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 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 treating 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 caused by the surgery or the 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, and imaging shows the tumor has completely disappeared.

At 84, to operate or not?

In April this year, Ms. Zhu sought 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".

Because the tumor invaded 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 said that after chemotherapy Ms. Zhu's tumor had shrunk and had not invaded the hepatic artery, theoretically meeting the surgical indications. Resuming chemotherapy would be a more conservative approach, but based on previous clinical experience the estimated survival would not exceed six months.

"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 succeeds, elderly patients may face risks such as inability to be weaned off the tracheal tube and severe cardio-cerebrovascular complications afterward."

While the family hesitated, Ms. Zhu's tumor markers rose again, indicating the pancreatic cancer had resumed progressing and that she might lose the opportunity for surgery entirely at any moment. The family finally made up their minds and asked the doctors to arrange the surgery as soon as possible.

The challenge then fell to the Department of Hepatobiliary and Pancreatic Surgery team at the Second Affiliated Hospital of Zhejiang University.

Which surgical plan to choose?

For 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.

Dr. Zhou Bo said: "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, and the surgical risk was extremely high, there was still an opportunity for radical resection — it belonged to 'borderline resectable' pancreatic head cancer."

There are two radical resection plans. One is the 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 corrodes tissues and blood vessels, causing infection, massive bleeding, and so on — almost intolerable for the 84-year-old Ms. Zhu."

The other plan is total pancreatectomy. "Total pancreatectomy means the important blood vessels behind the pancreas can be fully exposed to the surgeon'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 no pancreas is left," said Dr. Zhou Bo.

However, total pancreatectomy also faces a series of problems, the biggest being postoperative blood glucose management.

Once the pancreas is lost, the body no longer produces insulin, and Ms. Zhu would 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 large doses of exogenous insulin for a long time, and her blood glucose will fluctuate greatly."

"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 pros and cons. After weighing the options and further evaluating the benefit-risk ratio in detail, Professor Yan Sheng finally decided to perform a total pancreatectomy on Ms. Zhu, combined simultaneously with autologous islet transplantation (TP-IAT).

A pancreatic cancer surgery "unique in the country"

In fact, using TP-IAT to treat pancreatic cancer is clinically controversial. Aside from 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. "For this reason, 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 a frozen-section examination of the resection margin, and no tumor was found there either," said Dr. Zhou Bo.

In addition, hospitals performing TP-IAT must also have an experienced clinical hepatobiliary and pancreatic surgery team, 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.

TP-IAT is a major, highly difficult surgery. "But for the 84-year-old Ms. Zhu, if only total pancreatectomy were performed without islet transplantation, long-term blood glucose management would be extremely difficult, with the risk of fatal diabetic complications and severe impairment of quality of life. Based on previous clinical experience, we believe 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, began the operation.

According to Dr. Zhou Bo, after exploring and confirming no abdominal metastasis, 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 where it passes the upper edge of the pancreas, and the superior mesenteric vein was also involved," said Dr. Zhou Bo. This finding directly determined the subsequent surgical strategy: the involved blood-vessel segment had to be resected and vascular reconstruction performed to restore normal blood flow to the liver and intestines.

With this 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 portion was completed by Fu Hongxing and the islet preparation team. Meanwhile, the surgical team continued dissecting 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 portal vein defect was 3 to 4 centimeters long. We then selected the autologous splenic vein from the patient's resected pancreatic tail as a transplantation bypass," said Dr. Zhou Bo. Since this operation requires interrupting the blood supply in advance, the surgical team had to race against time to reduce ischemic injury to the liver.

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

Subsequently, digestive tract reconstruction was performed, including choledochojejunostomy and gastrojejunostomy. During this time, the laboratory reported that islet isolation had been 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 the autologous islet transplantation.

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

Dr. Zhou Bo said the surgery was very successful, with no fatal massive bleeding or other complications. Blood loss was only 200 milliliters. Postoperative CT and other examinations showed the tumor had been completely resected with no residual, the reconstructed blood vessels had unobstructed flow, and the autotransplanted islets had successfully engrafted and begun to exert physiological function.

Breaking "taboos" multiple times

On the 21st day after the operation, having passed the surgical danger period and rehabilitation stage, Ms. Zhu was successfully discharged. She can now eat and walk independently and has regained her daily living abilities.

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

"At 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. "At the most recent follow-up, the insulin dose 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 the Second Affiliated Hospital of Zhejiang University has "broken the taboo" and successfully treated elderly patients with 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 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, with about one-third of patients no longer needing insulin at discharge. Earlier this year, the team also successfully performed the surgery on another 77-year-old pancreatic cancer patient, who is recovering well.

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

Taking pancreatic transection as an example: "This is an extremely delicate operation. Especially in 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 TP-IAT technology currently shows great potential in treating pancreatic cancer, but still faces a series of technical bottlenecks and clinical challenges, such as early islet loss after transplantation, the need to improve long-term survival, 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 who need pancreatic resection surgery. At the same time, we are 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, and the like," said Professor Yan Sheng.