I. Preface
The latest statistics in 2014 showed that the estimated number of new cases of pancreatic cancer in the United States ranked 10th in the male population, 9th in the female population, and accounted for the 4th mortality rate of malignant tumors. According to the 2013 China Tumor Registry Annual Report, pancreatic cancer ranks 8th in incidence of malignant tumors in men and 7th in mortality of malignant tumors in the population in China, and its incidence and mortality rates are on a rapid rise worldwide.
In order to further standardize the diagnosis and treatment of pancreatic cancer and improve the level of comprehensive multidisciplinary diagnosis and treatment, the Pancreatic Surgery Group of the Chinese Medical Association combined with the progress in the diagnosis and treatment of pancreatic cancer at home and abroad in recent years, and revised the Guidelines for the Diagnosis and Treatment of Pancreatic Cancer formulated in 2007 to better align with international guidelines and standards and facilitate academic exchange. This guideline is only applicable to pancreatic ductal cancer.
This guideline is only applicable to malignant tumors of pancreatic ductal epithelial origin (pancreatic cancer).
The diagnosis and treatment of pancreatic cancer is recommended to be carried out in a large scale treatment center and under a multi-disciplinary team (MDT) model, including the participation of specialists in surgery, imaging, endoscopy, pathology, medical oncology, intervention, radiotherapy, etc., and throughout the whole process of patient diagnosis and treatment. Based on the patient’s underlying health status, clinical symptoms, tumor stage and pathological type, treatment plans are jointly formulated and multidisciplinary and multiple treatments are applied individually to enable patients to achieve the best treatment effect.
Recommendation level: Category 1: supported by high-level evidence and recommended by consensus of all experts; Category 2A: supported by lower-level evidence and recommended by consensus of all experts; Category 2B: supported by lower-level evidence and recommended by consensus of some experts; Category 3: supported by any level of evidence and more controversial. Unless otherwise indicated, this guideline is recommended at Category 2A level.
Diagnosis and differential diagnosis of pancreatic cancer
(A) Risk factors of pancreatic cancer
The risk of pancreatic cancer is significantly increased in those exposed to naphthylamine and benzene compounds, including smoking, obesity, alcohol abuse, chronic pancreatitis, etc. Diabetes is one of the risk factors for pancreatic cancer, especially in elderly patients with low body mass index and no family history of diabetes, who should be followed up and alerted to the possibility of pancreatic cancer when they have new onset of type 2 diabetes.
Pancreatic cancer has genetic susceptibility and about 10% of patients with pancreatic cancer have genetic background. Patients with hereditary pancreatitis, Peutz-Jeghers syndrome, familial malignant melanoma and other hereditary neoplastic diseases have significantly increased risk of pancreatic cancer.
(ii) Choice of diagnostic methods
The main symptoms of pancreatic cancer include epigastric discomfort, weight loss, nausea, jaundice, steatorrhea and pain, all of which are nonspecific. For patients with clinical suspicion of pancreatic cancer and those at high risk of pancreatic cancer, non-invasive testing means should be preferred for screening, such as serological tumor markers, ultrasound, CT or MRI of the pancreas. The combined results of tumor marker tests and imaging results can improve the positive rate and help the diagnosis and differential diagnosis of pancreatic cancer.
1. Tumor-associated antigen: CA19-9 can be abnormally expressed in patients with various hepatobiliary and pancreatic diseases and malignant tumors. Although it is not tumor-specific, the rising level of serum CA19-9 still helps to differentiate pancreatic cancer from other benign diseases. As a tumor marker, CA19-9 has a sensitivity of 79%-81% and a specificity of 82%-90% for the diagnosis of pancreatic cancer. monitoring of CA19-9 levels is also an important tool for determining postoperative tumor recurrence and assessing the effects of radiotherapy (Category 2B).
