Chinese Doctors Set New Record! Tumor Disappears in 84-Year-Old Pancreatic Cancer Patient

Ms. Zhu never imagined that at the age of 84, she would undergo such a "record-breaking" surgery. Doctors removed her entire pancreas, spleen, and gallbladder, reconstructed her gastrointestinal tract and blood vessels, and simultaneously performed an autologous islet transplantation.

Across the country, only one hospital can independently complete this surgery.

Recently, "MedJ" learned from the Second Affiliated Hospital of Zhejiang University School of Medicine (hereinafter referred to as the Second Affiliated Hospital of Zhejiang University) that Professor Yan Sheng's team from the Department of Hepatobiliary and Pancreatic Surgery successfully performed a "Total Pancreatectomy with Autologous Islet Transplantation (TP-IAT)" on Ms. Zhu, who suffered from advanced pancreatic cancer. This also sets the global record for the oldest patient to undergo such a surgery.

Globally, TP-IAT technology has been carried out for nearly 50 years, but its use in the treatment of pancreatic cancer remains controversial and is only performed in a few countries such as Italy and France. To date, the Second Affiliated Hospital of Zhejiang University has independently completed more than 50 TP-IAT surgeries, with no patient deaths due to the surgery or perioperative period.

"Being able to undergo such a major surgery at the age of 84 and recover to this level of quality of life is a new miracle," said Professor Yan Sheng. Currently, Ms. Zhu has been successfully discharged from the hospital, and imaging shows that the tumor has completely disappeared.

At 84, to Operate or Not?

In April this year, Ms. Zhu sought medical treatment for upper abdominal pain and was diagnosed with pancreatic cancer at a local hospital.

Pancreatic cancer is known as the "king of cancers" due to its concealment, strong invasiveness, rapid progression, and extremely high mortality rate. "At that time, imaging, puncture, and other examinations showed that Ms. Zhu's tumor was located in the pancreatic head and had involved the portal vein, belonging to stage III—locally advanced pancreatic head cancer," Dr. Zhou Bo, deputy chief physician of the Department of Hepatobiliary and Pancreatic Surgery at the Second Affiliated Hospital of Zhejiang University, told "MedJ".

Dr. Zhou Bo

Due to the tumor invading important blood vessels, Ms. Zhu had no immediate opportunity for surgery. She received 5 courses of standard chemotherapy. Although the lesions were controlled and tumor markers dropped rapidly, severe chemotherapy side effects followed—nausea, vomiting, and increasing physical weakness. She could barely walk a few steps and had to temporarily discontinue chemotherapy.

Later, Ms. Zhu's family took her to the Department of Hepatobiliary and Pancreatic Surgery at the Second Affiliated Hospital of Zhejiang University to re-evaluate the possibility of radical surgical treatment.

Dr. Zhou Bo told "MedJ" that after chemotherapy, Ms. Zhu's tumor had shrunk and had not invaded the hepatic artery, theoretically meeting the surgical indications. Choosing to resume chemotherapy is a more conservative treatment method, but based on previous clinical experience, the estimated survival period would not exceed six months.

"In fact, in clinical practice, when we encounter patients of similar age, most families choose conservative treatment because the surgical risk is too high," said Dr. Zhou Bo. "It is completely unknown whether the body can tolerate the surgical trauma and survive the operation. Even if the surgery is successful, elderly patients may face risks such as inability to wean off the tracheal tube and severe cardio-cerebrovascular complications after surgery."

While the family was hesitant, Ms. Zhu's tumor markers rose again, indicating that the pancreatic cancer had restarted progressing, and she might lose the opportunity for surgery completely at any time. Therefore, the family finally made up their minds and hoped that the doctors would arrange the surgery as soon as possible.

Challenges then came to the team of the Department of Hepatobiliary and Pancreatic Surgery at the Second Affiliated Hospital of Zhejiang University.

Which Surgical Plan to Choose?

Targeting Ms. Zhu's condition, Professor Yan Sheng, executive deputy director of the Department of Hepatobiliary Surgery at the Second Affiliated Hospital of Zhejiang University, initiated a multidisciplinary consultation.

Professor Yan Sheng

Dr. Zhou Bo told "MedJ": "After initial evaluation, we found that although Ms. Zhu's tumor had invaded the portal vein and was closely attached to the superior mesenteric artery and celiac trunk artery, the surgical risk was extremely high, but there was still an opportunity for radical resection, belonging to 'borderline resectable' pancreatic head cancer."

