0 Tis, N0, M0

ⅠA T1, M0, N0

ⅠB T2, N0, M0

IIA T3, N0, M0

IIB T1, N1, M0

IIB T2, N1, M0

IIB T3, N1, M0

III T1, N2, M0

III T2, N2, M0

III T3, N2, M0

III T4, anyN, M0

IV anyT ,< span style="font-family:Times New Roman">anyN, M1

IV.

(a) Principles of treatment.

Integrated multidisciplinary diagnosis and treatment is the basis for the treatment of any stage of pancreatic cancer, and a multidisciplinary consultation model can be used to apply the available treatment methods in a planned and rational manner according to different patients’ physical condition, tumor site, invasion range and clinical symptoms, in order to maximize the eradication and control of tumor, reduce complications and improve patients’ quality of life. The treatment of pancreatic cancer mainly includes surgery, surgery, and surgery. The treatment of pancreatic cancer mainly includes surgery, radiotherapy, chemotherapy, interventional therapy and best supportive therapy. For patients to be treated with radiotherapy or chemotherapy, a Karnofsky (Appendix 7) or 7 should be performed. =”font-family:Times New Roman”>ECOG score (Annex 8).

(ii) Surgical treatment.

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• Principles of surgical treatment
  

Surgical resection is the only effective way for patients with pancreatic cancer to have a chance of cure and long-term survival. However, more than 80% of patients with pancreatic cancer are lost to surgery due to late stage disease. Every effort should be made to perform radical resection (R0) for surgical procedures. Surgical margins are judged using the 1 mm principle of R0/R1 resection criteria, i.e., distance from the margin 1mm from the margin for R0 resection, otherwise R1 resection for R1 excision. Before treating the patient, the necessary imaging and assessment of the systemic condition should be completed, and a multidisciplinary consultation should include diagnostic imaging, pathology, chemotherapy, and radiotherapy.

The assessment of tumor status prior to surgical treatment is clinically important. The tumor is classified as resectable, potentially resectable, or unresectable on the basis of imaging findings before surgery, and specific treatment plans are developed. The determination is based on the presence of distant metastases, invasion of the superior mesenteric vein or portal vein, and the presence of tumors in the fatty spaces around the celiac trunk, hepatic artery, and superior mesenteric artery, as detailed in Appendix 9. Standard surgical treatment is the best way to obtain a good prognosis and should be guided by the following principles.

• Tumor-free principle: including the principle of tumor non-contact, the principle of whole tumor resection and the blockage of tumor supplying vessels.
  
• Adequate scope of resection: ①Standard pancreaticoduodenectomy: The scope of pancreatic The extent of duodenectomy includes 1/3toof the distal stomach family:Times New Roman”>1/2, the full length of the common bile duct and the cut edge of the gallbladder and head of the pancreas on the left side of the superior mesenteric vein/3 cm from the tumor, all of the duodenum, the proximal segment 15 cm of the jejunum; the fascia anterior to the pancreas and the soft tissue posterior to the pancreas were fully resected. Tissue in the region of the hooked eminence with local lymphatic reflux, the nerve plexus in the region. The loose connective tissue around large blood vessels, etc. ②Standard distal pancreatectomy: the scope includes the caudal part of the body of the pancreas, spleen and splenic artery, lymphatic clearance, may include the left renal fascia, may include part of the colonic mesentery, but does not include colonic resection. (3) Standard total pancreatectomy: the scope includes the head, neck and tail of the pancreas, duodenum and first jejunum, gallbladder and common bile duct, spleen and splenic artery, lymphatic clearance, may include the gastric sinus and pylorus, may include the renal fascia, may include part of the colonic mesentery, but does not include colectomy.
  
• Safe margins: pancreatic duodenal resection for pancreatic head cancer requires attention 6 incisional margins, including the pancreas (pancreatic neck), common bile duct (common hepatic duct), stomach, duodenum, retroperitoneum (which refers to skeletal clearance of the superior mesenteric artery), other soft tissue margins (such as posterior pancreatic The margins of the pancreas should be larger than 1mm(no tumor remains microscopically), and the margins of the pancreas can be frozen during surgery to ensure adequate Pathological examination.
  
  style=”margin-left: 72pt”>
  • Lymph node Lymph node dissection: With the standard lymph node dissection range, one should obtain
    

15 or more lymph nodes. Number of lymph nodes acquired in patients after neoadjuvant therapy

can be less than 15 . Whether to perform an expanded lymph node dissection is still controversial, as

This is not recommended for routine extended retroperitoneal lymph node dissection. The extent of lymph node dissection that should be performed in standard radical pancreatic cancer surgery is as follows.

1) Standard lymph node dissection for pancreaticoduodenectomy for pancreatic head cancer: Suprapyloric and inferior lymph nodes (No.5, No.6), anterior lymph nodes of the common hepatic artery (No.8a), lymph nodes of the hepatoduodenal ligament (common hepatic duct, common bile duct and gallbladder lymph nodes, No.12b1, 12b2, 12c), dorsal superior and inferior marginal lymph nodes of the pancreatic duodenum

(No.13a, 13b), lymph nodes on the right side of the superior mesenteric artery (No.14a,14b), lymph nodes on the ventral superior and inferior margins of the pancreaticoduodenum (No.17a,17b).

②Lymphatic clearance for standard pancreatic body tail cancer resection: splenic hilar lymph nodes

(No.10), peri-splenic artery lymph nodes (No.11) Roman”>No.11), lymph nodes at the lower margin of the pancreas

(No.18), and the above lymph nodes were excised in whole with the specimen. For lesions located in the body of the pancreas, the peri-abdominal trunk lymph nodes (No.9) plus part of the superior mesenteric artery (No.14) can be cleared. span>)+ periaortic lymph nodes (No.16).

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• Preoperative yellowing reduction
  

• The main purpose of preoperative yellowing reduction is to relieve biliary obstruction, reduce symptoms such as cholangitis, and at the same time improve liver function, correct coagulation abnormalities, and reduce surgical mortality. However, preoperative routine biliary drainage is not recommended.
  
• Preoperative reduction of yellowing is feasible in patients with severe symptoms, fever, sepsis, and septic cholangitis.
  
  style=”margin-left: 73pt”>
  • Yellowing can be reduced by transnasal bile duct drainage or percutaneous hepatic puncture biliary drainage
    

  (percutaneous transhepatic cholangiodrainage, PTCD) is completed, and choledochostomy is feasible in hospitals without it.

  style=”margin-left: 72pt”>
  • Usually done in decolonization . family:Times New Roman”>2 weeks later, the bilirubin decreases to the initial value of one
    

The procedure can be performed when the liver function recovers and the body temperature and blood picture are normal.

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• Indications for radical surgical resection
  

• Age<80 years, good general condition, multidisciplinary assessment of heart//years =”font-family:Arial”>lung/liver/ Renal function can tolerate the procedure.
  