In 3% to 7% of patients with Lewis antigen-negative blood group structure, CA19-9 is not expressed, so no abnormal CA19-9 level can be detected in these pancreatic cancer patients. In patients with biliary obstruction or cholangitis due to certain benign diseases, CA19-9 levels may also be elevated, so it is more meaningful to detect CA19-9 after the jaundice has resolved, and it is more accurate to use it as a baseline value (Category 3).
Other tumor markers include carcinoembryonic antigen, CA50 and CA242, etc. The combined application can help to improve the sensitivity and specificity of diagnosis.
2.Abdominal ultrasound: As a screening tool, it can make a preliminary assessment of the site of obstruction and the nature of the lesion. Due to the interference of gas in the gastrointestinal tract and the influence of the operator’s technique and experience level, the sensitivity and specificity are not high and the diagnostic value is limited.
3, pancreatic protocol CT: It is the imaging method of choice for patients suspected of having pancreatic tumors. Special scan parameters should be set for pancreatic tumors, and contrast-enhanced scans should be performed on the whole abdomen, including thin layer (<3 mm), flat scan, arterial phase, parenchymal phase, portal vein phase, and three-dimensional reconstruction, in order to accurately describe the size and location of tumors, the presence or absence of lymph node metastases, especially the structural relationship with surrounding blood vessels, etc.
4.Pancreatic protocol MRI: It is as important as CT, with the same parameter requirements as above. The sensitivity and specificity are better than CT in the exclusion and detection of liver metastases.
Endoscopic ultrasonography (EUS): It is an important supplement to CT and MRI, and can accurately describe the involvement of peripheral vessels and the presence of lymph node metastases, and has better sensitivity and specificity than the detection of superior mesenteric artery in diagnosing the involvement of portal vein or superior mesenteric vein. The accuracy of EUS is influenced by the operator’s technique and experience level.
PET/CT: It is not a substitute for CT or MRI of the pancreas, but as a supplement, it has advantages in excluding and detecting distant metastases. It is recommended for patients with large primary lesions, suspected regional lymph node metastases and significantly elevated CA19-9.
7.Laparoscopic exploration: Routine application is not recommended. For patients with large tumor and suspected abdominal implantation or distant metastasis, laparoscopic exploration is feasible to avoid unnecessary open exploration.
(III) Staging of pancreatic cancer
The staging methods of pancreatic cancer are shown in Tables 1 and 2.
(D) Preoperative pathological diagnosis
For patients with clear imaging diagnosis and indication for surgery, pathological diagnosis is not required before undergoing resection, and surgery should not be delayed because of waiting for pathological diagnosis. For patients who are to be treated with neoadjuvant therapy or unresectable lesions to be treated with radiotherapy, a clear pathological diagnosis must be made before treatment. The ways to obtain tissue or cells for pathological diagnosis include ultrasound or CT-guided percutaneous aspiration biopsy, endoscopic retrograde cholangio-pancreatography (ERCP), pancreatic fluid cell swabbing, EUS-guided fine-needle aspiration biopsy (EUS-FNA), etc. The EUS route is preferred to obtain tissue specimens. The EUS route is preferred for obtaining tissue specimens because its effectiveness and safety are better than other routes, and it can avoid complications such as bleeding, infection and needle tract implantation caused by percutaneous puncture. For patients with typical imaging and negative EUS-FNA biopsies, additional EUS-FNA biopsies should be performed. Because this technique is highly influenced by the operator’s skill and experience, it is recommended to go to a center with larger scale and experience for the examination. For patients who are unresectable for palliative treatment on intraoperative exploration, tissue specimens need to be obtained for pathological diagnosis to guide subsequent radiotherapy, either by direct excisional needle puncture or transduodenal aspiration biopsy, the latter of which can avoid pancreatic fistula due to puncture.
For patients with atypical clinical and imaging manifestations and negative fine-needle aspiration biopsy, attention should be paid to the differentiation of chronic pancreatitis of mass type and autoimmune pancreatitis, with the former being feasible for pancreatic head resection with preservation of duodenum and the latter mostly showing elevated serum IgG4 and effective hormonal therapy. For patients who cannot be clearly diagnosed or have difficulty in ruling out malignancy after multidisciplinary discussion, pancreaticoduodenectomy is feasible on the basis of good communication with patients and families. If the relevant auxiliary examination shows negative manifestation, malignant lesion can be excluded, but when it is difficult to exclude autoimmune pancreatitis, experimental hormone therapy can be tried under close observation.