There are two radical resection plans. One is the most classic pancreaticoduodenectomy, which requires removing the pancreatic head, duodenum, common bile duct, gallbladder, and part of the stomach and small intestine, then anastomosing the cut end of the remaining pancreas with the jejunum to reconstruct the digestive tract.

The risk here is that Ms. Zhu's tumor invaded deeply with complex anatomical structures, making it difficult to ensure complete removal of the deep tumor. "At the same time, pancreatic fistula is the most common and dangerous complication of pancreaticoduodenectomy. Once it occurs, the leaked pancreatic juice will corrode tissues and blood vessels, causing infection, massive bleeding, etc., which is almost intolerable for the 84-year-old Ms. Zhu."

The other plan is total pancreatectomy. "Total pancreatectomy means that the important blood vessels behind the pancreas can be fully exposed to the doctor's field of vision during the operation. This not only reduces the surgical difficulty and ensures complete tumor dissection but also eliminates the risk of postoperative pancreatic fistula since there is no pancreas left," said Dr. Zhou Bo.

However, total pancreatectomy also faces a series of problems, with the biggest challenge coming from postoperative blood glucose management.

Once the pancreas is lost, the body will no longer produce insulin, and Ms. Zhu will inevitably face permanent brittle diabetes and exocrine insufficiency. Researcher Fu Hongxing from the Pancreatic and Islet Transplantation Center of the Second Affiliated Hospital of Zhejiang University told MedJ: "After the operation, she will need to use large doses of exogenous insulin for a long time, and her blood glucose will fluctuate greatly."

Researcher Fu Hongxing

"At the same time, glucose metabolism disorders will affect postoperative recovery and may even affect subsequent chemotherapy due to physical weakness," said Fu Hongxing.

Different surgical plans have their own advantages and disadvantages. After weighing the pros and cons and further evaluating the benefit-risk ratio of different plans in detail, Professor Yan Sheng finally decided to perform total pancreatectomy on Ms. Zhu, combined with autologous islet transplantation (TP-IAT) simultaneously.

A Pancreatic Cancer Surgery "Unique in the Country"

In fact, the use of TP-IAT in the treatment of pancreatic cancer is clinically controversial. Except for the Second Affiliated Hospital of Zhejiang University, very few medical institutions in China have carried out such surgeries.

On one hand, TP-IAT carries the risk of tumor cell dissemination. Tumor cells in the body may be brought into the islet cell preparation and then transfused back into the patient's body. "To this end, we conducted a comprehensive imaging evaluation before the operation and found no tumor in the pancreatic tail. After resecting the pancreatic tail during the operation, we performed frozen section examination of the resection margin, and no tumor was found either," said Dr. Zhou Bo.

In addition, hospitals performing TP-IAT must also have an "experienced clinical team of hepatobiliary and pancreatic surgery", a "strong islet isolation research team", and an "independent in-hospital islet isolation laboratory". MedJ learned that currently, only 6 medical institutions in China meet the requirements for the last item alone.

Islet Isolation Operation

TP-IAT is a major high-difficulty surgery. "But for Ms. Zhu, who is 84 years old, if only total pancreatectomy is performed without islet transplantation, long-term blood glucose management will be extremely difficult, with the risk of fatal diabetic complications and severe impairment of quality of life. Based on previous clinical experience, we believe that TP-IAT is the option with a better benefit-risk ratio," said Dr. Zhou Bo.

All preparations were completed. At 9 a.m. on August 14, Professor Yan Sheng, the chief surgeon, started the operation.

According to Dr. Zhou Bo, after exploring and confirming no abdominal metastasis of the cancer, the team expanded the surgical incision, carefully dissected the lymph nodes and connective tissues around the blood vessels, and evaluated the vascular structure in the hepatic hilum area.

"We found that Ms. Zhu's hepatic artery, common hepatic duct, and other structures were normal, but the portal vein was invaded by the tumor when passing through the upper edge of the pancreas, and the superior mesenteric vein was also involved by the tumor," said Dr. Zhou Bo. This evaluation result directly determined the subsequent surgical strategy: the involved blood vessel segment must be resected and vascular reconstruction must be performed to restore normal blood flow to the liver and intestines.

With the initial judgment, the team first transected part of the stomach and pancreas, removed the pancreatic tail, and immediately sent it to the laboratory for islet cell isolation and extraction after confirming no residual tumor at the resection margin of the pancreatic tail.

The laboratory part was completed by Fu Hongxing and the islet preparation team. Meanwhile, the surgical team continued to dissect the remaining pancreas and duodenum on the operating table. For the pancreatic segment where the portal vein and superior mesenteric vein were adherent and invaded, the team resected the tumor together with the involved blood vessels as a whole.