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  • The clinical staging isStage II pancreatic cancer below.
    
  • No liver metastasis and no ascites.
    
• The intraoperative exploration of the mass was confined to the pancreas and did not invade important vessels such as the mesenteric portal vein and superior mesenteric vein.
  
  style=”margin-left: 72pt”>
  • No distant dissemination or metastasis.
    
  style=”margin-left: 44pt”>
  • Surgical Modality
    
    • Tumor located in the head and neck of the pancreas is feasible for pancreaticoduodenectomy.
      
    • Tumor located in the tail of the pancreatic body can be treated by pancreatic body tail plus splenectomy.
      
    • When the tumor is large and the scope includes the head, neck and body of the pancreas, total pancreatectomy is feasible.
      

Operation.

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• Minimally invasive radical pancreatic cancer radical surgery has been shown to be safe in surgery, lymph node clearance
  

Number of sweeps and R0 resection rates are comparable to open surgery, but its “oncological “benefit to be confirmed by further clinical studies and is recommended to be performed by experienced pancreatic surgeons in a large specialized pancreatic center.

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• Stump anastomosis after pancreatic resection
  

The purpose of post-pancreatic resection stump management is to prevent pancreatic leakage, and pancreatic-enteric anastomosis is the commonly used anastomosis. There are various anastomoses for pancreatic-enteric anastomosis, and the appropriate anastomosis should be selected to reduce the occurrence of pancreatic leakage.

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• Perioperative medication management. Patients undergoing major open heart surgery, regardless of their nutritional status
  

status, immunonutrition is recommended before surgery regardless of their nutritional status 5 to 7 days and continue until 7 days after surgery or until the patient consumes >60% of the required amount by mouth. Immune-enhanced enteral nutrition should contain both ω-3 polyunsaturated fatty acids, arginine, and nucleotide 3 class substrates. Adding any of the above 3 classes of nutrients alone or 1 or 2 species, the role of which requires further study. Oral enteral nutrition support is preferred.

Patients with moderate malnutrition planning major surgery or patients with severe malnutrition are recommended to receive nutritional therapy for 1 to 2 weeks before surgery, even if the surgery is delayed. Patients who are expected to be unable to meet their nutritional needs through a normal diet for more than 7 days after surgery, as well as those who cannot meet 60% of their 1 week, should be given postoperative nutritional therapy.

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• Management of complications and principles of management
  
  • Postoperative bleeding: postoperative bleeding after surgery 24 hours or less for acute
    

bleeding and more than 24 hours for delayed bleeding. This includes mainly abdominal bleeding and gastrointestinal bleeding. The ISGPS established a clinical staging system for postoperative bleeding, which divides postoperative bleeding into A phase, Phase B and Phase C . See Appendix 14.

1) Abdominal bleeding: mainly due to incomplete intraoperative hemostasis, the illusion of bleeding cessation in the intraoperative hypotensive state, or dislodged ligature wires or dislodged electrocoagulation scabs; impaired coagulation mechanisms are also a cause of intraoperative bleeding. The main methods of prevention are close hemostasis during surgery, careful examination before closing the abdomen, important vascular sutures, and preoperative correction of coagulation function. In the event of abdominal bleeding, great attention should be paid to the small amount of bleeding that can be treated conservatively with medication and blood transfusions; in the event of large blood loss in a short period of time, resulting in hemorrhagic shock, surgical hemostasis should be performed as soon as possible.

②Gastrointestinal bleeding: Stress ulcer bleeding, mostly occurring 3 days after surgery

or more. Its prevention and treatment is mainly to correct the patient’s nutritional status before surgery, to minimize the blow of surgery and anesthesia, to treat mainly conservatively, to apply hemostatic drugs, growth inhibitors, proton pump inhibitors, etc., to indwelling gastrointestinal decompression device, to inject 8mg/dl via gastric tube Ice noradrenaline saline, also gastroscopic hemostasis, angiographic embolization. If conservative treatment is ineffective, surgical treatment is indicated.

• Pancreatic fistula: according to 2016 Edition ISGPS criteria, the diagnosis of pancreatic fistula requires that the amylase value in the drainage fluid on the third postoperative day or later reaches the upper limit of normal 3 fold, while producing certain clinical effects that require aggressive clinical treatment. The original 2005 version of A grade pancreatic fistula is changed to a biochemical fistula, not a postoperative pancreatic fistula, independent of the clinical course. B Grade B fistula diagnosis needs to be clinically relevant and affect the postoperative course, including: continuous drainage 3 weeks or more; a clinically relevant change in pancreatic fistula treatment measures; the use of percutaneous or endoscopic puncture drainage; the use of angiographic interventions for bleeding; and the development of signs of infection other than organ failure. Once single or multiple organ dysfunction has occurred, including due to pancreatic fistula infection, the pancreatic fistula classification is adjusted from B to Grade span style=”font-family:Times New Roman”>Class C . The management of pancreatic fistula includes appropriate fasting, effective and adequate drainage, infection control, nutritional support, acid and enzyme suppression, etc. If abdominal bleeding occurs, interventional embolization can be considered to stop the bleeding. Surgical treatment is mainly suitable for patients with pancreatic fistula who have poor drainage, severe abdominal infection or hemorrhage.
  
  style=”margin-left: 72pt”>
  • Gastric emptying disorder
    

  1) There is no unified criterion for gastric emptying disorder, and the commonly used diagnostic criteria are no obstruction of the gastric outflow tract confirmed by examination; gastric fluid > 800 ml/d over 10 days; no significant water-electrolyte and acid-base balance abnormalities; no underlying disease causing gastroparesis; and no drugs affecting smooth muscle contraction.

② Diagnosis is mainly based on history, symptoms, signs, gastrointestinal imaging, gastroscopy, etc.

③The treatment of gastric emptying disorder is mainly based on adequate gastrointestinal decompression, enhanced nutritional psychotherapy or psychological suggestion therapy; application of gastrointestinal motility drugs; treatment of underlying disorders and disorders of nutritional metabolism. Traditional Chinese medicine treatment has good effect on promoting the recovery of gastrointestinal function and shortening the recovery time of gastric emptying.

