Pancreatic Cancer

Use high-resolution pancreas-protocol CT angiography as the principal preoperative study for local staging, vascular mapping, resectability assessment, and surgical planning; MRI is an alternative or complementary modality when needed for staging clarification. Review images in a pancreas-focused multidisciplinary conference before assigning resectability or scheduling resection. ASCO+1ASCOMultidisciplinary Management of Resectable and Borderline Resectable Pancreatic Cancer: How We Work TogetherASCOExploring Perioperative Therapy in Pancreatic Cancer

Establish the diagnosis and stage with cross-sectional imaging plus tissue confirmation when neoadjuvant or palliative systemic therapy is planned. Imaging alone may establish a surgical pathway for a clearly resectable pancreatic mass, but treatment sequencing should be revisited if radiographic findings are equivocal, regional adenopathy is suspicious, or CA 19-9 is elevated. ASCOASCOMultidisciplinary Management of Resectable and Borderline Resectable Pancreatic Cancer: How We Work Together

Use CA 19-9 as a baseline disease-burden and longitudinal monitoring adjunct, not as a screening or independent diagnostic test. A normal result does not exclude pancreatic ductal adenocarcinoma because some tumors do not secrete CA 19-9 in patients with Lewis antigen Le(a−b−). Interpret interval values with imaging-based response assessment rather than using marker change alone to declare progression or response. sciencescienceGenome-wide analyses of cell-free DNA for therapeutic monitoring of patients with pancreatic cancer

For resectable pancreatic ductal adenocarcinoma, surgery-first followed by adjuvant chemotherapy remains a standard pathway. The intent is an R0 resection followed by postoperative systemic treatment; therefore, assess whether the patient can realistically complete multimodality therapy before choosing the sequence. ASCO+1ASCOMultidisciplinary Management of Resectable and Borderline Resectable Pancreatic Cancer: How We Work TogetherASCOExploring Perioperative Therapy in Pancreatic Cancer

Use neoadjuvant chemotherapy selectively in resectable disease with high-risk biology or uncertain stage, particularly elevated CA 19-9, radiographically suspicious lymphadenopathy, or equivocal imaging findings. This approach may clarify disease trajectory before a major operation, but randomized evidence has not yet conclusively established a survival advantage over surgery-first treatment for all upfront-resectable tumors. ASCO+1ASCOMultidisciplinary Management of Resectable and Borderline Resectable Pancreatic Cancer: How We Work TogetherWolters KluwerPancreatic Cancer—Advances in the Last 50 Years : World Journal of Surgery

After resection, use adjuvant combination chemotherapy when tolerable. Combination regimens including modified FOLFIRINOX and gemcitabine-capecitabine have improved disease-free and overall survival compared with gemcitabine in the postoperative setting. Wolters KluwerWolters KluwerPancreatic Cancer—Advances in the Last 50 Years : World Journal of Surgery

Treat borderline-resectable pancreatic cancer with neoadjuvant chemotherapy, potentially followed by chemoradiotherapy, before attempting resection. This applies to limited arterial contact of 180° or less and to portal or superior mesenteric venous involvement that is reconstructable. ASCO+1ASCOMultidisciplinary Management of Resectable and Borderline Resectable Pancreatic Cancer: How We Work TogetherASCOExploring Perioperative Therapy in Pancreatic Cancer

Reassess after neoadjuvant treatment with repeat pancreas-protocol imaging, clinical status, and tumor-marker trajectory when informative. Surgical exploration is appropriate only when the multidisciplinary team judges that an R0 resection is feasible, including vascular reconstruction when required. ASCOASCOMultidisciplinary Management of Resectable and Borderline Resectable Pancreatic Cancer: How We Work Together

Manage locally advanced disease as unresectable at presentation when extensive vascular involvement precludes resection. Systemic therapy is the primary initial modality; radiotherapy may improve local control, while resection is reserved for selected patients with sufficient downstaging and favorable operative anatomy after treatment. ASCOASCOMultidisciplinary Management of Resectable and Borderline Resectable Pancreatic Cancer: How We Work Together

For localized disease receiving perioperative treatment, multiagent cytotoxic chemotherapy is integrated with surgery rather than used as an alternative to curative-intent local therapy. Modified FOLFIRINOX is one commonly used combination regimen; full-dose FOLFIRINOX consists of oxaliplatin 85 mg/m², leucovorin 400 mg/m², irinotecan 180 mg/m², and fluorouracil 2,400 mg/m², with or without a fluorouracil bolus. Oxford Academic+1Oxford AcademicFOLFIRINOX as Initial Treatment for Localized Pancreatic ...Wolters KluwerPancreatic Cancer—Advances in the Last 50 Years : World Journal of Surgery

For metastatic pancreatic cancer, systemic therapy is the core treatment modality. Treatment selection must account for performance status because chemotherapy toxicity is clinically significant; contemporary trial and guideline frameworks commonly evaluate systemic treatment in patients with ECOG performance status 0-2. ASCOASCOTumor Treating Fields With Gemcitabine and Nab-Paclitaxel for Locally Advanced Pancreatic Adenocarcinoma: Randomized, Open-Label, Pivotal Phase III PANOVA-3 Study

Do not routinely expect benefit from immune-checkpoint therapy in unselected pancreatic ductal adenocarcinoma. Pancreatic cancer is largely resistant to immunotherapy, with reported response rates below 5%; investigational immune, cellular, and molecularly targeted approaches should not displace established stage-directed treatment outside appropriate clinical contexts. Oxford Academic+1Oxford AcademicKRAS-driven immune exclusion in pancreatic ductal ...Wolters KluwerRole of CAR-T cell therapy in pancreatic cancer:...

Refer patients with borderline-resectable or locally advanced disease to a center with pancreatic surgical, vascular reconstruction, medical oncology, radiation oncology, and dedicated radiology expertise. Focused review of pancreas-protocol CT can change resectability assignment, and multidisciplinary management is central to treatment planning across localized disease states. ASCO+1ASCOExploring Perioperative Therapy in Pancreatic CancerWolters KluwerPancreatic Cancer—Advances in the Last 50 Years : World Journal of Surgery

Reconsider surgery after induction therapy only through iterative multidisciplinary assessment of vascular anatomy, metastatic progression, treatment tolerance, and the prospect of an R0 resection. Approximately 20% of patients undergo surgery overall, underscoring the need to avoid nonbeneficial exploration in persistently unresectable disease. ASCOASCOMultidisciplinary Management of Resectable and Borderline Resectable Pancreatic Cancer: How We Work Together

Use shared decision-making when choosing surgery-first, neoadjuvant, or nonsurgical treatment, explicitly discussing anatomic resectability, likelihood of completing multimodality therapy, performance status, toxicity burden, and the patient's goals. ESMO+1ESMOESMO Clinical Practice Guideline: Pancreatic CancerASCOTumor Treating Fields With Gemcitabine and Nab-Paclitaxel for Locally Advanced Pancreatic Adenocarcinoma: Randomized, Open-Label, Pivotal Phase III PANOVA-3 Study