The Society of Surgical Oncology surgical practice guidelines focus
on the signs and symptoms of primary cancer, timely evaluation of the symptomatic
patient, appropriate preoperative extent of disease evaluation, and role
of the surgeon in diagnosis and treatment. Separate sections on adjuvant
therapy, follow-up programs, or management of recurrent cancer have been
intentionally omitted. Where appropriate, perioperative adjuvant combined-modality
therapy is discussed under surgical management. Each guideline is presented
in minimal outline form as a delineation of therapeutic options.
Since the development of treatment protocols was not the specific aim
of the Society, the extensive development cycle necessary to produce evidence-based
practice guidelines did not apply. We used the broad clinical experience
residing in the membership of the Society, under the direction of Alfred
M. Cohen, MD, Chief, Colorectal Service, Memorial Sloan-Kettering Cancer
Center, to produce guidelines that were not likely to result in significant
Following each guideline is a brief narrative highlighting and expanding
on selected sections of the guideline document, with a few relevant references.
The current staging system for the site and approximate 5-year survival
data are also included.
The Society does not suggest that these guidelines replace good medical
judgment. That always comes first. We do believe that the family physician,
as well as the health maintenance organization director, will appreciate
the provision of these guidelines as a reference for better patient care.
Symptoms and Signs
- Adenocarcinoma involving the pancreatic head or uncinate process often
causes obstruction of the intrapancreatic portion of the common bile duct,
resulting in jaundice.
- Tumors in the pancreatic body and tail do not obstruct the bile duct,
and therefore, patients are rarely diagnosed prior to the development of
locally advanced or metastatic disease.
- In the absence of jaundice, patients often present with complaints
of vague upper abdominal or back pain, weight loss due to anorexia, decreased
energy level, and nonspecific upper gastrointestinal or dyspeptic symptoms.
- An occasional patient may present with a change in bowel habits secondary
to pancreatic exocrine insufficiency due to tumor obstruction of the pancreatic
duct; bowel movements may be loose, malodorous, and consistent with steatorrhea.
- New-onset hyperglycemia
- Nausea and vomiting secondary to duodenal obstruction
Evaluation of the Symptomatic Patient
- Physical examination
- Liver function tests and ultrasound (to confirm extrahepatic biliary
obstruction in jaundiced patients)
- Extent of disease (both locoregional and distant) is assessed by contrast-enhanced
helical CT scan.
- Distant metastatic disease:
- Confirm cytologic diagnosis.
- Fine needle aspiration (FNA) cytology--CT-guided, endoscopic ultrasound
(EUS)-guided, fluoroscopy-guided paracentesis (if ascites is present)
- Mass in pancreas considered unresectable-- EUS-guided or CT-guided
- No mass in pancreas--endoscopic retrograde cholangiopancreatography
(ERCP) with biopsy demonstrating a malignant stricture
- Evaluation should begin as soon as symptoms are reported.
Appropriate timeliness of surgical referral
Preoperative Evaluation for Extent of Disease
- History and physical examination
- In the absence of hyperbilirubinemia, routine laboratory studies are
of little value in arriving at the diagnosis of a pancreatic neoplasm.
Most patients with adenocarcinoma will evidence a mild degree of hyperglycemia,
yet this finding is often subtle and difficult to discriminate from very
mild adult-onset diabetes mellitus.
- In the absence of extrahepatic biliary obstruction, elevated liver
function tests should raise the suspicion of metastatic disease (as is
true with other solid tumors).
- Intraoperative biopsy has a false-negative rate of at least 30% and
has been associated with such complications as pancreatic fistula and pancreatitis.
Since a negative biopsy is unlikely to alter the therapeutic strategy,
intraoperative biopsy of the pancreas should generally be avoided.
- Many surgeons, however, are reluctant to proceed with pancreaticoduodenectomy
in the absence of cytologic or histologic confirmation of disease. For
those surgeons, EUS-guided or CT-guided FNA is a reasonable alternative.
In patients eligible for clinical trials examining the value of preoperative
radiation, chemotherapy, or both, preoperative EUS-guided FNA is the preferred
method of cytologic confirmation of disease.
- Local criteria for resectability can be determined with a high degree
of accuracy by preoperative imaging modalities.
- The use of contrast-enhanced helical CT obtained at 1.5- or 3.0-mm
section thickness and 5-mm scan interval gives precise information regarding
the relationship of the tumor to the superior mesen- teric artery (SMA),
hepatic artery, and celiac axis. The relationship of the tumor to the superior
mesenteric-portal venous confluence is less reliably assessed by CT scan.
However, the absence of a normal fat plane between the tumor and this venous
structure should suggest the potential for tumor involvement of the lateral
or posterior wall of the superior mesenteric or portal vein.
- Celiac and SMA angiography with venous phase imaging in selected patients
(ie, patients considered for reoperative pancreaticoduodenectomy)
- Absolute criteria for unresectability include:
- The presence of distant metastatic disease
- Encasement of the celiac axis or SMA
- Occlusion of the superior mesenteric-portal venous confluence
Role of the Surgeon in Initial Management
- The majority of patients with pancreatic cancer present with locally
- Following an initial evaluation consisting of a physical examination,
chest x-ray, and contrast-enhanced CT, it is possible to determine the
extent of disease and the potential for surgical resection.