• Other complications include abdominal infection, biliary fistula, celiac leakage, and long-term postoperative complications.
  
  style=”margin-left: 44pt”>
  • Surgical treatment for those whose tumors may be resected
    

  Patients with potentially resectable tumors have low access to R0 resection rates, and the optimal treatment strategy has been controversial. A neoadjuvant-first treatment model is currently advocated, in which patients with potential benefit are considered for neoadjuvant treatment (chemotherapy, or radiotherapy, or induction chemotherapy followed by concurrent radiotherapy, etc.) in a multidisciplinary discussion, evaluated to achieve tumor downstaging, and then treated with surgery. For patients with sequential tumor resection after neoadjuvant therapy, combined venous resection that achieves R0 radicalization is associated with a comparable survival benefit to resectable patients. The improvement in patient prognosis with combined atherectomy is controversial and needs to be evaluated in a prospective large sample of data. Given the lack of sufficient high-level evidence-based medical evidence, participation in clinical studies is recommended for patients with borderline resectable pancreatic cancer. Surgical exploration can also be performed directly if requested by the patient. Palliative R2 resection is not recommended in this group of patients, except in special circumstances such as life-saving hemostasis.

  style=”margin-left: 40pt”>
  • Surgical treatment of locally advanced unresectable pancreatic cancer
    

  For this group of patients, aggressive treatment is still possible to achieve a better outcome. In patients with tentative duodenal obstruction but expected survival ≥3 months.

Patients with clinical indications for prophylactic gastrojejunostomy; patients with unresectable tumors but combined biliary obstruction, or those who are expected to have possible biliary obstruction, may be considered for choledochal < span style="font-family:Times New Roman">/ common hepatic duct jejunostomy; patients with duodenal obstruction who have an expected survival ≥3 months, gastrojejunostomy is feasible. Intraoperative local treatment of the tumor can be performed by intraoperative radiotherapy and irreversible electroporation therapy (nano-knife ablation) to achieve increased local control rate and pain relief. Postoperative combination chemotherapy ± radiotherapy is required

(iii) Internal medicine treatment.

Medical treatment of pancreatic cancer can be applied to patients at all stages, including preoperative neoadjuvant/conversion therapy for resectable and critically resectable patients, adjuvant therapy for post-radical patients, and treatment for patients with locally advanced or metastatic recurrence. Internal drug therapy not only prolongs survival, but also reduces pain and improves quality of life in patients with advanced disease. Timely medication and dose adjustments are made according to the patient’s condition and physical status score. Emphasis is placed on improving patients’ quality of life and comorbidity management, including pain, nutrition, and psychosomatic. Genetic testing for locally advanced and metastatic pancreatic cancer, including but not limited to BRCA1/2, NTRK1/2/3, PALB2, ATM/ATR and RAS, is recommended prior to medical drug therapy to help guide the optimal drug regimen and participate in clinical studies of new drugs. For patients with advanced metastatic pancreatic cancer who have failed standard therapy, high-throughput sequencing at a qualified genetic testing facility may be considered to find appropriate clinical studies or drug therapies to participate in.

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• Neoadjuvant/translational therapy for resectable or critically resectable pancreatic cancer
  

The goal of neoadjuvant/transformation therapy for patients with resectable or critically resectable pancreatic cancer is to improve surgical R0 resection rates and thereby prolong patient disease-free and overall survival.

However, there is a lack of evidence from high-level clinical studies, and relevant clinical studies are recommended. For resectable pancreatic cancer in good physical status with high-risk factors (e.g.

High serum CA19-9 levels, large primary pancreatic tumors, extensive lymph node metastases, severe wasting, and extreme pain) and Preoperative neoadjuvant/conversion therapy can be considered for patients with borderline resectable pancreatic cancer. Patients who undergo radical surgery 4-8 weeks after preoperative chemotherapy and have no evidence of recurrence or metastasis after surgery are recommended to continue adjuvant chemotherapy after multidisciplinary evaluation, with the regimen taking into account the efficacy of neoadjuvant chemotherapy or other clinical factors such as the patient’s general condition and tolerance of chemotherapy. A two-drug combination based on gemcitabine or a three-drug combination with mFOLFIRINOX is recommended. See Table 2 for details of commonly used regimens.

For patients in poor physical status who cannot tolerate surgical treatment, a puncture biopsy is recommended to clarify the pathology, followed by late palliative chemotherapy and optimal supportive care.

Table 2 Neoadjuvant/translational treatment options for resectable or critically resectable pancreatic cancer

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• Postoperative adjuvant therapy for resectable pancreatic cancer
  

Patients with pancreatic cancer after radical surgery should undergo adjuvant chemotherapy if there is no contraindication. Adjuvant chemotherapy regimens based on gemcitabine or fluorouracil-based agents (5-FU, capecitabine, or tegeo) are recommended; in patients with good physical status, combination chemotherapy, including gemcitabine + capecitabine, mFOLFIRINOX, etc., is recommended. Patients in poorer physical status are recommended to be given gemcitabine or fluorouracil-based monotherapy with optimal supportive therapy. Adjuvant chemotherapy should be initiated within 12 weeks of surgery and continued for 6 months if possible.

Table 3 Postoperative adjuvant adjuvant treatment options for resectable pancreatic cancer treatment options for resectable pancreatic cancer

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• Unresectable locally advanced or metastatic pancreatic cancer
  

The overall treatment of unresectable locally advanced or combined distant metastatic pancreatic cancer is not effective, and clinical studies are recommended. Currently, the commonly used chemotherapeutic agents for unresectable locally advanced or metastatic pancreatic cancer include gemcitabine, albumin-bound paclitaxel, 5-FU/LV, cisplatin, oxaliplatin, irinotecan, tegeo, and capecitabine. Targeted agents include erlotinib.

First-line chemotherapy regimens were selected based on the patient’s fitness status (see Table 4). Combination chemotherapy is recommended for patients in good general condition. For patients with ECOG PS score 0 to 1, the three-drug combination FOLFIRINOX or mFOLFIRINOX regimen can be considered. For patients with advanced pancreatic cancer with BRCA1/2 germline mutations who may be sensitive to platinum drugs, a regimen containing cisplatin or oxaliplatin (GP or FOLFIRINOX, mFOLFIRINOX) may be considered as the first choice. Other regimens include FOLFOX (oxaliplatin/5-FU/LV), CapeOx (oxaliplatin/capecitabine), and FOLFIRI (irinotecan/5-FU/LV) are often used as second-line treatment options.

Follow-up strategies for patients with effective combination chemotherapy include continuing treatment with the previously effective regimen, stopping treatment altogether, withdrawing the more toxic drugs from the previous combination regimen, withdrawal of the more toxic drug from the previous combination regimen, or switching to a new drug for maintenance therapy. For patients with

Patients with BRCA1/2 germline mutations who have not progressed after ≥16 weeks of first-line treatment with a platinum-containing regimen are treated with polyglandular therapy. Patients who have progressed are treated with maintenance therapy with the polyadenosine diphosphate ribose polymerase inhibitor olaparib monotherapy. Patients with systemic BRCA1/2 gene mutations or other abnormalities in the homologous recombination repair pathway may be treated equally with reference to germline mutations. If GN regimen was previously used, gemcitabine monotherapy may be used for maintenance; if (m)FOLFIRINOX regimen was previously used, capecitabine or 5-FU/LV, or FOLFIRI regimen may be considered for maintenance (oxaliplatin maintenance is not recommended due to cumulative neurotoxicity of oxaliplatin).

