Introduction
Diagnosis and staging
Diagnosis
Complete history and physical examination |
Laboratory test: blood count and serum chemistry including PCR, albumin and levels of the carbohydrate antigen CA19-9 |
CT of the chest and abdomen |
Histologic or cytologic diagnosis |
Bone scan in presence of bone pain, elevated serum calcium or elevated alkaline phosphatase levels |
In patients with resectable tumors (optional), border-line or locally advanced pancreatic cancer (mandatory) |
EUS+FNA |
In patients with borderline resectable tumors |
Diagnostic laparoscopy will be assessed in cases of suspicion of peritoneal involvement (no consensus) |
Staging system
Primary tumor (T) |
T1: Maximum tumor diameter ≤2 cm |
T2: Maximum tumor diameter >2 ≤ 4 cm |
T3: Maximum tumor diameter >4 cm |
T4: Tumor involves the celiac axis or the superior mesenteric artery (unresectable primary tumor) |
Regional lymph nodes (N) |
N0: No regional lymph node metastasis |
N1: Metastasis in 1–3 regional lymph nodes |
N2: Metastasis in 4 regional lymph nodes |
Distant metastases (M) |
M0: No distant metastasis |
M1: Distant metastasis |
Stage | T | N | M |
---|---|---|---|
0 | Tis | N0 | M0 |
IA | T1 | N0 | M0 |
IB | T2 | N0 | M0 |
IIA | T3 | N0 | M0 |
IIB | T1–3 | N1 | M0 |
III | Any T T4 | Any N | M0 |
IV | Any T | Any N | M1 |
Resectability status | Distant metastases | Arterial | Venous |
---|---|---|---|
Resectable | No | 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 |
Boderline resectable | No | Head/uncinated process: Solid tumor contact with CHA without extension to CA or hepatic artery bifurcation allowing for safe and complete resection and reconstruction Solid tumor contact with the SMA of ≤180° Body and 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 | 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 vessel proximal and distal to the site of involvement allowing for safe and complete resection and vein reconstruction Solid tumor contact with the inferior vena cava (IVC) |
Unresectable | Yes (including non-regional lymph node metastasis) | Head/uncinated process: Solid tumor contact with SMA >180° Solid tumor contact with CA >180° Solid tumor contact with the first jejunal SMA branch Body and tail: Solid tumor contact of >180° with de SMA or CA Solid tumor contact with the CA and aortic involvement | Head/uncinated process: Unreconstructible SMV/PV due to tumor involvement or occlusion (can be due 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 tumor or bland thrombus) |
Recommendations
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Laboratory test with CA19-9, CT chest and abdomen, histologic or cytologic diagnostic, EUS in resectable tumors (IV, C).
Treatment
Resectable disease
Recommendations
Borderline resectable disease
Recommendations
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Patients with borderline resectable lesions should be included in clinical trials wherever possible. Acceptable regimens include FOLFIRINOX or gemcitabine + albumin-bound paclitaxel (III, B).
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Chemoradiation with gemcitabine or capecitabine-based regimens are another option (III, C).
Locally advanced unresectable disease
Recommendations
Metastatic disease
Recommendations
Supportive care
Recommendations
Follow-up
Recommendations
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There is no evidence that regular follow-up after initial therapy with curative intent is useful (IV, D).