Introduction
Methodology
Diagnosis and staging
What is the best imaging modality for the diagnosis and staging of PC?
What are the indications for endoscopic ultrasonography (EUS)?
When is cytohistological confirmation necessary before starting treatment?
When is biliary drainage indicated before surgery, and how is it performed?
How is resectability/unresectability of PC defined?
Resectability status | Arterial | Venous |
---|---|---|
Resectable | No arterial tumor contact: celiac axis (CA), superior mesenteric artery (SMA), or common hepatic artery (CHA) | No tumor contact with the superior mesenteric vein (SMV) or portal vein (PV) or ≤ 180° contact without vein contour irregularity |
Borderline resectable | Pancreatic head/uncinate process: Solid tumor with CHA without extension to the celiac axis or hepatic artery bifurcation allowing safe and complete resection and reconstruction Solid tumor contact with the SMA ≤ 180° Solid tumor contact with variant arterial anatomy (e.g., accessory right hepatic artery, replaced right hepatic artery, replaced CHA, and the origin of replaced or accessory artery) and the presence and degree of the tumor should be noted if present, as it may affect surgical planning Pancreatic body/tail: Solid tumor contact with the CA of ≤ 180° Solid tumor contact with the CA of > 180° without involvement of the aorta and with intact and uninvolved gastroduodenal artery (some members prefer these criteria to be in the unresectable category) | Solid tumor contact with the SMV or PV of > 180°, contact of ≤ 180° with contour irregularity of the vein or thrombosis of the vein but with suitable vessels proximal and distal to the site of involvement allowing safe and complete resection and vein reconstruction Solid tumor contact with the inferior vena cava (IVC) |
Unresectable | Distant metastases Pancreatic head/uncinate process: Solid tumor contact with SMA > 180° Solid tumor contact with the CA > 180° Solid tumor contact with the first jejunal SMA branch Body and tail: Solid tumor contact with the SMA or CA Solid tumor contact with the CA and aorta | Pancreatic head/uncinate process: Unreconstructible SMV/PV due to tumor involvement or occlusion (can be due to tumor or bland thrombus) Contact with most proximal draining jejunal branch into SMV Body and tail: Unreconstructible SMV/PV due to tumor involvement or occlusion (can be due to the tumor or a bland thrombus) |
Surgical treatment
When is surgical treatment indicated for PC?
What operative technique should be used for patients with PC according to the localization?
What should be the extent of lymphadenectomy in the surgical treatment of PC?
When and how is vascular resection performed?
When should a total pancreatectomy be considered in PC?
What is the role of staging laparoscopy for assessing resectability in PC?
Is there an indication for surgical resection of metastases in patients with PC?
What should be the recommended annual minimum volume of patients per center and surgeon to obtain optimal surgical results in PC surgery?
Systemic treatment
When is neoadjuvant treatment indicated?
What is the neoadjuvant treatment indicated in patients with borderline tumors?
Which neoadjuvant treatment is indicated in patients with unresectable tumors?
When should adjuvant therapy be given after surgical resection of PC?
What is the appropriate adjuvant treatment for patients with PC who underwent an R0 or R1 resection?
What are the first-line treatment options for metastatic PC?
What is the treatment in patients with metastatic PC who progress after first-line chemotherapy?
Radiotherapy
When is radiotherapy recommended in neoadjuvant treatment?
When is adjuvant radiation therapy indicated?
What is the role of radiotherapy in the treatment of unresectable PC?
What are the most appropriate radiation doses and techniques to treat PC?
Palliative treatment
For patients with unresectable/metastatic PC, what is the preferred method for the management of bile duct obstruction?
For patients with unresectable/metastatic PC, what are the recommended strategies for the management of gastric outlet obstruction?
For patients with unresectable/metastatic PC, what are the recommended strategies for the management of pain?
Pathology
Is it necessary to analyze intraoperative frozen sections of resection margins during pancreatic resections?
What is the best gross dissection protocol of the resection specimen of PC?
When is a resection considered R0?
How many lymph nodes should be histologically examined to improve staging accuracy?
What pathological parameters should be evaluated in the assessment of the resection specimen with PC and after neoadjuvant therapy?
-Type of specimen |
-Maximum size of the tumor |
-Histological type (WHO classification of exocrine pancreatic carcinomas) (Appendix A) |
-Histological grading (Appendix B) |
-Local invasion* |
-Perineural, lymphatic and vascular vessel invasion |
-Superior mesenteric vein or portal vein involvement |
-Resection margins: |
+Surgical transection margins: |
•Pancreatic neck •Common bile duct |
+ Circumferential resection margins: |
•Superior mesenteric vein margin •Superior mesenteric artery margin •Posterior margin •Anterior surface of the pancreas |
- Lymph node involvement |
•Total number of nodes examined •Number of metastatic nodes |
-UICC TNM staging (8th edition) |
-Completeness of excision (R category) |
Grade | Proportion of residual viable tumor |
---|---|
0 | No viable cancer cells (complete histological response) |
1 | Single cells or rare small groups of cancer cells (nearly complete response) |
2 | Residual cancer with evident tumor regression, but more than single cells or rare small groups of cancer cells (partial response) |
3 | Extensive residual cancer with no evident tumor regression (poor or no response) |