Patients who have failed first-line therapy may choose nanoliposomal irinotecan + 5-Fu/LV if they are in good health, or they may choose non-overlapping drugs as second-line based on drugs already used in first-line, patient comorbidities and toxicities The patient may choose non-overlapping drugs as second-line chemotherapy or participate in clinical studies. For advanced pancreatic cancer with specific genetic variants (e.g. NTRK fusion, ALK gene rearrangement, HER2 amplification, high microsatellite instability), studies have shown the efficacy of their corresponding targeted therapy or immune checkpoint inhibitor therapy. The first recommendation is to enroll these patients in their corresponding clinical studies, or to consider targeted therapy or immunotherapy with specific targets under the guidance of an experienced medical oncologist.

If the physical status is poor, monotherapy or/and best supportive care is recommended. The continuation of chemotherapy for pancreatic cancer patients after failure of first- or second-line chemotherapy regimens is controversial, and no definitive chemotherapy regimen is available. The WHO criteria for evaluating the efficacy of solid tumors and the RECIST criteria can be used for post-chemotherapy evaluation, as described in Annex 10 and Annex 11.

Table 4 Treatment options for unresectable locally advanced or metastatic pancreatic cancer

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• Surgically resectable pancreatic cancer
  

For surgically resectable limited stage pancreatic cancer that refuses surgical treatment or is medically intolerant to surgical treatment, it is recommended to receive high-dose less fractionated or SBRT radiotherapy in combination with neoadjuvant or concurrent radiotherapy. There is no clear standard for the total dose and fractionated dose of SBRT, and the currently recommended fractionated dose is 5 times per SBRT. span style=”font-family:Times New Roman”>25 to 45 Gy or every 5 sessions 33 to 40 Gy per 6.6 to 8.0 Gy.

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• Critically resectable pancreatic cancer
  

There is no standard model for radiation therapy for borderline resectable pancreatic cancer. High-dose fractionated radiotherapy or SBRT can be administered directly to the tumor area, and radiotherapy followed by surgery to improve R0 resection rate. It is beneficial to improve patient survival. Neoadjuvant radiotherapy

Total radiotherapy dose is 45 at the time of therapy. ~50.4 Gy at 1.8~ 2.0 Gy at 5 weekly exposures, or a total dose of 36 Gy at 2.4 Gy at 5 weekly exposures can be used.

Irradiation. For surgically resectable cases, surgery is recommended around 4 weeks after neoadjuvant radiotherapy or chemotherapy, while for critically resectable cases, the best time to operate is 4 to 8 weeks after neoadjuvant radiotherapy or chemotherapy to allow sufficient time for the tumor to shrink sufficiently before surgery. It is also possible to undergo surgery beyond 8 weeks, but fibrosis from radiation therapy can make surgery more difficult.

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• Low stage pancreatic cancer
  

For locally advanced pancreatic cancer, high-dose fractionated intensity-modulated radiation therapy or SBRT in combination with neoadjuvant or concurrent radiotherapy or chemotherapy. This can have a better prognosis compared to conventional radiotherapy modalities.

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• Oligometastatic pancreatic cancer
  

Patients with metastatic pancreatic cancer who are well treated with systemic systemic therapy or who have a relatively slow rate of progression receive high-dose radiotherapy for both primary and metastatic sites, and the rate of local control translates into prolonged survival time.

style=”margin-left: 85pt”>
• Recurrent pancreatic cancer
  

Patients with recurrent pancreatic cancer after surgery or other local treatments such as radiofrequency therapy are at higher risk for radiotherapy than primary patients because of the adverse gastrointestinal diversion for visualization and previous treatment damage.

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• Postoperative adjuvant radiotherapy
  

Postoperative adjuvant radiotherapy is controversial and lacks high-level evidence-based medical rationale. The use of conventional radiotherapy modalities in combination with chemotherapy may improve the local recurrence rate of tumors compared to chemotherapy alone. The total dose of radiotherapy was 45~50.4 Gy , fractionated dose 1.8~2 Gy per dose, with an additional 52 Gy for sites with high risk of recurrence family:Times New Roman”>~9 Gy.

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• Radiotherapy Techniques
  

SBRT and IMRT including volumetric rotational intensity modulated radiotherapy and spiral tomography intensity modulated radiotherapy, have better dose distribution conformality and focus than 3D conformal radiotherapy, and can increase the dose of pancreatic tumor irradiation without increasing the dose to normal tissues when combined with the synchronous dose of target-in-target or target-in-zone radiation therapy. In the case of pancreatic cancer, it is important to refine all aspects of radiotherapy to improve the accuracy of the target area outline and to reduce positional errors and interference from respiratory motion.

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• Radiotherapy target area
  

For non-surgically resected lesions, irradiation of primary or recurrent pancreatic lesions and metastatic lymph nodes, excluding regional lymph node drainage areas, is recommended.

The target area volume for postoperative radiotherapy should be determined based on preoperative CT scan results or surgically placed silver clips and should include the primary tumor bed and regional high-risk lymph node areas.

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• Radiotherapy dose
  

Increasing the dose of radiotherapy is one of the key factors to improve the local control rate of pancreatic cancer, and the dose pattern to be used is determined by the equipment technology, the optional range is 40 to 70Gy/5 to 20 times, the higher the biologically effective dose, the higher the local control rate, provided that ensure avoidance or reduction of gastrointestinal radiation damage occurrence. The total conventional dose pattern is 45 to 54Gy, with a single dose of 1.8 to 2.0Gy.

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• Concurrent chemotherapy
  

Concomitant chemotherapy regimens with gemcitabine or fluorouracil are preferred as single agents.

(5-FU continuous intravenous infusion, or capecitabine, or S-1), or give multi

drug in combination with gemcitabine or a fluorouracil-based regimen.

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• Intraoperative radiotherapy
  

Intraoperative radiotherapy is usually planned or used when the tumor is found to be unresectable during the exploratory dissection, when the tumor margin is close or when the margin is positive during surgery. Intraoperative electron beam irradiation radiotherapy is recommended for 15 to 20Gy, postoperatively (within 1 month, supplemented with external irradiation 30Gy/10f or 40Gy/10f or 40Gy/10f. Roman”>40Gy/20f.

(v) ERCP and related treatments.

Solely diagnostic ERCP operations are no longer recommended as the first choice for the diagnosis of pancreaticobiliary system diseases, but more is to perform diagnostic cholangiography during therapeutic ERCP operations. A flow chart of the role of pancreatic cancer ERCP diagnosis is shown in Appendix 12.

