Treatment of Pancreatic Head Cancer in Israel

Pancreatic head cancer remains one of the most challenging oncological diagnoses, but over the past decade, treatment outcomes have significantly improved due to a combination of precise surgery, new chemotherapy regimens, targeted therapies, and radionuclide therapy. The Sourasky (Ichilov) Medical Center in Tel Aviv is one of the largest centers for treating tumors of the pancreatobiliary zone in Israel. Here, dozens of Whipple procedures are performed annually, neoadjuvant protocols with FOLFIRINOX and gemcitabine with nab-paclitaxel are used, genetic testing for BRCA1/BRCA2 mutations is conducted to prescribe targeted therapy with olaparib, and neuroendocrine tumors are treated, including with lutetium-177 radionuclide therapy. The treatment program is tailored individually after a multidisciplinary consultation involving hepatobiliary surgeons, oncologists, endoscopists, radiologists, and pathologists. For patients from the CIS, Ichilov organizes a complete cycle: review of slides and CT scans, further examination, surgery or systemic therapy, postoperative monitoring, and communication with the treating physician after returning home. This article details the stages of the disease, modern diagnostic and treatment methods, approximate prices, and answers to the most frequently asked questions by patients considering treatment for pancreatic head cancer at Sourasky.

What is this disease

The pancreas is anatomically divided into the head, body, and tail. Tumors of the head account for 60–70% of all neoplasms of this organ. The vast majority of cases (about 90%) are ductal adenocarcinomas, an aggressive epithelial tumor. The remaining 10% consist of neuroendocrine tumors (NET, previously known as carcinoids and insulinomas), acinar cell carcinoma, solid pseudopapillary tumors, and rare histological variants. Adenocarcinoma and NET require fundamentally different treatment strategies, so the first step is always accurate morphological verification of the diagnosis.

According to international registries, the annual incidence of pancreatic cancer in developed countries is 10–13 cases per 100,000 population. Major risk factors include smoking (which increases the risk by about twofold), chronic pancreatitis, type 2 diabetes with a long history, obesity, alcohol abuse, and hereditary syndromes: BRCA1/BRCA2, Peutz-Jeghers syndrome, Lynch syndrome, familial atypical multiple melanoma (FAMMM), hereditary pancreatitis. In 5–10% of patients, there is a first-degree relative with the same diagnosis.

Pancreatic head tumors often manifest earlier than tumors of the body and tail because the growing mass quickly compresses the common bile duct, leading to mechanical jaundice. The classic triad of symptoms includes jaundice without pain syndrome, dark urine, and pale stools, along with weight loss. Additionally, patients complain of epigastric pain radiating to the back, itching, newly diagnosed diabetes, steatorrhea, and nausea. Neuroendocrine tumors are characterized by hormonal syndromes: hypoglycemia in insulinoma, diarrhea and flushing in carcinoid syndrome, Zollinger-Ellison syndrome in gastrinoma.

Diagnosis at Ichilov Clinic

The diagnostic program at Sourasky is designed for rapid acquisition of a complete picture: from confirming the diagnosis to determining the resectability of the tumor and its molecular profile. Typically, a full examination is completed within 3–5 working days.

CT of the pancreas with dual-phase contrast (pancreas protocol). This is the reference method for assessing tumor spread and its relationship with vessels — the portal and superior mesenteric veins, celiac trunk, and superior mesenteric artery. Based on the CT results, surgeons determine the stage according to resectability criteria: resectable, borderline resectable, locally advanced unresectable, and metastatic.

MRI with cholangiopancreatography (MRCP). Provides detailed visualization of ducts without contrast and better detects small metastases in the liver, as well as cystic tumors. It is mandatory when there is suspicion of IPMN and mucinous cysts, which may be precursors to cancer.

Endoscopic ultrasound (EUS) with fine-needle biopsy. A key method for obtaining material for histology. The probe is introduced through the duodenum, allowing visualization of the head of the gland "from the inside," assessment of regional lymph nodes, and biopsy under imaging guidance. The verification accuracy exceeds 90%.

ERCP (endoscopic retrograde cholangiopancreatography). Used as a therapeutic and diagnostic procedure in mechanical jaundice: during the study, a stent is placed in the bile duct, which reduces bilirubin levels before surgery or chemotherapy.

