherapy is one of the important arguments in favor of surgery, along with CT and general condition.
Diagnostic laparoscopy — before major surgery, to rule out small peritoneal deposits.
Assessment of the heart, lungs and nutrition — it determines whether the patient can tolerate extended surgery.

When surgery is possible

First, chemotherapy is given — usually 4–6 months of a combination regimen, sometimes followed by radiotherapy. It destroys micrometastases and selects patients with favorable tumor biology: if metastases appear during this time, surgery would not have helped.

After chemotherapy, CT often shows the tumor looking almost the same, because scar tissue remains around the vessels where tumor cells used to be. So the decision on surgery is not based on CT alone: what matters is the absence of new lesions, a fall in CA 19-9 and good general condition. If these conditions are met, the MDT reassesses whether a curative operation is technically possible.

If surgery is not possible now

If the tumor progresses on chemotherapy or metastases appear, drug treatment continues with other regimens. For a stable locally advanced tumor, radiotherapy, including stereotactic, and further monitoring are options.

The response to treatment is reassessed every few months: in some patients the question of surgery comes up later. Jaundice, bowel narrowing and pain are treated alongside.

How the operation is performed

Depending on the location, a pancreaticoduodenectomy, a distal pancreatectomy or removal of the whole pancreas is performed — together with the involved segment of the vein en bloc. A segment of the portal or superior mesenteric vein is removed and reconstructed with a direct suture or a graft from the patient’s own vein or a prosthesis.

We resect the vein together with the team. We do not perform arterial resections.

“Tumor near the vessels” is not a diagnosis of inoperability. It is a reason to show the CT to a surgeon who performs vascular reconstructions, and to discuss treatment at the MDT.

Kateryna Valikhnovska, MD, surgical oncologist

Recovery after surgery

Care follows the enhanced recovery after surgery (ERAS) protocol: early mobilization, early feeding, controlled pain relief. After operations with vascular reconstruction the hospital stay is longer, usually with the first days in intensive care; the reconstructed vessels are checked by ultrasound or CT, and anticoagulants are prescribed if needed.

Enzyme supplements and diabetes treatment are needed just as after standard pancreatic resections. Whether to continue chemotherapy after surgery is decided by the MDT based on the pathology report.

Follow-up

For the first 2 years, CT and CA 19-9 every 3–4 months, then less often; the doctor sets the schedule. Pain, jaundice, weight loss or changes in digestion should be reported right away.

What to bring to the consultation

pancreatic protocol CT discs from before treatment and after each stage of chemotherapy — the discs themselves, not just the reports;
CA 19-9 values over time;
the biopsy report;
records of chemotherapy or radiotherapy with regimens and number of cycles;
the written opinion in which surgery was declined, if you have one.

If some materials are missing, that is no reason to postpone the consultation: some examinations can be done on site.

The consultation is free of charge. How it goes and how long it takes is described on the page “Oncologist Consultation”.