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• ERCP for preoperative yellowing reduction in pancreatic cancer
  

Cholestasis caused by compression of bile duct strictures by pancreatic cancer theoretically increases the complication rate after surgical treatment, leading to high postoperative mortality and disability rates. Preoperative drainage can also improve the synthetic function of the liver, improve the clearance of endogenous toxins and improve the function of the mucosa of the digestive tract, thus contributing to the smooth operation. In contrast, preoperative reduction of jaundice in pancreatic cancer patients with indications for surgery needs to be carefully considered, and the results of a randomized controlled trial have shown that within the range of surgically acceptable jaundice

(≤250 μmol/l), patients who underwent direct surgery had better postoperative outcomes than those who underwent preoperative biliary The postoperative outcome is better in patients with direct surgery than in patients with preoperative application of biliary stents for anterior reduction of yellowing. Therefore, the selection of the indications for preoperative drainage for yellowing reduction should be strictly controlled, and the indications for preoperative yellowing reduction are as follows.

• Patients with fever, sepsis, and significant cholangitis who require preoperative improvement of symptoms.
  
  style=”margin-left: 72pt”>
  • Patients with severe symptoms, pruritus and purulent cholangitis.
    

style=”margin-left: 85pt”>
• Patients with various reasons for delayed surgery.
  
• Patients who need preoperative radiotherapy or chemotherapy.
  

Reduction of yellowing is possible with nasobiliary drains (ENBD) or removable bile duct stents, avoiding the use of non-removable bare metal stents.

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• ERCPin the treatment of pancreatic cancer without surgical indications
  

More than 80% of pancreatic cancer patients cannot be treated with radical surgery at the time of initial diagnosis because of progressive local invasion or distant metastases, so palliative care for pancreatic cancer patients is particularly important. Therefore, palliative care for pancreatic cancer patients is particularly important, with the goal of relieving symptoms and improving quality of life. Patients with advanced pancreatic cancer 70% to 80% will have bile duct obstruction, and the main objective of palliative care for advanced pancreatic cancer is Bile duct decompression. Compared to PTCD, endoscopic bile duct drainage has a greater chance of successful placement and more accurate stent positioning, less risk of bleeding and bile leakage, and a higher overall complication rate than PTCD. “font-family:Times New Roman”>PTCD is lower. In general, ERCP is recommended as the preferred method for palliative bile duct drainage, only when ERCP is not available, the The use of PTCD was considered only when ERCP was not available, failed, or when endoscopic treatment was not effective. Based on efficacy and cost-effectiveness analysis, plastic bile duct stenting is recommended for patients with an expected survival <3 months, whereas for patients with an expected survival ≥3 months Roman”>≥3 months, a metal biliary stent should be implanted and a nasobiliary drainage tube should be used to reduce pressure and drainage if necessary before stenting.

(vi) Interventional therapy.

Interventional treatment of pancreatic cancer includes: interventional treatment of pancreatic cancer and pancreatic cancer metastases and treatment of complications related to pancreatic cancer, including transarterial infusion chemotherapy, ablation therapy, PTCD, biliary stenting, gastrointestinal stenting, bleeding embolization, abdominal plexus block for cancer pain (celiac

plexus neurolysis, CPN). 1. Principles of interventional therapy

• Must have digital subtraction angiography machine,CT/MR, ultrasound and other image-guided equipment, strictly grasp clinical indications and contraindications, and emphasize standardized and individualized treatment.
  
  style=”margin-left: 72pt”>
  • Interventional treatment is mainly applied to the following cases
    

  ① Locally advanced pancreatic cancer that cannot be surgically resected as assessed by imaging.

  ②Pancreatic cancer that has been lost to surgery for other reasons.

  ③Infusion chemotherapy as a special form of neoadjuvant chemotherapy for pancreatic cancer.

  ④Postoperative prophylactic infusion chemotherapy or adjuvant chemotherapy.

  5 Pancreatic cancer with liver metastases.

  ⑥Treatment of pancreatic cancer-related complications such as control of pain, bleeding, gastrointestinal obstruction and obstructive jaundice.

  style=”margin-left: 44pt”>
  • Transcatheter arterial infusion chemotherapy
    
• Infusion chemotherapy for pancreatic cancer: place catheters selectively in the celiac artery, mesenteric artery, and superior mesenteric artery, respectively. If the tumor-supplying vessels are clearly visible, carefully analyze the imaging performance to clarify the site, size, number and blood-supplying arteries of the tumor, and super-select to the tumor-supplying arteries for perfusion chemotherapy; if the tumor-supplying arteries are not visible, the target vessels should be determined according to the tumor site, invasion range and blood supply as shown by imaging. In principle, tumors in the head and neck of the pancreas are treated by perfusion chemotherapy via the gastroduodenal artery; tumors in the body and tail of the pancreas are mostly treated by perfusion chemotherapy via the celiac artery, superior mesenteric artery or splenic artery.
  
  style=”margin-left: 72pt”>
  • Infusion embolization chemotherapy for liver metastasis of pancreatic cancer: if the patient also has liver
    

liver metastases, then concurrent hepatic artery perfusion chemotherapy and/or embolization is required.

• Primary perfusion chemotherapy is used: commonly used drugs include gemcitabine, fluorouracil, adriamycin (epi-adriamycin), platinum drugs (cisplatin and the new chemotherapy drug lopressor) These drugs are used as single agents or in combination. The drug dose is determined by patient-specific parameters such as body surface area, liver/renal function, and blood count.
  
  style=”margin-left: 44pt”>
  • Ablation therapy
    

  The operating physician must undergo rigorous training and sufficient practice. Before treatment, the patient’s general condition, the tumor situation (size, location, number, etc.), and the relationship between the tumor and the surrounding adjacent organs should be fully evaluated, and the appropriate puncture path and ablation range should be formulated. The choice of appropriate imaging-guided techniques (ultrasound, CT or MRI) and ablative means (e.g. irreversible electroporation treatment).

  Ablation should aim to include at least 5 mm of paracancerous tissue to completely kill the tumor. For some tumors with unclear borders and irregular shapes, it is recommended to extend the ablation area appropriately when the adjacent tissue and structural conditions allow.

  style=”margin-left: 44pt”>
  • Interventional treatment of complications of pancreatic cancer
    
• Interventional Treatment of Jaundice: Approaching 65%～75% of patients with pancreatic cancer have symptoms of biliary obstruction, which can be treated by percutaneous transhepatic endobiliary stenting andPTCD treatment can effectively lower the patient’s bilirubin level, reduce jaundice, diminish symptoms such as pruritus, prevent other complications such as cholecystitis, and provide opportunities for surgery and chemotherapy.
  
• Interventional treatment of GI obstruction. Approximately 5%~10% of pancreatic cancer patients will have symptoms of GI obstruction such as gastric outflow tract obstruction and duodenal obstruction, and GI stenting can reduce early satiety, nausea, postprandial vomiting, body
  

Reducing discomfort such as early satiety, nausea, postprandial vomiting, body weight reduction, and improving patients’ quality of life.

