Pishvaian, Gastrointestinal Oncology

Surgery is the only way to cure pancreatic cancer that has not spread (metastasized), and the best way to contain tumors. Unfortunately, doctors often see later-stage disease, with tumors wrapped around arteries and veins, nerves and the bile duct—making operations more challenging or even impossible.

We provide a full range of pancreatic cancer treatment, with our recommendations based on:

  • The cancer’s stage (the size of the tumor, how far it has grown into the wall of the pancreas and whether the cancer has spread to nearby tissues, lymph nodes or other parts of the body)
  • Whether the tumor is operable
  • Whether the cancer is newly diagnosed or has returned
  • Your overall health

At MedStar Health, we’re pioneering new ways to make these tumors operable, including chemotherapy followed by precise radiation (CyberKnife). We’re also looking at a new way to give heated chemotherapy (HIPEC) immediately after surgery, to reduce the chance the cancer will return (recur).

While pancreatic surgeries are the most complex abdominal operations, we have the most experienced team in the area, performing more procedures than any other group.

Surgery

Your pancreas has three portions: a wider end (the head), a middle section (the body) and a narrow end (the tail).

Our goal in surgery is to leave enough of the pancreas to produce digestive juices and insulin, reattaching the remaining organ so that it functions like it did before. But sometimes that’s not possible. We often have to remove all or other parts of nearby organs as well, to ensure we get as much of the cancer as possible. Your team will thoroughly explain its recommendation:

  • Distal Pancreatectomy: The tail and body of the pancreas are removed, and usually your spleen (splenectomy) as well, since it shares blood vessels.
  • Laparoscopic Distal Pancreatectomy: This procedure targets the same area as a distal pancreatectomy but is done with a minimally invasive approach.
  • Pancreaticoduodenectomy (Whipple Procedure): The head of the pancreas, the gallbladder, part of the small intestine and the bile duct are removed. We may also need to remove part of the stomach, though that’s often avoidable. The Whipple is the most common pancreatic surgery, with the best chance for a cure or long-term disease control. Research shows that the this complex operation is best performed by experienced surgeons who stay sharp by regularly treating patients—our highly skilled specialists’ volume is higher than the national average.
  • Laparoscopic Pancreaticoduodenectomy (Whipple Procedure): This procedure targets the same area as a pancreaticoduodenectomy but is done with a minimally invasive approach. That makes it even more complex—meaning it should only be done by experienced surgeons like ours.
  • Total Pancreatectomy: The entire pancreas is removed, as well as part of the stomach, part of the small intestine, the common bile duct, the gallbladder, the spleen and nearby lymph nodes. The operation is unusual and only done when the cancer has invaded the whole organ and there are no other options.

Biliary Obstructions

Sometimes, a pancreatic tumor blocks the tubes that transport bile. That causes a biliary obstruction, which requires treatment. Your doctor may recommend one of two approaches:

  • Surgery
  • Placement of a biliary stent (tiny metal tube) during an endoscopic retrograde cholangiopancreatography (ERCP).

Follow-up Care

Patients who have their spleen or pancreas removed (or who otherwise lose pancreatic function) receive additional follow-up care:

  • Insulin: You will need to follow a diabetic diet and take insulin if your pancreas is removed.
  • Pancreatic Enzyme Insufficiency: Pancreatic enzyme replacement therapy will help aid your digestion if you lose your pancreas, or its function.
  • Vaccines: Certain vaccines are recommended for all patients whose spleen is removed, since the organ plays an important role in the immune system and your risk of infection rises.

Minimally Invasive Surgery

Whenever possible, we take a minimally invasive approach with our surgeries, making a smaller incision(s) and using special instruments and a laparoscope—a thin tube with a tiny video camera that allows our surgeons to view the targeted area in real time. While conventional, open surgery is still recommended for some patients, a minimally invasive procedure means:

  • Less post-operative pain
  • Shorter hospitalization
  • Faster recovery (typically 2-3 weeks, vs. 6 weeks)
  • Much smaller scar

Minimally invasive pancreatic procedures are demanding, requiring surgeons who already have expertise with conventional approaches. But our experienced team is finding success with these newer techniques, and we’re among the few places in the country to offer them. We’ve also performed more of them than other center in the D.C. metro area.

