Pancreatic Cancer Resectability Assessment - NCCN 2024

Algorithm Steps

1. ▶

   Start

   Pancreatic Adenocarcinoma Diagnosed

   Biopsy-proven or highly suspicious imaging

   1. ●

      Action

      Staging Workup

      Pancreas protocol CT, CA 19-9, staging laparoscopy

      • High-quality CT with arterial/venous phases
      • Assess SMA, celiac, SMV, portal vein
      • Check for liver mets, peritoneal disease
      1. ◆

         Decision

         Distant Metastases?

         • Liver mets
         • Peritoneal implants
         • Distant lymph nodes
         • Positive peritoneal cytology
         1. ●

            Action

            Metastatic Disease

            Systemic therapy

            • FOLFIRINOX or gem/nab-paclitaxel
            • Palliative care integration
            • Biliary stent if obstructed
            1. ■

               End

               Adjuvant Therapy & Surveillance

               Complete 6 months perioperative chemo, surveillance CT/CA 19-9

         2. ◆

            Decision

            Vascular Involvement (NCCN)

            • Resectable: no arterial contact, no/minimal venous contact
            • Borderline: venous involvement or limited arterial abutment
            • Locally Advanced: unreconstructable venous or arterial encasement
            1. ●

               Action

               Resectable

               No vascular involvement or reconstructable

               1. ●

                  Action

                  Upfront Surgery

                  If excellent PS, no high-risk features

                  1. ●

                     Action

                     Surgical Resection

                     Whipple or distal pancreatectomy

                     • High-volume center preferred
                     • Vascular resection if needed
                     • R0 resection goal
               2. ●

                  Action

                  Neoadjuvant Therapy

                  FOLFIRINOX or gem-based

                  • 2-4 months of chemo ± RT
                  • Restaging CT after treatment
                  • Proceed to surgery if no progression
            2. ●

               Action

               Borderline Resectable

               May be resectable after neoadjuvant

               • SMV/PV involvement with reconstruction possible
               • SMA abutment ≤180°
               • GDA encasement up to hepatic artery
            3. ●

               Action

               Locally Advanced

               Not currently resectable

               • SMA/celiac encasement >180°
               • Unreconstructable SMV/PV
               • Aortic invasion
               1. ●

                  Action

                  Induction Therapy

                  Goal: convert to resectable

                  • FOLFIRINOX preferred if tolerated
                  • SBRT or chemoRT
                  • Reassess for resectability