• Interventional treatment of bleeding: For patients with bleeding from the primary site of pancreatic tumor, bleeding from metastatic tumor of pancreatic cancer and post-surgical bleeding, if conservative treatment is ineffective, embolization therapy can be performed to clarify the location of bleeding through interventional angiography. The patient can be embolized by interventional angiography to identify the location of bleeding and embolize the bleeding vessel to stop the bleeding.
  
• Nerve block therapy for cancer pain: Patients with pancreatic cancer causing persistent pain in the upper abdomen, who cannot tolerate the effects of oral pain medication or who cannot tolerate the adverse effects of opioid pain medication, may be considered. Patients with adverse effects may be considered for CPN. The treatment is performed on CT/MR, ultrasound/ Ultrasound endoscopy and other imaging-guided injections of drugs (anhydrous ethanol and local anesthetic drugs) into the abdominal plexus to achieve relief of abdominal pain by blocking the sympathetic pathways innervating the viscera.
  

  (vii) Supportive therapy.

  Common symptoms in patients with end-stage pancreatic cancer can be divided into 4 categories: pain, malnutrition, obstructive jaundice, tumor-associated thrombosis, etc. Optimal supportive care should be provided throughout the treatment of pancreatic cancer, especially in patients with end-stage disease, with the aim of preventing or reducing clinical symptoms and improving quality of life.

  style=”margin-left: 44pt”>
  • Control of pain
    

  Pancreatic cancer invasive pain is the primary symptom for the vast majority of pancreatic cancer patients at the time of presentation. The main causes of pain due to pancreatic cancer include: direct infiltration of the peripheral nerves by pancreatic cancer; inflammation of the peripheral nerves of the pancreas; increased pericardial tension due to pancreatic masses and increased pressure in the pancreatic duct due to pancreatic head masses. Pain management is based on analgesic medication and often requires a combination of surgery, intervention, nerve block, chemotherapy, radiotherapy, psychotherapy, and other multidisciplinary and multimodal combinations to select the best analgesic treatment.

First, the cause of pain needs to be identified, and surgical management is often required for non-cancerous pain caused by emergencies such as gastrointestinal obstruction or perforation. Analgesic drug therapy follows the WHO three step analgesic drug therapy. For mild pain, non-opioid medications such as indomethacin, acetaminophen, and aspirin can be given orally; for moderate pain, weak morphine-based medications such as codeine, commonly used as amfungin and lofungin, are given daily 3 to 3. family:Times New Roman”>4 times; oral morphine should be applied promptly for severe pain. For cancer pain, the degree of pain should be clarified, and oral opioid analgesics should be administered on time and in sufficient quantity according to the patient’s pain level. Avoid only intramuscular injection of pethidine, etc. Pay attention to timely management of adverse reactions to oral pain medications such as nausea and vomiting, constipation, dizziness and headache, etc.

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• Improve nutritional status
  

Patients with pancreatic cancer require routine nutritional screening and assessment, and if they are at nutritional risk or malnourished, they should be treated with aggressive nutritional support to prevent or delay the development of cancer cachexia. Recommended calories 25 to 30kcal/kg/ body weight per day, protein 1.2 to 2.0g/kg body weight, and adjust the nutrition supply according to the patient’s nutritional and metabolic status. For patients with complications, the caloric intake can be increased to 30 to 35kcal/kg body weight, depending on the patient’s nutritional and metabolic status. The amount of nutrients supplied is adjusted according to the patient’s nutritional and metabolic status. Commonly used nutritional support treatments include: nutrition education, enteral nutrition, and parenteral nutrition. The recommended nutritional therapy is based on the five steps of malnutrition. When patients have anorexia or dyspepsia, medications such as medroxyprogesterone or megestrol and pancreatic enzyme tablets can be used to improve appetite and promote digestion.

(H) Chinese medicine treatment of pancreatic cancer.

TCM helps to promote the recovery of body functions after pancreatic cancer surgery, reduce the toxic reactions of radiotherapy, chemotherapy and targeted drug therapy, relieve patients’ symptoms and improve patients’

Quality of life, possibly prolonging survival, can be one of the important means of pancreatic cancer treatment, either alone or in combination with other anti-tumor drugs.

China’s drug regulatory authority once approved a variety of modern Chinese medicine preparations can be used to treat pancreatic cancer, which have been widely used in clinical practice and accumulated certain practical experience, with certain efficacy and respective characteristics, and better patient compliance, safety and tolerability. However, these drugs have been on the market for many years, and early experimental and clinical studies are weak, lacking sufficient support from high-level evidence-based medical evidence, and require active, in-depth research.

In addition to these marketed proprietary Chinese medicines, the use of Chinese herbal medicine compound treatment according to the principles of Chinese medicine diagnosis and treatment is one of the most common methods in Chinese medicine, which can be individualized according to the differences of patients and has certain advantages; it can reduce tumor-related complications, improve patients’ quality of life and prolong their survival. It has certain efficacy in reducing tumor-related complications, improving patients’ quality of life, and prolonging their survival.

The main purpose of follow-up is to detect potential metastatic recurrence that is still amenable to treatment aimed at eradication, to detect tumor recurrence or second primary cancer earlier, and to intervene in a timely manner to manage it in order to improve the overall survival and quality of life of patients. In patients with postoperative pancreatic cancer, the first 1 year after surgery, it is recommended to follow up every 3 months 1 time; in the second 2 to 3 years, every

3 to 6 monthly follow-up visits 1 time; and every 6 monthly follow-up visits 1 . follow-up visits include routine blood, biochemistry, CA19-9, CA125, CEA and other serum tumor markers, ultrasound, X ray, thin-section CT scan of the chest, and enhanced CT of the upper abdomen, etc. At follow-up

At least 5 years for patients with suspected liver metastases or bone metastases, plus liver MRI and bone scan at least every 2 to 3 monthly follow-up visits 1 . follow-up visits include routine blood, biochemistry, CA19-9, CA125, CEA and other serum tumor markers, chest CT, upper abdominal enhancement Attachment

Attachment 1: Preferred roadmap for imaging pancreatic cancer before treatment

Annex 2: Preferred roadmap for imaging follow-up after pancreatic cancer treatment