Surgical treatment of pancreatic cancer
(1) Evaluation criteria of resectability of pancreatic cancer
Under the multidisciplinary collaboration model, the patient’s age, general condition, clinical symptoms, complications, serological and imaging findings are combined to complete the diagnosis and differential diagnosis and assess the resectability of the lesion.
1.resectable: (1) no distant metastasis; (2) normal morphology and structure of superior mesenteric vein and portal vein as shown in the image of imaging examination; (3) clear boundary of abdominal arterial trunk, hepatic artery and fat around superior mesenteric artery.
2.possible resection (borderline resectable): (1) no distant metastasis; (2) limited involvement of superior mesenteric vein and portal vein, stenosis, distortion or occlusion, but their distal and proximal ends are normal and can be resected and reconstructed; (3) tumor wraps around gastroduodenal artery or limited wrapping around hepatic artery, but does not infiltrate into celiac artery trunk; (4) tumor is close to superior mesenteric artery, but does not (4) the tumor is close to the superior mesenteric artery, but not more than 180°.
(3) Unresectable: (1) pancreatic head cancer: (1) distant metastasis; (2) superior mesenteric artery wrapping more than 180°, tumor immediately adjacent to the celiac artery trunk; (3) involvement of superior mesenteric vein or portal vein, unresectable reconstruction; (4) infiltration or wrapping of aorta or inferior vena cava. (2) Tail cancer of pancreatic body: ① distant metastasis; ② wrapping of superior mesenteric artery or abdominal cavernous artery trunk more than 180°; ③ involvement of superior mesenteric vein and portal vein, unresectable for reconstruction; ④ aortic infiltration.
4. Lymph node metastasis status: the presence of lymph node metastasis outside the scope of surgical resection should be considered unresectable.
(B) Preoperative biliary drainage
The effectiveness and necessity of preoperative biliary drainage to relieve obstructive jaundice is controversial in terms of improving patients’ liver function and reducing the incidence of perioperative complications and mortality. Preoperative biliary drainage is not recommended routinely. In patients with combined manifestations of infection such as fever and cholangitis, preoperative biliary drainage is recommended to control infection and improve perioperative safety. Depending on the technical conditions, endoscopic transduodenal papillary stenting or percutaneous transhepatic cholangial drainage (PTCD) can be chosen. If the patient is to be treated with neoadjuvant therapy, a stent should also be placed to relieve jaundice before treatment. If the endoscopic stent is for short-term drainage, a plastic stent is recommended.
Both PTCD and endoscopic stent placement can lead to complications, the former can lead to bleeding, bile leak or infection, the latter can lead to acute pancreatitis or biliary tract infection, and it is recommended to complete these practices in a larger center.
(C) The scope of lymph node dissection for radical surgery of pancreatic head cancer and pancreatic body tail cancer
As for the grouping of lymph nodes in pancreatic cancer, the current domestic and international literature and guidelines are mostly based on the grouping of the Japanese Pancreas Society as the naming standard.
The results of previous limited prospective studies have shown that compared with the standard surgical group, expanded lymph node dissection did not significantly increase the incidence of perioperative complications and mortality, but also failed to improve the prognosis of patients. Therefore, expanded retroperitoneal lymph node dissection is not recommended as a routine procedure. Due to the shortcomings of the aforementioned studies in terms of sample size and comparability between studies, the role of the extent of lymph node dissection and the number of lymph nodes obtained during radical pancreatic cancer surgery in improving prognosis remains controversial. Except for clinical studies, standard lymph node dissection is recommended. Metastases in the lymph nodes around the parietal aorta, the celiac artery trunk and the left side of the superior mesenteric artery can be considered as distant metastases (M1), and further resection is not recommended for patients with preoperative imaging findings suggesting metastases in these areas. For patients with preoperative imaging results showing no abnormality in the above-mentioned areas, but intraoperative metastasis to the above-mentioned lymph nodes is suspected, lymph node freezing biopsy can be performed first. If metastasis is confirmed, there is no consensus in the literature on whether to perform pancreaticoduodenectomy again, but a comprehensive evaluation of the patient’s age, general condition, medical complications, and whether the tumor infiltrates the surrounding blood vessels is possible. A multicenter prospective study on the above mentioned topics is advocated to objectively evaluate the significance of expanded lymph node dissection on improving prognosis.
