Treatment Guideline Chart
Pancreatic cancer is malignancy arising from the pancreas.
It is the 13th most common cancer in the world, 10th most common in the United States, and 4th leading cause of cancer-related deaths in the United Stated and Europe.
Exocrine tumors account for 95% of malignant pancreatic disease.
It is more common in women.
The median age of occurrence is at 71 years old.

Pancreatic%20cancer Treatment

Surgical Intervention

  • Surgical resection is the definitive treatment of pancreatic cancer with a goal of achieving negative (R0) margins of resection
    • Upfront surgery is the standard of care for resectable tumors
  • Must be performed 4-8 weeks after neoadjuvant therapy
    • Resection after >8 weeks following neoadjuvant therapy may be difficult due to radiation-induced fibrosis
  • Decisions regarding resectability status should involve multidisciplinary consultation

Resectability Status Criteria

Locally and Clearly Resectable Tumors

  • Distant metastases absent
  • Evidence of superior mesenteric vein (SMV) or portal vein (PV) invasion absent on radiographic exam or ≤180 degrees encasement without vein distortion
  • Surrounding structures of the celiac axis, common hepatic artery (CHA), and superior mesenteric artery (SMA) clear

Borderline Resectable Tumors

  • Distant metastases absent
  • Head/uncinate process: CHA encasement without extension to celiac axis or hepatic artery bifurcation allowing for complete resection and reconstruction; ≤180 degrees contact with SMA
  • Body/tail: ≤180 degrees contact with the celiac axis or >180 degrees contact with celiac axis without involvement of the aorta and with intact and uninvolved gastroduodenal artery
  • >180 degrees contact of tumor with SMV/PV or ≤180 degrees contact with SMV or PV venous involvement with distortion or narrowing, or venous occlusion with patent proximal and distal vessel allowing venous reconstruction
  • Solid tumor contact with the inferior vena cava (IVC)

Locally Advanced Tumors

  • Head/uncinate process: Distant metastases present; >180 degrees SMA encasement or celiac axis abutment; unreconstructable SMV/PV occlusion
  • Body/tail: Distant metastases present; >180 degrees SMA or celiac axis encasement; unreconstructable SMV/PV occlusion; tumor contact with the celiac axis and aortic involvement
  • All: Metastases to lymph node beyond the field of resection

Surgical Procedures

Pancreatoduodenectomy (Whipple Technique)

  • Procedure of choice for pancreatic head and uncinate tumors
  • Preserves the distal stomach and pylorus
    • Further studies are suggested to prove the benefit of pylorus-preserving pancreatoduodenectomy as an alternative to the classic pancreatoduodenectomy
    • Extended lymphadenectomy does not increase overall survival of patients undergoing Whipple technique

Distal Pancreatectomy with En-bloc Splenectomy

  • Procedure of choice for pancreatic body and tail tumors
  • Reports have shown a tumor clearance of 72-91% after distal pancreatectomy, with good long-term survival rates comparable to that of total resection for localized tumors
  • Minimally invasive distal pancreatectomy (MIDP) may be considered for benign and low-grade malignant tumors
    • Shown to have equivalent complication rates compared with open distal pancreatectomy and is associated with shorter hospital stay and reduced blood loss

Total Pancreatectomy

  • The only curative treatment option for pancreatic cancer patients with stage I/II disease
  • Indicated for multifocal tumors and tumors with borders that cannot be delineated with other techniques
  • Involves removal of the entire pancreas, part of the small intestine, portion of the stomach, common bile duct, gall bladder, spleen and nearby lymph nodes 
  • Not recommended for patients ≥75 yr due to possible comorbidities
Editor's Recommendations
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