PET-CT with ⁶⁸Ga-DOTATATE. A specialized study for neuroendocrine tumors — shows the density of somatostatin receptors, which is necessary for planning therapy with somatostatin analogs and radionuclide therapy with lutetium-177.

Oncomarkers and genetics. The standard panel includes CA 19-9 (a marker for adenocarcinoma, useful for monitoring treatment response), CEA, and for NET — chromogranin A. In cases of suspected hereditary variants or for planning targeted therapy, sequencing of BRCA1/BRCA2, a panel of hereditary syndromes, and from tumor material — extended molecular profiling (NGS) assessing KRAS, TP53, microsatellite instability (MSI-H), mutation load, NTRK and NRG1 translocations are performed.

Treatment Methods

The choice of strategy depends on histology, stage, overall patient condition (performance status), and the molecular profile of the tumor. At Sourasky, all cases are discussed at a weekly multidisciplinary consultation, where the decision on the sequence of treatment (surgery / chemotherapy / radiation therapy / targeted therapy) is made collectively.

Surgical Treatment

Whipple procedure (pancreaticoduodenectomy). The standard radical surgery for pancreatic head cancer. The head of the gland, duodenum, part of the stomach, gallbladder, distal part of the common bile duct, and regional lymph nodes are removed. At Ichilov, the surgery is performed either via open access or laparoscopically or robotically assisted in selected patients. A pylorus-preserving modification is used when it is oncologically safe. The duration of the surgery is 6–8 hours, and hospitalization lasts 10–14 days.

Distal pancreatectomy. Used for tumors of the body and tail, but sometimes combined with extended resections when the head is involved. Often performed with splenectomy and lymphadenectomy.

Total pancreatectomy. Indicated for multifocal tumors, hereditary syndromes with a high risk of malignancy, and in some cases of IPMN of the entire duct. After surgery, the patient requires lifelong replacement therapy with insulin and enzymes.

Resection and reconstruction of vessels. In borderline resectable tumors with local involvement of the portal or superior mesenteric vein, surgeons at Sourasky perform resection of the vessel in a single block with the tumor followed by reconstruction. This significantly expands the pool of patients who can be offered radical treatment.

Chemotherapy for Adenocarcinoma

Neoadjuvant therapy. Increasingly becoming the standard even for initially resectable tumors. The main regimens are modified FOLFIRINOX (oxaliplatin, irinotecan, leucovorin, fluorouracil) and gemcitabine in combination with nab-paclitaxel (MPACT protocol). Usually, 4–6 cycles are prescribed, followed by CT reassessment and a decision regarding surgery. This approach allows for tumor size reduction, increases R0 resectability, and assesses the biology of the disease.

Adjuvant therapy. After surgery, the standard is modified FOLFIRINOX (according to PRODIGE 24, it significantly increases survival compared to gemcitabine) or gemcitabine with capecitabine. Duration is 6 months.

First line for metastatic disease. For patients with good overall status — FOLFIRINOX or gemcitabine + nab-paclitaxel. NALIRIFOX (liposomal irinotecan + oxaliplatin + fluorouracil + leucovorin) is increasingly used — according to NAPOLI 3, this regimen demonstrated an advantage in overall survival.

Second and subsequent lines. Gemcitabine + erlotinib, liposomal irinotecan with fluorouracil, re-administration of platinum-containing regimens if sensitive.

Targeted and Immunotherapy

Olaparib (PARP inhibitor) is the standard of supportive therapy for patients with germline BRCA1/BRCA2 mutations after response to platinum-based chemotherapy (POLO trial). At Ichilov, all patients with adenocarcinoma are recommended to undergo genetic testing to identify these candidates.

Pembrolizumab is used for tumors with high microsatellite instability (MSI-H/dMMR) — this is a rare finding (about 1% of cases), but when identified, immunotherapy provides long-lasting responses.

Larotrectinib and entrectinib are used for tumors with rare NTRK translocations.

Treatment of Neuroendocrine Tumors (NET)

The approach for NET is fundamentally different: growth is slow, sensitivity to conventional chemotherapy is low, but there are effective targeted and radionuclide options.

