Revised 1 Feb 2014
Treatment options are based on current evidence.
Resectable:
- No evidence of metastatic disease
- No evidence of SMV or PV distortion
- <180o circumferential involvement of SMV or PV
- Clear tissue fat planes around celiac axis, hepatic artery and SMA
- Consider laparoscopy or CT/PET for patients at high risk of metastatic disease
- Laparotomy for planned R0 resection with curative intent
Borderline Resectable:
- No evidence of metastatic disease
- Venous involvement of SMV or PV with distortion of vein or short distance occlusion allowing for resection and reconstruction
- Venous involvement <180o circumference
- Gastroduodenal artery involvement up to hepatic artery but not involving celiac axis
- Multidisciplinary Team review
- While technically resectable these patients should be considered for neoadjuvant therapy
- Biopsy (EUS preferred) to confirm diagnosis
- Stent placement if duct obstruction present
- If biopsy (+) proceed to neoadjuvant therapy
- Restage for consideration of resection including laparoscopy
Stage I – II and Resectable
- Assumes patient physiologically appropriate for surgery and has undergone MDT Review
- Pancreaticoduodenectomy (Whipple procedure: classic or pylorus-preserving)
- Total pancreatectomy when necessary for R0 resection (rare)
- Distal pancreatectomy +/- splenectomy
- Extended lymphadenectomy not indicated
- Resection of adjacent organs only in highly selected patients
- If patient found to be unresectable at time of laparotomy:
- Biopsy confirmation if not previously performed
- Biliary + gastric bypass
- Consider celiac plexus block
- Adjuvant chemotherapy (GIPAJGEM) should be considered for all suitable patients with pancreatic cancer and for node-positive, margin-negative ampullary cancers. Adjuvant chemotherapy should typically commence within 3 months of resection..
- Adjuvant radiation may be considered for resections with positive margins or other adverse clinical features on a case by case basis
- Consider treatment on a clinical trial, if available.
Stage III: Unresectable (Locally Advanced)
- Palliative surgical biliary and/or gastric bypass (usually reserved for patients undergoing attempted Whipple resection and found to have unresectable disease)
- Endoscopic biliary stent placement
- Percutaneous radiologic biliary stent placement
- Palliative chemotherapy may be given to help improve symptoms and quality of life, and extend survival in appropriately selected patients.
- Currently approved chemotherapeutic agents for unresectable pancreatic cancer include: gemcitabine, 5-fluorouracil (5-FU), cisplatin.
- The most commonly used regimens are:
- gemcitabine alone
(GIPGEM)
- 5-FU and cisplatin
(GIFUC)
- single-agent 5-FU (GIAVFL - needs CAP)
- 5-FU, irinotecan and oxaliplatin per the FOLFIRINOX regimen (UGIFIRINOX) is currently under review for funding
- The choice and sequence of chemotherapy is determined by disease-related factors, patient factors and patient preferences as assessed by the medical oncologist.
- Chemoradiation may be considered for selected patients with locally advanced disease who do not progress to distant metastatic disease after initial chemotherapy. Concurrent chemotherapy may be with:
- capecitabine (dosing per GIRCRT)
- Consider treatment on a clinical trial, if available
- If there is a tumour response re-assessment of resectability by a hepatobiliary surgeon could be considered
Stage IV: Metastatic
- Palliative surgical biliary and/or gastric bypass (usually reserved for patients undergoing attempted Whipple resection and found to have unresectable disease)
- Endoscopic biliary stent placement
- Percutaneous radiologic biliary stent placement
- Palliative radiotherapy for pain control
- Palliative chemotherapy may be given to help improve symptoms and quality of life, and extend survival in appropriately selected patients.
- Currently approved chemotherapeutic agents for unresectable pancreatic cancer include: gemcitabine, 5-fluorouracil (5-FU), cisplatin, irinotecan, oxaliplatin.
- The standard 1st line treatment options are:
- gemcitabine alone (GIPGEM)
- 5-FU, irinotecan, and oxaliplatin (UGIFIRINOX)
- Clinical trial if available
- The choice and sequence of chemotherapy is determined by disease-related factors, patient factors and patient preferences as assessed by the medical oncologist.
- 2nd line treatment options include:
- gemcitabine alone (GIPGEM) (if did not receive 1st line)
- single-agent 5-FU (GIAVFL - needs CAP)
- Clinical trial if available
- Symptom management (including celiac or intrapleural block for tumour-related pain), best supportive care, and involvement of palliative care services as indicated by patient’s clinical status.