Summary of Literature Review
Pancreatic cancer diagnosis and treatment remain among the most challenging areas of oncology. The American Cancer Society estimates that there will be approximately 49,000 cases of pancreatic cancer diagnosed in 2015, with an essentially equal distribution between men and women. This incidence will be associated with approximately 40,500 deaths, again about equal in men and women, and representing 3% of all cancers and 7% of cancer deaths. Even for cases of early-stage disease, the 5-year survival rate between 1999 and 2006 was only 23%. Once the disease involves lymph node metastases, the 5-year survival rate drops to 9%; the 5-year survival rate among patients with metastatic disease is approximately 2%. Given these results, and with no effective screening techniques yet identified, the challenge to develop effective therapy remains daunting.
Treatment recommendations are clearly defined for patients with resectable or distantly metastatic pancreatic cancer. Surgical resection of localized disease remains the only proven curative treatment, and even then, rates of 5-year survival are only 18% to 24%. Widely metastatic disease is treated with chemotherapy. Questions remain regarding the optimal treatment for locally advanced and borderline resectable disease, and the purpose of these appropriateness criteria is to assess the merits of these options for different patient groups (see Variants 1–5).
Diagnosis and Definition of Locally Advanced and Borderline Pancreas Cancer
The clinical evaluation of the patient suspected of having pancreas cancer begins with appropriate imaging studies, ideally through a multidisciplinary clinic or tumor board. Based on these results, surgery at a high-volume institution should be considered in patients with a high likelihood of resection based on current guidelines, with others being spared exploration as a means of defining the extent of their disease.
The most common choice of imaging for visualization of the pancreatic tumor is the multiphase or triphasic computed tomography (CT) scan. Triphasic CT imaging (rapid, small-increment arterial-phase, portal-venous–phase, and parenchymal contrast data sets) allows assessment of the pancreas and adjacent vasculature as compared to standard CT techniques. These images are best obtained prior to interventions such as biopsy or stent placement, as these can limit the accuracy of interpretation. Endoscopic ultrasound can provide information regarding the extent of disease and it can be used to obtain tissue for diagnosis with fine-needle aspiration. Magnetic resonance imaging and magnetic resonance cholangiopancreatography can also be used and may provide more refined assessment of point of pancreatic duct obstruction, peritoneal carcinomatosis, vascular involvement, and small liver lesions.[8,9]
With these tools, the resectability of pancreatic cancer can be determined preoperatively in the great majority of cases. Per the guidelines of the National Comprehensive Cancer Network (NCCN), resectable tumors are those with no arterial tumor contact (ie, no contact with the celiac axis [CA], superior mesenteric artery [SMA], or common hepatic artery [CHA]), no tumor contact with the superior mesenteric vein (SMV) or portal vein (PV), or ≤ 180° contact without vein contour irregularity.
NCCN defines unresectable disease, in lesions of the pancreatic head/uncinate process, as including solid tumor contact with the SMA > 180°, solid tumor contact with the CA > 180°, solid tumor contact with the first jejunal SMA branch, an unreconstructible SMV/PV due to tumor involvement or occlusion, or contact with the most proximal draining jejunal branch into the SMV. In the body and tail of the pancreas, this includes solid tumor contact of > 180° with the SMA or CA, solid tumor contact with the CA and aortic involvement, or unreconstructible SMV/PV due to tumor involvement or occlusion.
Borderline resectable tumors in the pancreatic head/uncinate process are classified as having solid tumor contact with the CHA without extension to the CA, hepatic artery bifurcation allowing for safe and complete resection and reconstruction, or solid tumor contact with the SMA of ≤ 180°. In the pancreatic body/tail, borderline resectable tumors include solid tumor contact with the CA of ≤ 180° and solid tumor contact with the CA of > 180° without involvement of the aorta and with an intact and uninvolved gastroduodenal artery. Borderline unresectable (venous) disease includes solid tumor contact with the SMV or PV of > 180°; contact of ≤ 180° with contour irregularity of the vein or thrombosis of the vein but with a suitable vessel proximal and distal to the site of involvement, allowing for safe and complete resection and vein reconstruction; or solid tumor contact with the inferior vena cava.
The ideal definition of borderline resectable tumor should be free of subjective terminology, can be applied using routine axial pancreatic-protocol CT images, and should be reproducible. According to Katz et al, borderline resectable pancreatic cancer is defined radiographically as localized tumors with 1 or more of the following: (1) interface between the primary tumor and SMV/PV measuring ≥ 180° of the circumference of the vein wall; (2) short-segment occlusion of the SMV/PV, with normal vein above and below the level of obstruction amenable to resection and venous reconstruction; (3) short-segment interface (of any degree) between tumor and hepatic artery, with normal artery proximal and distal to the interface that is amenable to resection and arterial reconstruction; and/or (4) an interface between the tumor and SMA or celiac trunk measuring < 180° of the circumference of the artery wall.
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