Somatostatin analogs (octreotide LAR, lanreotide) are the first line for controlling symptoms and tumor growth.

Everolimus (mTOR inhibitor) and sunitinib (multikinase inhibitor) are oral targeted therapies registered for pancreatic NET after progression on somatostatin analogs.

Radionuclide therapy with lutetium-177-DOTATATE (⁷⁷Lu-DOTATATE, the drug "Luvedictra") — a course of 4 infusions at 8-week intervals for patients with receptor-positive tumors according to PET-CT with gallium-68. In Israel, this therapy is widely available, and Ichilov has a nuclear medicine department with the appropriate infrastructure.

Chemotherapy with capecitabine + temozolomide (CAPTEM) is used for more aggressive, well-differentiated NET.

Radiation Therapy

Used as consolidation after chemotherapy for locally advanced tumors, for symptom control, and in rare cases for intraoperative radiation therapy. At Sourasky, SBRT (stereotactic body radiation therapy) is used on linear accelerators with respiratory gating systems.

Treatment Program — Stages

The clinic's experience in working with foreign patients allows minimizing the time between the first contact and the start of treatment.

Stage 1. Remote assessment. The patient sends medical records, CT/MRI scans, and histology reports. The international department translates the documents into Hebrew/English, and the senior oncologist provides a preliminary assessment and drafts an estimated plan and budget. This usually takes 2–5 working days.

Stage 2. Review of slides. If the histology was performed in another country, the slides and paraffin blocks are sent to the Sourasky pathology laboratory. This is critically important: in 5–15% of cases, the review changes the diagnosis, which directly affects the choice of therapy.

Stage 3. Arrival and in-person examination. Usually 3–5 days: CT pancreas protocol, if necessary MRCP, EUS with biopsy, laboratory tests, consultations with the surgeon and oncologist.

Stage 4. Multidisciplinary consultation. The decision on the tactics is made collectively. The patient receives the protocol in hand.

Stage 5. Implementation of the plan. Whipple procedure with subsequent hospitalization for 10–14 days, or cycles of chemotherapy (outpatient in a day hospital), or radionuclide therapy.

Stage 6. Early rehabilitation. Diet, enzyme replacement therapy, blood sugar correction, working with an endocrinologist and dietitian.

Stage 7. Remote monitoring. After returning home, the patient remains in contact with the Ichilov oncologist: interpretation of control CT scans, adjustment of regimens, consultations on any complications.

Prices and Costs

The exact cost of treatment depends on the stage, volume of surgery, and duration of systemic therapy. Below are typical benchmarks in US dollars — these should be considered as a range, and the final estimate is formed after the initial document assessment.

• Consultation with a professor-oncologist or hepatobiliary surgeon: 600–900 USD.
• Review of slides with immunohistochemistry: 800–1,500 USD.
• CT pancreas protocol: 800–1,200 USD; MRCP: 1,200–1,800 USD.
• EUS with fine-needle biopsy: 3,500–5,500 USD.
• ERCP with stent placement: 5,000–7,500 USD.
• Extended molecular profiling (NGS panel): 2,500–4,500 USD.
• Complete diagnostic package "turnkey": 6,000–9,000 USD.
• Whipple procedure with hospitalization: 55,000–75,000 USD.
• Distal pancreatectomy: 40,000–55,000 USD.
• Cycle of FOLFIRINOX or gemcitabine + nab-paclitaxel: 2,500–4,000 USD per cycle.
• One infusion of ⁷⁷Lu-DOTATATE (one of 4): 25,000–35,000 USD.
• Olaparib (monthly course, original drug): 6,500–8,500 USD.

The clinic provides a transparent estimate before the start of treatment and signs a contract with fixed positions. Diagnostic costs are always indicated before surgery — this distinguishes Ichilov from many private networks.

Leading Doctors in the Field

The pancreatic cancer treatment program at Sourasky is led by a multidisciplinary team from several departments — hepatobiliary surgery, gastrointestinal oncology, interventional endoscopy, nuclear medicine, and pathology. After the initial assessment, a treating oncologist is assigned to the patient, and if surgery is planned, a leading hepatobiliary surgeon.