The standard lymph node dissection areas for pancreaticoduodenectomy for pancreatic head cancer: suprapyloric and inferior lymph nodes (No.5, No.6), lymph nodes in front of common hepatic artery (No.8a), lymph nodes of hepatoduodenal ligament (common hepatic duct, common bile duct and cystic duct lymph nodes, No.12b1, 12b2, 12c), lymph nodes of dorsal superior and inferior margins of pancreaticoduodenum (No.13a-b ), lymph nodes on the right side of the superior mesenteric artery (No.14a-b), and lymph nodes on the ventral superior and inferior margins of the pancreaticoduodenum (No.17a-b). The leptomeninges were completely excised and the right side of the superior mesenteric artery was skeletonized at 180°. The above lymph nodes were excised in whole with the specimen. Routine clearance of posterior hepatic artery (No.8p) and para-abdominal aorta (No.16b1) lymph nodes, clearance of abdominal cavernous artery trunk (No.9), left gastric artery (No.7) and peri-splenic artery (No.11) lymph nodes, and full circumferential clearance of peri-superior mesenteric artery lymph nodes (No.14d-c) are not recommended.
2. Expanded lymph node dissection for pancreaticoduodenectomy for pancreatic head cancer: on the basis of the standard dissection scope, lymph nodes behind the hepatic artery (No.8p), lymph nodes around the celiac artery trunk (No.9), lymph nodes around the intrinsic hepatic artery (No.12a), lymph nodes behind the portal vein (No.12p), lymph nodes around the superior mesenteric artery (No.14a-d), lymph nodes around the abdominal No.16a2, No.16b1). The area to be cleaned up to the hepatic hilum, down to the beginning of the inferior mesenteric artery, right to the right renal hilum and left to the left edge of the abdominal aorta, completing the lymphatic, nerve and connective tissue clearance in the area.
3.The standard lymphatic clearance scope of pancreatic body and tail cancer resection: splenic hilar lymph nodes (No.10), peri-splenic artery lymph nodes (No.11) and lymph nodes at the lower edge of the pancreas (No.18) with the whole specimen removed. For lesions located in the body of the pancreas, the lymph nodes around the abdominal arterial trunk (No. 9) can be cleared (Figure 3). Patients with definite diagnosis of pancreatic body and tail cancer should undergo pancreatic body and tail resection without preserving the spleen.
4. Expanded lymphatic clearance scope of pancreatic body tail cancer resection: on the basis of the standard clearance scope, the lymph nodes around the common hepatic artery (No.8), the lymph nodes around the celiac artery trunk (No.9), the lymph nodes around the superior mesenteric artery (No.14a-d), and the lymph nodes around the abdominal aorta (No.16a2, No.16b1) should be cleared.
5. Correlation between the number of lymph nodes dissected, the ratio of positive lymph nodes and total lymph nodes and prognosis: It is controversial whether there is a correlation between the number of lymph nodes dissected, the ratio of positive lymph nodes and total lymph nodes and prognosis, but a certain number of lymph nodes within the sent specimens can help accurate N staging and guide the subsequent adjuvant treatment. However, this depends on the extent of intraoperative lymph node dissection and the standardized treatment of resected specimens by the pathology department. With the standard lymphatic clearance extent described above, 15 or more lymph nodes should be obtained. In patients after neoadjuvant therapy, the number of lymph nodes obtained can be less than 15.
