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Treatment Options

​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 ReviewPancreaticoduodenectomy (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 tumor 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.

SOURCE: Treatment Options ( )
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