Patient background

A 61-year-old woman, diabetic on metformin, presented with painless jaundice, pruritus, weight loss of 5 kg over two months, and dark urine. CT at a regional centre identified a 3.8 cm pancreatic head mass with contact along the superior mesenteric vein and a short stretch of the superior mesenteric artery. Two centres had advised her that surgery was not possible.

Re-evaluation

A dedicated contrast-enhanced CT pancreas protocol at Apollo was reviewed jointly with radiology. The tumour was classified as borderline resectable rather than locally advanced. Vascular contact with the SMV was short-segment and the SMA involvement was less than 180°. The case was discussed at the hepatobiliary multidisciplinary meeting.

Recommendation: neoadjuvant chemotherapy with modified FOLFIRINOX for four months, with restaging before considering surgery. Endoscopic biliary drainage was performed first to relieve the jaundice and optimise liver function before chemotherapy.

Response to neoadjuvant therapy

The patient tolerated six cycles of mFOLFIRINOX with dose adjustments. Restaging imaging after four months showed:

  • Tumour reduced to 2.4 cm
  • SMV contact now less than 90°
  • No new metastatic disease
  • Normalisation of CA 19-9

She was re-discussed at the MDT and offered a Whipple procedure.

Operation

An open pancreaticoduodenectomy was performed. Intra-operative findings matched imaging. The tumour was mobilised off the SMV without requiring vascular resection. A standard Child reconstruction was performed with a duct-to-mucosa pancreaticojejunostomy.

Operative time was 9 hours. Blood loss was 350 mL. No intra-operative transfusion was required.

Recovery

  • ICU stay: 2 days
  • Standard post-operative drains, all removed in stages between day 5 and 10
  • Resumed oral intake on day 4, transitioned to soft diet by day 8
  • Discharged on day 12

The final histopathology confirmed a ypT2 ypN1 moderately differentiated ductal adenocarcinoma, clear margins, with good treatment response to neoadjuvant therapy.

Adjuvant therapy and outcome at 9 months

The patient completed an additional four months of adjuvant chemotherapy. At 9 months from surgery, she is clinically well, has regained weight, is back to light daily activity, and has no radiographic or biochemical evidence of recurrence. She remains under structured oncology follow-up.

Discussion

Two lessons stand out. First, "inoperable" is not always a final judgement. Pancreatic tumour resectability depends on careful vascular assessment, and borderline cases often convert to resectable after well-chosen neoadjuvant chemotherapy. A second opinion from an HPB-trained surgeon working with a dedicated multidisciplinary team is worth seeking.

Second, the outcome in pancreatic surgery depends as much on the hospital and team as on the surgeon. Critical care, interventional radiology, medical oncology, and nutrition support all matter. This case would not have been possible without that infrastructure.

Case presented with patient consent. All identifying details have been changed.