- Biliary decompression, when necessary, in patients with locally advanced,
unresectable primary tumors and/or metastatic disease, should be performed
- Transhepatic decompression is a second-line alternative.
- Laparoscopically assisted cholecystojejunostomy in carefully selected
- In general, biliary enteric bypass via a standard laparotomy should
be reserved for patients who experience repeated episodes of stent occlusion
or cholangitis. The majority of operative biliary enteric bypass procedures
should be performed in patients who are brought to the operating room for
planned pancreatectomy and are found to be unresectable due to unsuspected
metastatic disease or locally advanced primary tumors.
advanced or metastatic disease. The surgeon is often the entry point for
the patient into the realm of therapeutic options.
- For tumors to the right of the mesenteric vessels--pancreaticoduodenectomy
(standard, pylorus-preserving, or extended pancreatectomy to include vascular
resection and reconstruction in highly selected patients)
- For tumors to the left of the mesenteric vessels--distal pancreatectomy
- Palliative open or laparoscopic bypass surgery in selected patients
not amenable to nonoperative biliary decompression
- Endoscopic, laparoscopic, and open laparotomy for biliary decompression
or gastric bypass are all useful in selected patients. The role of each
procedure in the individual patient depends on many variables, and definitive
algorithms are lacking.
These guidelines are copyrighted by the Society of Surgical Oncology
(SSO). All rights reserved. These guidelines may not be reproduced in any
form without the express written permission of SSO. Requests for reprints
should be sent to: James R. Slawny, Executive Director, Society of Surgical
Oncology, 85 W Algonquin Road, Arlington Heights, IL 60005.
Pancreatic cancer remains the fourth leading cause of cancer-related
deaths in adults in the United States. Its etiology is unknown, and there
is currently no effective method of early diagnosis. The development of
molecular techniques to diagnose pancreatic cancer at a time when the tumor
is localized to the pancreas would allow a greater number of patients to
receive potentially curative therapy. In addition, effective treatment
of subclinical, micrometastatic disease (which exists in the liver of most
patients at the time of removal of the primary pancreatic tumor) would
dramatically increase long-term survival rates following pancreaticoduodenectomy.
These are areas of active laboratory investigation and early preclinical
1. Staley CA, Cleary KR, Abbruzzese JL, et al: Need for standardized
pathologic evaluation of pancreaticoduodenectomy specimens: Pancreaticoduodenectomy
specimens. Pancreas 12:373-380, 1996.
2. Evans DB, Abbruzzese JL, Rich TA: Cancer of the pancreas, in DeVita
VT Jr, Hellman S, Rosenberg SA (eds): Cancer: Principles and Practice of
Oncology, 5th ed, pp 1054-1087. Philadelphia, Lippincott, 1997.
3. Spitz FR, Abbruzzese JL, Lee JE, et al: Preoperative and postoperatiave
chemoradiation strategies in patients treated with pancreaticoduodenectomy
for adenocarcinoma of the pancreas. J Clin Oncol 15:928-937, 1997.
4. Fuhrman GM, Charnsagavej C, Abbruz-zese JL, et al: Thin-section contrast
enhanced computed tomography accurately predicts resectability of malignant
pancreatic neoplasms. Am J Surg 167:104-113, 1994.
5. Nitecki SS, Sarr MG, Colby TV, et al: Long-term survival after resection
for ductal adenocarcinoma of the pancreas: Is it really improving? Ann
Surg 221:59-66, 1995.
6. Willet CG, Lewandrowski K, Warshaw AL, et al: Resection margins in
carcinoma of the head of the pancreas: Implications for radiation therapy.
Ann Surg 217:144-148, 1993.
7. Evans DB, Staley CA, Lee JE, et al: Adenocarcinoma of the pancreas:
Recent controversies, current management, and future therapies. GI Cancer
8. Staley CA, Lee JE, Cleary KA, et al: Preoperative chemoradiation,
pancreaticoduodenectomy, and intraoperative radiation therapy for adenocarcinoma
of the pancreatic head. Am J Surg 171:118-125, 1996.
9. Kalser MH, Ellenberg SS: Pancreatic cancer: Adjuvant combined radiation
and chemotherapy following curative resection. Arch Surg 120:899-903, 1985.
10. Gastrointestinal Tumor Study Group: Further evidence of effective
adjuvant combined radiation and chemotherapy following curative resection
of pancreatic cancer. Cancer 59:2006-2110, 1987.
11. Leach SD, Rose JA, Lowy AM, et al: Significance of peritoneal cytology
findings in patients with potentially resectable adenocarcinoma of the
pancreatic head. Surgery 118:472-478, 1995.
12. Robinson EK, Lee JE, Pisters PWT, et al: Reoperatiave pancreaticoduodenectomy
for periampullary carcinoma. Am J Surg 172:432-438, 1996.