(D) The resection scope and definition of different resection styles for pancreatic cancer
According to the location of the tumor and the extent of resection, the different ranges of pancreatic resection should be defined accordingly to facilitate academic exchange and summary. In addition, the extent of pancreatic cancer resection is different from the extent of lymph node dissection, and it is appropriate to describe and define them separately.
Standard pancreaticoduodenectomy: the scope of resection includes the head of the pancreas and hook, duodenum and the first jejunum, gallbladder and common bile duct, and lymph node dissection may include the gastric sinus, pylorus and part of the colonic mesentery, but does not include colon resection.
2.Standard distal pancreatectomy: the resection area includes the caudal part of the body of the pancreas, the spleen and splenic artery, and lymph node dissection may include the left Gerota’s fascia and part of the colonic mesentery, but does not include colectomy.
3.Standard total pancreatectomy: the resection area includes the head, neck and tail of the pancreas, as well as the duodenum and the first jejunum, gallbladder, common bile duct, spleen and splenic artery, and lymph node dissection may include the gastric sinus and pylorus, Gerota’s fascia and part of the colonic mesentery, but does not include colectomy.
4. Extended pancreaticoduodenectomy: on the basis of the above standard resection scope, there is resection of any of the following organs: gastrectomy beyond the gastric sinus or the distal 1/2, partial resection of the colonic mesentery and colon, resection of the jejunum above the first segmental extent, partial resection of the portal vein, superior mesenteric vein and/or inferior mesenteric vein, partial resection of the hepatic artery, celiac artery trunk and/or superior mesenteric artery, the partial resection of inferior vena cava, right adrenalectomy, right kidney and its vessels, partial hepatectomy, partial diaphragm resection.
5.Extended distal pancreatectomy: on the basis of the standard scope of resection mentioned above, there is resection of any of the following organs: any scope of gastrectomy, partial mesocolic and colonic resection, any scope of small bowel resection, partial portal vein, superior mesenteric vein and/or inferior mesenteric vein resection, partial hepatic artery, celiac artery trunk and/or superior mesenteric artery resection, partial inferior vena cava resection, left adrenalectomy, left kidney and its vascular resection, partial hepatectomy, partial diaphragm resection.
6.Extended total pancreatectomy: on the basis of the above standard resection scope, there is resection of any of the following organs: gastrectomy beyond the gastric sinus or the distal 1/2, partial mesocolic and colonic resection, resection of the jejunum above the first segment, partial portal vein, superior mesenteric vein and/or inferior mesenteric vein resection, partial hepatic artery, celiac artery trunk and/or superior mesenteric artery resection, partial inferior vena cava resection, right and/or left adrenalectomy, resection of the kidney and its vessels, partial hepatectomy, and partial diaphragm resection.
In the expanded pancreatectomy procedure described above, the specimen should be removed in its entirety. The term “combined organ resection” is no longer recommended, because the standard procedure also includes other organ resections.
There is a lack of high-level evidence to support the indications for the use of the extended resection approach. In the literature, it has been reported that there is no difference in the mortality rate between the two groups, despite the increased operative time, intraoperative blood loss and transfusion, length of hospital stay, and perioperative complication rate when compared with standard surgery; compared with palliative radiotherapy only, extended resection significantly improves the prognosis of patients. Patients requiring expanded resection are mostly in the localized progressive stage, and the role of this procedure in ensuring perioperative safety and improving patient prognosis is not supported by previous studies in terms of sample size and comparability, and there is a lack of multicenter, large sample size prospective studies, which can be considered based on patients’ general condition, clinical performance, tumor resectability assessment, and patient tolerance. Negative sarcomere margins (R0 or R1) should be achieved through extended resection. Multicenter prospective studies on this topic are advocated and encouraged.
The prevention and treatment of common postoperative surgical complications of the pancreas are recommended in the expert consensus developed by the Pancreatic Surgery Group of the Chinese Society of Medical Surgery in 2010.