"After resecting the involved blood vessels, the defect of the portal vein was 3 to 4 centimeters long. We then selected the autologous splenic vein from the resected pancreatic tail of the patient for transplantation bypass," said Dr. Zhou Bo. Since this operation requires interrupting blood supply in advance, the surgical team must race against time to reduce ischemic injury to the liver.

"After completing the bypass vascular reconstruction, we quickly removed the vascular clamp. The entire process took only about 20 minutes, and the liver resumed perfusion immediately," introduced Dr. Zhou Bo.

Subsequently, digestive tract reconstruction was performed, including choledochojejunostomy and gastrojejunostomy. During this period, the laboratory reported that islet isolation was successfully completed. The team immediately established an islet cell reinfusion pathway through portal vein puncture and slowly infused the islet cell suspension sent back to the operating room into Ms. Zhu's portal vein system, completing the final step of autologous islet transplantation.

Finally, after 7 hours and 40 minutes, the surgery was successfully completed.

Dr. Zhou Bo told MedJ that the surgery was very successful, with no fatal massive bleeding or other complications. The blood loss was only 200 milliliters. At the same time, postoperative CT and other examinations showed that the tumor had been completely resected with no residual, the reconstructed blood vessels had unobstructed blood supply, and the autotransplanted islets had successfully engrafted and started to exert physiological functions.

Surgery scene

Breaking "Taboos" Multiple Times

On the 21st day after the operation, after passing the surgical danger period and rehabilitation stage, Ms. Zhu was successfully discharged from the hospital. Currently, she can eat and walk independently and has regained her daily living abilities.

Dr. Zhou Bo introduced that since only the islets from the uninvolved pancreatic tail were transplanted, Ms. Zhu still needs to take exogenous insulin after the operation, but the dosage is significantly reduced compared with simple total pancreatectomy, and her blood glucose is easier to control.

"At the time of discharge, her fasting C-peptide level was 0.13 nmol/L, and we formulated a treatment plan of 10 units of insulin per day," said Dr. Zhou Bo. "During the most recent follow-up, the insulin dosage has been reduced to 4 units per day, and her blood glucose is stable."

On the Mid-Autumn Festival (October 6), Ms. Zhu's son sent blessings to the medical team, writing: "My mother has recovered really well and has a good appetite. Thank you so much for your exquisite medical skills......"

In fact, this is not the first time that the Second Affiliated Hospital of Zhejiang University has "broken the taboo" and successfully treated elderly patients through TP-IAT. As early as 2008, relying on Zhejiang University, Professor Wang Weilin, director of the Department of Hepatobiliary and Pancreatic Surgery at the Second Affiliated Hospital of Zhejiang University, took the lead in establishing the first islet isolation laboratory in Zhejiang Province and simultaneously launched clinical allogeneic islet transplantation and autologous islet transplantation projects.

In September 2023, the Islet Transplantation Center of the Second Affiliated Hospital of Zhejiang University was officially established. Targeting different diseases, the joint surgical team has independently completed more than 50 clinical TP-IAT surgeries so far, among which about one-third of the patients no longer need insulin treatment at the time of discharge. Earlier this year, the team also successfully performed the surgery on another 77-year-old elderly pancreatic cancer patient, who is currently recovering well.

Fu Hongxing told MedJ that in addition to the experienced islet isolation team, the surgical level of the hepatobiliary and pancreatic surgery team directly determines the success of TP-IAT surgery.

Taking pancreatic transection as an example: "This is an extremely delicate operation. Especially for elderly pancreatic cancer patients, the condition of their blood vessels, pancreas, and other tissues is often poor. During the surgical transection and processing of pancreatic tissue fragments, if severe ischemia and hypoxia injury are caused, subsequent islet isolation and purification will be impossible, or the transplantation prognosis will be seriously affected," said Fu Hongxing.

Professor Yan Sheng said that currently, TP-IAT technology has shown great potential in the treatment of pancreatic cancer, but it still faces a series of technical bottlenecks and clinical challenges, such as early islet loss after transplantation, the need to improve long-term survival rate, and limited indication selection.

"In the future, we will continue to explore new islet transplantation sites and methods to make islet transplantation simpler and minimally invasive, applicable to more patients in need of pancreatic resection surgery. At the same time, we are also actively trying the transplantation of differentiated and expanded human islet organoids to expand the source of islet cells, benefiting more patients with type 1 diabetes, pancreatogenic diabetes, etc.," said Professor Yan Sheng.