Annex 3: Diagnostic grading of pancreaticobiliary duct cytology

Ⅰ Not diagnosableⅡ Not malignantIII Atypical

IVNeoplastic lesions

A A A =”font-family:仿宋”>Benign

Plasmacytoid cystadenoma

Neuroendocrine microadenoma lymphangioadenoma

BOther

Intraductal papillary mucinous neoplasm (cells can be mild, moderate, or severe atypical) Mucinous cystic neoplasm (cells can be mild, moderate and severe atypical)

well-differentiated solid neuroendocrine tumors–pseudopapillary tumors

VVV =”font-family:imitation-song”>Suspicious malignancy

VI VI VI =”font-family:imitation-song”>Malignant

Ductal adenocarcinoma

High-grade (G3) neuroendocrine carcinoma adenoidal cell carcinoma

Pancreaticoblastoma lymphoma

Secondary tumors

Pancreatic duodenum

Pancreaticoduodenectomy specimen, distal stomach, greater curvature length cm, lesser curvature length cm, duodenum length < span style="text-decoration:underline"> cm, circumference cm, common bile duct length cm, circumference cm, pancreas size–×–×– cm, in (duodenal papilla/inferior aspect of common bile duct/ (head of pancreas) see (description of appearance) mass, size –×–×– cm, cut surface properties; depth of infiltration (duodenal papilla >/infiltration of the lower bile duct) to . Involvement/ of other organs adjacent to the swelling is not involved. The mucosa of the intestinal canal next to or around the mass/is seen within the muscle wall (polyps/adenoma/ulcerative colitis/required negative visualization), gastric wall visualization (required negative visualization), pancreatic visualization (required negative visualization). (necessary). Duodenal, gastric, common bile duct, pancreatic dissection, and retroperitoneal margins (labeled or sent clinically alone) . Lymph nodes were found in the greater curvature (number/many/more than ten/ (dozens of) pieces, diameter to cm; small curved found lymph nodes
(number/more/more than ten/ (several dozen), with diameters to cm. Lymph nodes were found in the intestinal wall (number

/More/than ten///dozens), with a diameter of
to
cm; mesenteric found lymph nodes (number/ more/more than ten/dozens), with a diameter of
to
cm; peripancreatic lymph nodes were found (number/more/more than ten/dozens), with a diameter of
to
cm.

Annex 5: Routine description of pancreatic cancer as seen microscopically

1. Tumor.

style=”margin-left: 95pt”>
• Tissue staging.
  
• Tissue grading.
  
• Dip and range.
  
• Vascular infiltration.
  

style=”margin-left: 43pt”>
• Perineural infiltrates. 2. Cut margins.
  
  style=”margin-left: 40pt”>
  • Distal pancreas.
    
  • Common bile duct.
    
  • Proximal (stomach).
    
• distal (duodenum). 3. Other pathology seen.
  
  style=”margin-left: 40pt”>
  • Chronic pancreatitis.
    
  • Atypical hyperplasia.
    
  • Chemical growth.
    
  • Other.
    

4. Regional lymph nodes (including gastric, duodenal, parapancreatic and separately sent lymph nodes).

style=”margin-left: 83pt”>
• Total.
  

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• Number of involved. 5. Distant metastases.
  
  • Other tissues/organs.
    

• Special ancillary findings (histochemical staining, immunohistochemical staining, etc.).
  
• Difficult pathologies are referred to higher level hospitals for consultation (provide original pathology report to verify the correctness of the sent sections, reduce errors, provide adequate lesion sections or wax blocks, and what was seen intraoperatively, etc.).
  

Annex 6: Histologic Classification of Pancreatic Tumors (WHO 2019)

Benign epithelial tumors and precursor lesions

8441/0 Plasmacytoid cystadenoma, non-specific Oligocystic plasmacytoid cystadenoma

Solid plasmacytoid adenoma

Mixed plasmacytoma associated with cerebral retinal angiomatosis–endocrine tumors

8441/3 Plasmacytoid cystic adenocarcinoma, non-specific

8148/0 Pancreatic intraepithelial neoplasia, low grade

8148/2 Pancreatic intraepithelial neoplasia, high grade

8453/0 Intraductal papillary mucinous neoplasm with low-grade heterogeneous hyperplasia

8453/2 Intraductal papillary mucinous neoplasm with high-grade heterogeneous hyperplasia

8453/3 Intraductal papillary mucinous neoplasm with infiltrative carcinoma

8455/2 Ductal eosinophilic papillary neoplasm Non-specific type

8455/3 Ductal eosinophilic papillary neoplasm with invasive carcinoma

8503/2 Intraductal tubular papillary neoplasm

8503/3 Intraductal ductal papillary neoplasm with invasive carcinoma

8470/0 Mucinous cystic neoplasm with low-grade heterogeneous hyperplasia

8470/2 Mucinous cystic neoplasm with high-grade heterogeneous hyperplasia

8470/3 Mucinous cystic neoplasm with infiltrative carcinoma Malignant epithelial neoplasm.

8500/3 Ductal adenocarcinoma,Non-specific

8480/3 Glial carcinoma

8490/3 Low-adherent carcinoma

8490/3 Indolent cell carcinoma

8510/3 Medullary carcinoma, non-specific type

8560/3 Adenosquamous carcinoma

8576/3 Hepatocellular carcinoma

8014/3 Large cell carcinoma with transverse myeloid phenotype

8020/3 Undifferentiated carcinoma,Non-specific

8035/3 Undifferentiated carcinoma with osteoblastic giant cells

8550/3 Adenosquamous cell carcinoma

8551/3 Adenocarcinoma of the blastocyst

8154/3 Mixed glandular blasts –Endocrine carcinoma

8154/3 Mixed glandular blasts –Endocrine–Ductal carcinoma

8552/3 Mixed glandular blasts –Ductal carcinoma

8971/3 Pancreaticoblastoma

8452/3 Pancreatic solid< span style="font-family:Times New Roman">–pseudopapillary tumor

Pancreatic solid–Pseudopapillary tumor with high-grade carcinoma pancreatic neuroendocrine tumor

8150/0 Pancreatic neuroendocrine microadenoma

8240/3 Pancreatic neuroendocrine tumor

8240/3 Neuroendocrine Tumors,G1

8249/3 Neuroendocrine tumors,G2

8249/3 Neuroendocrine Tumor,G3

8150/3 Neuroendocrine tumor of the pancreas, no Functional eosinophilic neuroendocrine tumor, no Functional pleomorphic neuroendocrine tumor, no Functional

Transparent cell neuroendocrine tumor, no Functional cystic neuroendocrine tumor, no Functional

Functional pancreatic neuroendocrine tumor

8241/3 Secretion < span style="font-family:imitation-song span style="font-family:Times New Roman">5-hydroxytryptamine tumors

8153/3 Gastrinoma

8152/3 Hyperglycemia

8151/3 Insulinoma

8156/3 Growth-inhibiting hormone tumor

5155/3 VIP tumor

8158/3 Adrenocorticotropin-secreting tumor

8241/3 Chromophobe carcinoid tumor of the intestine

8246/3 Neuroendocrine carcinoma

8154/3 Mixed glandular blasts–Neuroendocrine carcinoma

8154/3 Mixed glandular blasts –Endocrine–Ductal carcinoma

Mature teratoma Mesenchymal tumor Malignant lymphoma Secondary tumor

Annex 7: Karnofsky score (KPS, percent method)

100 Normal health status, no complaints and no obvious objective signs and symptoms.

90 Normal activity with minor signs and symptoms.

80 Very barely able to perform normal activities with some symptoms or signs and symptoms.

70 Self-supporting, but unable to maintain a normal life or work.

60 Mostly able to take care of themselves, but occasionally need help and cannot do their normal work. Mostly able to take care of myself, but occasionally need help with normal tasks.