(V) Treatment of borderline resectable pancreatic cancer (BRPC)
It is recommended to adopt the definition criteria of NCCN guidelines, and the judgment is based on the preoperative pancreatic CT or MRI examination results, mainly based on whether the superior mesenteric vein and portal vein are involved and whether they can be resected and reconstructed, if there is a negative margin and safe reconstruction after combined vein resection, it is considered possible to resect, otherwise it is unresectable. Combined superior mesenteric vein or portal vein resection does not significantly increase the incidence of perioperative complications and morbidity and mortality, and the prognosis is similar to that of patients who undergo standard surgery without venous involvement, so combined venous resection is advocated for pancreatic resection. Combined arterial resection is not recommended because it increases the incidence of perioperative complications and morbidity and mortality without significant improvement in patient prognosis.
For BRPC, direct surgical resection to obtain R1 or R2 resection is more likely (Category 2B), and neoadjuvant treatment is advocated for it, followed by imaging evaluation if the tumor is downstaged or progression-free, and then surgical resection to improve the R0 resection rate. Regarding the significance of neoadjuvant therapy, there are more retrospective findings showing that it improves the R0 resection rate and improves patient prognosis, but does not increase the incidence of perioperative complications. The number of prospective studies on neoadjuvant therapy is limited and the sample size is generally small. Some multicenter prospective studies with large sample size are underway, but there is a lack of high-level evidence and a lack of uniform and standardized treatment cycles and protocols, and multicenter prospective studies on this topic are advocated.
For patients with limited superior mesenteric vein or portal vein involvement and stenosis, direct surgical resection and reconstruction of the involved vein is recommended.
Criteria for determining the cut edge
The presence or absence of tumor cells on the surface of the cut edge is used as a criterion to determine R0 or R1 resection in the previous literature. Based on this criterion, there is no difference in prognosis between R0 and R1 patients, and patients with R0 resection still have a high rate of local recurrence. It is suggested that the presence or absence of tumor infiltration within 1 mm from the incisional margin should be used as the criterion for judging R0 or R1 resection, and if there is tumor cell infiltration in the tissue 1 mm from the incisional margin, it is R1 resection; if there is no tumor cell infiltration, it is R0 resection. Using 1 mm as the judgment principle, there is a difference between the prognosis of R0 and R1 patients. Due to the anatomical location of pancreatic cancer and the adjacent relationship with surrounding blood vessels, most patients with pancreatic cancer are resected as R1. If the cut edge is positive as judged by the naked eye, it is an R2 resection.
The aim of surgery is R0 resection, but due to the anatomical characteristics of the pancreas and the biological behavior of the tumor, it is difficult to avoid R1 resection as the surgical outcome, but it can still improve the patient’s prognosis. Palliative resection refers specifically to R2 resection, whose role in improving prognosis has yet to be evaluated. The literature reports that R2 resection failed to improve patient prognosis and quality of life compared to patients who underwent only palliative short-circuit surgery. Therefore, it is not recommended to be routinely performed and applied outside of specifically conducted clinical studies.
V. Standardized testing of pancreaticoduodenectomy specimens
It is recommended that standardized testing of pancreaticoduodenectomy specimens should be performed by the cooperation of surgeons and pathologists under the premise of ensuring the integrity of the specimen, and the following margins of the specimen should be marked and described separately to objectively and accurately reflect the status of the margins, including the anterior (ventral) margin of the pancreas, the posterior (dorsal) margin of the pancreas, the superior mesenteric vein groove margin of the pancreas, the superior mesenteric artery margin of the pancreas, the pancreatic dissection, the bile duct margin, the jejunum margin, and the bile duct margin. The bile duct cut edge, jejunum cut edge.
In case of combined superior mesenteric vein or portal vein resection, the venous involvement should be reported separately and the following classification should be made according to the depth of infiltration: involvement of the outer membrane of the venous wall; involvement of the venous wall but not the inner membrane; involvement of the whole venous wall.