Chemotherapy

The standard approach for chemotherapy to treat pancreatic cancer is to give the drugs after surgery to kill off any remaining cancer cells, or as a treatment for inoperable tumors (with or without radiation, in either case), or help surgeons make the tumor operable. But it’s a challenging therapy for the disease: Only 25 percent of surgical patients benefit, and digestive tumors can quickly develop a resistance to today’s chemotherapies.

We believe the answers lie in more tailored, personalized therapies. We are studying new chemotherapy combinations, as well as using existing drugs with newer, targeted therapies. Our clinical trials also include:

  • Testing tumors for chemotherapy susceptibility
  • Shrinking tumors before surgery with chemotherapy and special radiation
  • Giving chemotherapy (HIPEC) immediately after some surgeries

Our team includes internationally renowned research physicians and one of the area’s largest and most experienced groups of medical oncologists specializing in gastrointestinal cancers.

Testing Tumors

Chemotherapy given after surgery (a typical approach) only benefits 25 percent of those undergoing successful pancreatic operations, but there is currently no way to predict the effectiveness beforehand. That’s why a specialized team of our surgeons, radiation oncologists and medical oncologists is collaborating on a clinical trial to test the vulnerability of individual tumors before treatment starts.

The goal is to maximize the effectiveness of chemotherapy in appropriate patients, while avoiding unnecessary treatment in the rest.

Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Pancreatic cancer is a particularly challenging condition, and approximately 90 percent of patients eventually see the disease return (recur) after surgery. One of the treatment options available for pancreatic cancer is Hyperthermic Intraperitoneal Chemotherapy (HIPEC), a technique co-developed by Dr. Paul Sugarbaker who is one of the world’s leading experts in the surgical treatment of complex and advanced cancers.

Here’s how it works:

  • The primary tumor is removed using a Whipple procedure, but any cancer that has spread to the lining of the abdominal cavity (the peritoneum) is left in place.
  • Patients usually take chemotherapy at home and then recuperate.
  • Doctors surgically remove all visible, remaining cancer with a special electroevaporative technique (cytoreductive surgery, or debulking).
  • Before the operation ends, chemotherapy is heated to make it more effective, then applied directly to the surgical site while doctors manipulate the organs to control distribution. This allows a higher dose of chemotherapy while minimizing side effects.
  • A catheter is placed for any further chemotherapy and the surgical site is repaired.

Dr. Sugarbaker expects the procedure can extend survival, and that it is most effect when patients are:

  • Young
  • Otherwise healthy
  • Faced with a limited number of metastases (tumors that have spread)

Radiation

Radiation therapy uses high-energy X-rays or other radiation to attack tumors. Doctors often try to shrink pancreatic tumors before surgery with radiation and chemotherapy, combine chemotherapy and radiation (chemoradiation) after surgery to kill any remaining cancer cells or apply radiation if cancer returns.

Armed with the cutting-edge CyberKnife system, our experienced radiation oncologists are studying a way to shrink even more tumors so additional patients can receive surgery. Other clinical trials include a look at using a targeted therapy to make cancerous cells more vulnerable to radiation, increasing treatment effectiveness.

Types

We offer several types of radiation therapy for pancreatic cancer:

  • External-Beam Radiation Therapy: Given by a machine outside the body and includes:
    • Intensity-Modulated Radiation Therapy (IMRT): Our radiation oncologists can change treatment intensity as they go based on tissue type, delivering specific doses to different parts of a tumor and sparing healthy tissue.
    • Image-Guided Radiation Therapy (IGRT): Your radiation oncology team uses high-quality imaging to carefully adjust radiation beams and doses to best fit the size, shape and location of the tumor, sparing healthy tissue.

CyberKnife

CyberKnife is an advanced external radiation technology that delivers precisely targeted, laser-like radiation through image-guidance systems and a robot arm rotating around your body. We were one of the first teams in the country to use CyberKnife for both newly diagnosed and returning (recurring) pancreatic cancer, and remain among the most experienced.

