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Pancreas

Pancreas

Revised 12 June 2013

Please note:

  • These guidelines reflect current optimal practice in BC and were developed through consensus of the Provincial GI Tumour Group.
  • These guidelines are not a substitute for a consultation with an appropriate specialist.
  • These guidelines are current as of April 2013. Every effort will be made to update them to reflect changes in practice.

The pancreas is comprised predominantly of exocrine cells (acini and ductal cells) and endocrine cells (islets of Langerhans).

The exocrine component gives rise to adenocarcinomata, defined based on line of differentiation (ductal or acinar) , with usual ductal adenocarcinoma (PDAC) being the most common lesion; up to 85% of all malignant neoplasms of the pancreas. Less common subtypes include adenosquamous carcinomas, squamous cell carcinomas, and giant cell carcinomas.​

The ampulla of Vater usually refers to confluence of distal common bile duct and main pancreatic duct in second portion of duodenum near pancreatic head. Ampullary cancers may block the bile duct resulting in clinical jaundice and sometimes diagnosis at an earlier stage. Overall,  ampullary cancers have a better prognosis than pancreatic adenocarcinoma.

1. Screening

Revised 12 June 2013​

There are no effective means of screening for pancreatic cancer or ampullary cancer at this time.

​Screening with EUS or MRI may be indicated in high risk patients including first degree relatives of patients with genetic predisposition to pancreatic carcinoma, carriers of BRCA2 mutations, p16 mutations and patients with Lynch Syndrome with affected first degree relatives, or patients with Peutz-Jeghers syndrome.

2. Diagnostic and Staging Work Up

Revised 12 June 2013

CT scan of the chest and abdomen/pelvis is recommended to assess the extent of local involvement and to exclude distant metastases. A pancreas-protocol CT scan or MRI is indicated if the patient is thought to be an operative candidate. If a mass is not clearly identified or if there is uncertainty regarding vascular involvement, an EUS should be performed.

If there appears to be an isolated pancreatic lesion, refer to a hepatobilliary surgeon who will determine if the disease is resectable or unresectable. If definitive resection is being planned then a biopsy is not always required but may be performed if clinically indicated.

CT/PET scan is not routinely recommended for staging purposes, but may be considered in high-risk patients.

If there are obvious metastases, then the pancreatic mass or metastases can be biopsied percutaneously with ultrasound CT guidance or by endoscopic with fine needle aspiration.

If no metastases are seen on baseline imaging, a laparoscopic evaluation for peritoneal metastases may be considered in high risk patients prior to surgical resection.

​Recommend baseline tumour markers at diagnosis: CEA, CA 19-9

2.1 Biliary Decompression

​Revised 12 June 2013

Patients presenting with jaundice and cholangitis should receive antibiotics and undergo biliary decompression, usually by ERCP.

Patients with jaundice only who are potentially operative candidates do not require stenting unless operative intervention will be delayed by > 1-2 weeks.

CA 19-9 should be repeated after stenting.

Patients without jaundice do not require stenting.

3. Primary Surgical

Revised 12 June 2013

Surgical treatment of pancreatic cancer should be undertaken by surgeons having expertise and experience with these tumours.​

For resectable adenocarcinomas: The goal of surgery should be an R0 resection with curative intent.

  • surgical resection of the primary tumour by a Whipple procedure (pancreaticoduodenectomy) or distal pancreatectomy

For unresectable locally advanced or metastatic adenocarcinoma: palliative surgical biliary and/or gastric bypass, percutaneous radiologic biliary stent placement, or endoscopic biliary stent placement can be considered for symptomatic relief.

4. Pathology

​Revised 12 June 2013

Pathology (per College of American Pathologists 2012)

Specimen: specify

  • Type
  • Procedure

Tumour: specify

  • Site
  • Size
  • Histologic type
  • Histologic grade
  • Microscopic tumour extension
  • Margins
  • Treatment effect (if neo-adjuvant therapy given)
  • Lymph-Vascular invasion
  • Perineural invasion
  • Lymph nodes: number examined, number involved
  • pTNM (AJCC 7th edition)

Additional pathologic findings

6. 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.

7. Follow Up

​Revised 12 June 2013

  • There is no evidence that routine imaging or laboratory investigations are useful in detecting recurrences or metastases at a stage where interventions are curative. Early detection of asymptomatic metastases does not enhance survival.
  • Investigations should be performed based on the clinical presentation of a patient who is suspected of having recurrent or metastatic disease.
SOURCE: Pancreas ( )
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