50 Mostly unable to care for themselves and need frequent treatment and care.

40 Living on their own and needing specialist treatment and care.

30 Complete loss of self-care, requiring hospitalization and Total loss of self-care requiring hospitalization and active supportive treatment.

20 Severe enough to require supportive care.

10 Dying, rapidly deteriorating and near death.

0 Death.

Attachment 8: Zubrod-ECOG-WHO score (ZPS, 5-point scale)

style=”margin-left: 66pt”>
• Normal activity.
  

style=”margin-left: 66pt”>
• Mild symptoms, self-care, able to perform light physical activities.
  

style=”margin-left: 69pt”>
• Tolerate the symptoms of tumor and live on their own, but not more than 50% of the time they are in bed during the day. Severe tumor symptoms with more than 50% of daytime bed rest, but still able to get up and stand, part
  
• Partly self-care.
  

style=”margin-left: 66pt”>
• Seriously ill and bedridden.
  

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• Death.
  

Annex 9: Criteria for resectable pancreatic cancer

resectable status Arterial Venous

Removable pancreatic cancer

Critical resectable pancreatic cancer

No Partial

Progressable

Cutting period

Excluding

Pancreatic cancer

Combined distant metastases

The tumor did not invade the celiac trunk, superior mesenteric artery, or common hepatic artery.

Tumors of the head and neck of the pancreas.

Tumors invading the common hepatic artery but not involving the abdominal trunk or left and right hepatic artery initiation, can be completely resected and reconstructed; the tumor invades the superior mesenteric artery but does not exceed 180 degrees; if a variant artery is present anatomy

(e.g., collateral right hepatic artery, alternative right hepatic artery, alternative common hepatic artery and alternative or collateral arteries of origin), care should be taken to clarify whether tumor invasion and the extent of invasion may influence surgical decisions.

PancreasCaudal tumors.

Tumor invades the abdominal trunk without exceeding 180 degrees; tumor invasion of the abdominal trunk exceeds 180 180 degrees. span>degree, but without invasion of the abdominal aorta and with the gastroduodenal artery intact and uninvaded.

Tumors of the head and neck of the pancreas.

Tumor invading superior mesenteric artery more than180 degrees; tumor invading the celiac trunk more than 180 degrees; tumor invades the first jejunal branch of the superior mesenteric artery.

PancreasCaudal tumors.

Tumor invading superior mesenteric artery or celiac trunk more than

180180 span>degree; tumor invades the abdominal trunk and abdominal aorta. Distant metastases (including non-regional lymph node metastases).

Tumor does not invade the superior mesenteric vein and portal vein, or invades but does not exceed 180degrees, and the vein contour is regular.

< span style="font-family:imitation-song; font-size:12pt">Tumors of the head and neck of the pancreas.

Tumor invading the superior mesenteric vein or portal vein beyond 180 degrees or invasion although not exceeding

180degree, but there is venous contour irregularity; or there is venous thrombosis, which allows for safe venous reconstruction after resection; the tumor touches the inferior vena cava.

< span style="font-size:12pt">胰体/Caudal tumors.

Tumor invasion of splenic vein portal venous confluence, or invasion of the left side of the portal vein does not exceed 180 degree, but there is venous contour irregularity; and there are suitable proximal or distal vessels available for safe and complete resection and venous reconstruction; and the tumor touches the inferior vena cava. Tumors of the head and neck of the pancreas.

Tumor invasion or embolization (tumor thrombus or thrombus) resulting in non-resectable reconstruction of the superior mesenteric vein or portal vein.

The tumor invades most of the proximal jejunal draining branches of the superior mesenteric vein.

Pancreas/Caudal tumors.

Tumor invasion or embolization (possibly tumor embolus or thrombus) leading to unresectable reconstruction of the superior mesenteric vein or portal vein.

Distant metastases (including non-regional lymph node metastases).

Annex 10: WHO criteria for evaluating the efficacy of solid tumors

style=”margin-left: 55pt”>
• Complete remission: complete disappearance of tumor beyond 1 month.
  

• Partial remission: reduction of the product of the maximum tumor diameter and the maximum vertical diameter by up to “font-family:Times New Roman”>50%, with no increase in other lesions that persist beyond 1 . span>months.
  
• Stable lesion: the product of the two diameters of the lesion is reduced by no more than 50%, enlargement not more than 25% for more than 1 month.
  
  style=”margin-left: 44pt”>
  • Progression of the lesion: the product of the two diameters of the lesion increases by more than 25%.
    

Annex 11: RECIST Efficacy Evaluation Criteria

Evaluation of target lesions

Complete remission: all target lesions disappeared.

Partial remission: the sum of the longest diameter of the target lesions is reduced compared to the baseline status by at least 30%.

Lesion progression: increase in the sum of the longest diameter of the target lesion compared to the sum of the longest diameter of the smallest target lesion recorded after the start of treatment 20%, or the appearance of one or more new lesions.

Stable lesions: between partial remission and disease progression. Evaluation of non-target lesions

Complete remission: disappearance of all non-target lesions and return of tumor markers to normal. Incomplete remission/Stable: presence of one or more non-target lesions and/or

persistent above-normal tumor markers.

Progression of lesion(s): One or more new lesions and/or definite progression of existing non-target lesions.

Evaluation of best overall outcome

The evaluation of best overall outcome is the smallest value measured between the start of treatment and disease progression or relapse. Typically, the classification of a patient’s best outcome consists of focal measurement and confirmation.

Annex 12: Flowchart of the role of ERCP in the diagnosis and treatment of pancreatic cancer

Attachment 13: Pancreatic Cancer Treatment Flow

Annex 14: Clinical staging system for postoperative bleeding

Attachment 15

Pancreatic Cancer Guidelines (2022 Edition) Development and Validation Expert Group

(in order of surname stroke)

Team leader: Zhao Yupei Vice team leader: Wang Chengfeng

Members: Wang Liwei, Ba Yi, Shi Susheng, Cong Minghua, Liu Jun, Liu Rong, Liu Xuebao, Tang Zhaohui, Du Chunxia, Li Shengping, Li Jiangtao, Li Yexiong, Li Shu, Yang Yinmer, Yang Zhiying, Yang Lin, Yang Liu, Zhang Taiping, Zhang Jianwei, Chen Rufus, Lin Dongmei, Ouyang Han, Jin Gang, Zhao Xinming, Zhao Haiping, Hao Jihui Qin Renyi, Yuan Yufeng, Peng Li, Peng Bing, Jiang Kui Rong, Fu Deliang, Dai Guanghai, Dai Menghua

Secretary: Zhang Jianwei