CyberKnife provides several advantages over other external radiation:

  • Precision and Tolerance
    • External: The broad sweep of typical external radiation not only hits the tumor, but also the small bowel and nearby organs—causing cramping, pain, nausea and diarrhea. External radiation also can’t adjust for tumor movement while you breathe, so a larger area gets irradiated to ensure no cancer cells are missed.
    • CyberKnife: CyberKnife delivers hundreds of tiny beams at various angles, with sub-millimeter precision. It can also track and adjust for tumor motion, minimizing the harm to surrounding areas while delivering a higher dose of radiation to the cancer.
  • Convenience
    • External: Radiation is given over six weeks.
    • CyberKnife: Since higher radiation doses can safely be given during each session, treatment takes just one or two weeks.

Preparation for CyberKnife

Before CyberKnife treatment begins, tiny gold markers (fiducials) get placed around the tumor to mark the target. In the past, this required minimally invasive surgery. But one of our gastroenterologists developed a way to avoid surgery, threading a special tube (endoscope) through the mouth and to the pancreas.

CyberKnife Clinical Trials

While doctors attempt to make many pancreatic tumors operable by first shrinking them with traditional external radiation and chemotherapy, they are often not successful.

That’s why our team is running a clinical trial to use CyberKnife for the radiation portion, driven by two motivations:

  • CyberKnife can safely deliver a higher dose of radiation to the tumor with fewer side effects during treatment.
  • Patients won’t need as much time to recover between chemotherapy and radiation, maximizing the effectiveness of each therapy and giving the tumor less time to advance.

Our goal is to provide a surgical option to more patients, helping them live longer. As part of the trial, we are also giving some patients a targeted therapy, to see if we can make cancerous cells more susceptible to radiation.

Targeted Therapy

Targeted therapy represents a new front in attacking cancer—drugs and other substances aimed at specific molecules that help tumors grow, progress, and spread. The idea is to target a tumor’s unique characteristics, including genes, proteins, supporting blood vessels, or host tissue, while limiting damage to healthy cells.

Targeted therapies may replace current treatments, or complement them, and we are studying a number of new targets and approaches.

Types

We offer several types of targeted therapies, many of them in clinical trials:

  • Growth Factor Inhibitors: These therapies target certain surface molecules—growth factor receptors—on cancer cells that help them grow.
  • Anti-Angiogenesis Factors: They block the growth of blood vessels needed by tumors.
  • Drugs for Tumor Stroma (Supporting Tissue): They attack dense supporting tissue around pancreatic tumors, to potentially make them more susceptible to chemotherapy.
  • Monoclonal Antibodies: They mimic immune system proteins to deliver toxins or radioactive substances directly to cancerous cells.
  • Checkpoint Inhibitors: They release the normal brakes on the body’s immune system.
  • Cancer Vaccines: They are designed to treat, not prevent, pancreatic cancer by boosting the immune system’s response

Metastatic Pancreatic Cancer

Pancreatic cancer cells spread quickly, and the disease is hard to diagnose in its early stages. That means by the time the cancer is found, it has often spread (metastasized) to other areas of the body. If that happens, our experienced and compassionate team can still provide top care. Our treatment recommendations may include:

  • Chemotherapy: If surgery is not an option, these drugs might slow the cancer’s growth, even if they may not be able to destroy the entire tumor.
  • Targeted Therapy: Although there are many types of targeted therapies, one type of targeted therapy called immunotherapy might be able to direct your immune system to identify and target the cancer.
  • Pain Management: Our specialized palliative care team can help manage your pain and other symptoms. They do everything they can to make you as comfortable as possible.

Palliative Care and Pain Management

While our medical oncologists are trained to help relieve pain during pancreatic treatment and provide other quality of life support, complex or challenging situations are often best handled by our palliative care team. The team provides physical, psychological and spiritual comfort, using medications, physical therapy, relaxation and other approaches. Members can help with:

  • Pain (90 to 95 percent of pancreatic cancer pain is controllable with the right help)
  • Nausea
  • Fatigue
  • Loss of appetite
  • Constipation
  • Weakness
  • Anxiety
  • Sleeplessness