VI. Palliative treatment
The purpose of palliative treatment is to relieve biliary and digestive tract obstruction, improve the quality of life and prolong survival. For patients with unresectable pancreatic cancer with obstructive jaundice, endoscopic stenting via the duodenal papilla is preferred to relieve jaundice, including metal stents and plastic stents, which can be applied according to patients’ expected survival and economic conditions. Plastic stents have a higher incidence of blockage and induced cholangitis than metal stents and need to be removed and replaced. In patients with duodenal obstruction who cannot be endoscopically stented, percutaneous external drainage via hepatic puncture can be used, or drainage tubes can be placed into the duodenum via the papilla for internal and external drainage. Stenting of the duodenum may also be attempted to relieve gastrointestinal obstruction.
For patients with open exploration or intraoperative diagnosis of unresectability, the gallbladder can be removed and a bile duct jejunostomy Roux-en-Y anastomosis can be performed, but a gallbladder jejunostomy is not recommended because the incidence of rejaundice is significantly higher. In patients who undergo short-circuit surgery, prophylactic gastrojejunostomy and alcohol injection block of the abdominal plexus (Category 2B) may be performed as appropriate.
In some patients with pancreatic head cancer due to local infiltration of the tumor combined with duodenal obstruction, if the tumor is unresectable and the patient’s expected survival is 3-6 months, open or laparoscopic gastrojejunostomy (Category 2B) is recommended, and jejunostomy can be performed at the same time for enteral nutrition. Endoscopic stenting may be attempted in patients with an expected survival of less than 3 months.
There is no high-level evidence to support whether to perform prophylactic gastrojejunostomy in patients with open exploration or intraoperative diagnosis of unresectability. There are reports in the literature that the incidence of late upper gastrointestinal obstruction can be significantly reduced after prophylactic gastrojejunostomy (Category 2B).
VII. Postoperative adjuvant therapy
Postoperative adjuvant chemotherapy for pancreatic cancer is effective in preventing or delaying tumor recurrence and can significantly improve patient prognosis compared with the control group, and should be actively implemented (Category 1). Fluorouracil or gemcitabine monotherapy is recommended for postoperative adjuvant chemotherapy (Category 1), while combination chemotherapy may be considered for patients in good physical condition. Adjuvant therapy should be started as early as possible, with 6 cycles of chemotherapy recommended.
The role of postoperative adjuvant radiotherapy in delaying recurrence and improving prognosis is controversial, and there is a lack of high-level evidence-based medical evidence to support it.
Treatment of unresectable locally progressive or metastatic pancreatic cancer
For unresectable locally progressive or metastatic pancreatic cancer, aggressive chemotherapy can help relieve symptoms, prolong survival and improve quality of life. Depending on the patient’s physical status, options include: gemcitabine monotherapy (Category 1), fluorouracil monotherapy (Category 2B), gemcitabine fluorouracil analogues (Category 1), gemcitabine + albumin-bound paclitaxel (Category 1), and FOLFIRINOX regimen (Category 1). Gemcitabine in combination with molecular targeted therapy is also a viable option (Category 1). Alternative agents such as oxaliplatin are also available for those with progressive tumors.
For unresectable locally advanced pancreatic cancer in good systemic condition, simultaneous radiotherapy or radiotherapy after induction chemotherapy based on gemcitabine or fluorouracil can effectively relieve symptoms and improve patient’s prognosis. The radiotherapy dose in synchronous radiotherapy is 50-54 Gy, and each split dose is 1.8-2.0 Gy.
Other treatments include radiofrequency ablation, cryopreservation, high-energy focused ultrasound, gamma-knife, and radioactive particle implantation, for which there is no clear evidence to prolong survival.
For the comprehensive treatment of locally advanced or metastatic pancreatic cancer, there are many uncertainties in the program, and it is advocated to carry out and participate in relevant clinical studies.
IX. Follow-up of postoperative patients with pancreatic cancer
Patients after resection should be followed up every 3 to 6 months for 2 years after surgery. Laboratory tests include tumor markers, routine blood and biochemical tests, and imaging tests include ultrasound, X-ray and abdominal CT (Category 2B).