Surgical direction. The department of hepatobiliary and pancreatic surgery at Sourasky performs the full range of interventions — from classic open Whipple surgery to robot-assisted resections and interventions with vascular reconstruction. Surgeons in the department undergo internships at leading European and American centers and participate in international protocols.

Oncological direction. The gastrointestinal oncology department at Ichilov manages patients at all stages: neoadjuvant chemotherapy, adjuvant, metastatic disease, supportive therapy. The clinic participates in international clinical trials, providing patients access to experimental drugs.

Nuclear medicine and radiotherapy. The department is equipped with the latest generation linear accelerators, PET-CT with gallium-68, and infrastructure for radionuclide therapy with lutetium-177.

The specific names of leading doctors are provided in a written response after the remote assessment of documents — this way, the patient immediately knows who is responsible for their case.

FAQ

In what language is treatment conducted?

The international department at Sourasky has Russian-speaking coordinators who accompany the patient from the first letter to discharge. Translators are present at consultations with doctors, and all key documents — discharge summaries, operation protocols, recommendations — are translated into Russian. Additionally, educational materials on nutrition and enzyme replacement therapy are provided in Russian.

What documents are needed to start the program?

For remote assessment, the latest discharge summaries, a disk with CT or MRI, histological conclusion (with the slide number if a review is planned), and results of oncomarkers are sufficient. The clinic accepts documents via email or through a secure portal. If something is missing, the coordinator will advise what to order locally.

How long does diagnosis and treatment take?

The diagnostic phase in Tel Aviv takes 3–5 working days. If a Whipple procedure is planned — hospitalization for 10–14 days plus 2–3 weeks of early rehabilitation before flying home. The chemotherapy course is outpatient: the patient can return home between cycles. Radionuclide therapy with ⁷⁷Lu-DOTATATE involves 4 infusions at 8-week intervals, with visits lasting 3–4 days each.

Is an advance required and how is treatment paid for?

The advance is divided by stages: first, the diagnostic package is paid (which allows clarifying the stage and forming the final estimate), then — surgery or cycles of therapy based on actual services rendered. The clinic accepts bank transfers and cards and signs a contract with a legal entity. There is no cash payment "at the cash desk" at Ichilov.

Who is included in the multidisciplinary consultation?

The pancreatic tumor board at Sourasky makes decisions for each patient with pancreatic cancer: hepatobiliary surgeon, oncologist, radiation therapist, radiologist, endoscopist, pathologist, and nuclear medicine specialist. A geneticist is invited for hereditary syndromes.

Can I get a second opinion on the results without coming in?

Yes, Sourasky provides a second opinion service completely remotely: review of slides, independent assessment of CT by a radiologist at the clinic, and consultation with a specialized oncologist. This is often chosen by patients who have already started treatment at home and want to confirm the correctness of the regimen or discuss alternative protocols.

Will my insurance cover treatment at Ichilov?

The Sourasky Medical Center is a state-municipal clinic that works with most international insurance companies. The international department provides a preliminary estimate that can be sent to the insurer for a guarantee letter. According to the clinic's experience, policies from serious international insurance companies cover treatment fully or with a small co-payment; travel insurance policies usually do not cover oncology.

How is monitoring organized after returning home?

The patient remains assigned to the treating oncologist at Sourasky. Every 3 months, a remote consultation is conducted: the patient sends results of control CT scans and tests, and the doctor sends a written conclusion and, if necessary, adjusts the regimen. If there is suspicion of progression, the clinic promptly organizes a visit for further examination and change of therapy line.

How to obtain a treatment program

Leave a request through the form on the website or contact the international department of Ichilov Clinic directly. Within 24–48 hours, a Russian-speaking coordinator will contact you, request discharge summaries and images, and after a remote review of the documents by the senior oncologist, you will receive a written conclusion, an estimated plan, and budget. If the decision to come is made, the coordinator will arrange an invitation for a visa, hotel booking near the clinic in Tel Aviv, transfer, and the first in-person consultation. All these services are provided free of charge, and the cost is only accounted for the medical part of the program. Treatment for pancreatic head cancer is a marathon, not a sprint, and the right first step is to contact a center with experience and complete infrastructure. For patients from the CIS, Sourasky (Ichilov) has been such a center for over two decades.