The treatment of pancreatic cancer is recommended to be carried out in a large scale treatment center and under the model of multidisciplinary treatment team, including the participation of specialists in surgery, imaging, endoscopy, pathology, medical oncology, interventional and radiotherapy, etc., and throughout the whole process of patient treatment. According to the patient’s basic health condition, clinical symptoms, tumor stage and pathology, the patient will be treated by the team.
The treatment plan should be jointly formulated and multidisciplinary and multiple treatments should be applied individually to achieve the best treatment results. This guideline only applies to malignant tumors of pancreatic ductal epithelial origin (pancreatic cancer).
1. Diagnosis and differential diagnosis of pancreatic cancer
(1) Risk factors of pancreatic cancer
(1) Risk factors for pancreatic cancer include smoking, obesity, alcohol abuse, chronic pancreatitis, etc. The risk of pancreatic cancer is significantly increased in those exposed to naphthylamine and benzene compounds. 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, and new onset of type 2 diabetes should be followed up and alerted to the possibility of pancreatic cancer.
The risk of pancreatic cancer is significantly increased in patients with hereditary pancreatitis, Peutz-Jeghers syndrome, familial malignant melanoma and other hereditary tumor disorders.
(2) Choice of diagnostic method
The main symptoms of pancreatic cancer patients include upper abdominal discomfort, weight loss, nausea, jaundice, steatorrhea and pain, all of which are non-specific. For patients with clinical suspicion of pancreatic cancer and those at high risk of pancreatic cancer, non-invasive tests should be preferred for screening, such as serological tumor markers, ultrasound, CT or MRI of the pancreas. The combination of tumor markers and imaging results can increase the positive rate and help to diagnose and differential diagnosis of pancreatic cancer.
2.Surgical treatment of pancreatic cancer
(1) Evaluation criteria of resectability of pancreatic cancer
Under the MDT model, the diagnosis and differential diagnosis are completed by combining the patient’s age, general condition, clinical symptoms, comorbidities, serological and imaging findings to assess the resectability of the lesion.
(2) Preoperative biliary drainage
The effectiveness and necessity of preoperative biliary drainage to relieve obstructive jaundice is controversial in terms of improving the patient’s liver function and reducing the incidence of perioperative complications and morbidity and mortality. Preoperative biliary drainage is not recommended as a routine procedure. If the patient is combined with fever and infectious manifestations such as 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 biliary drainage can be chosen. If the patient is to undergo neoadjuvant therapy, a stent should also be placed to relieve jaundice prior to treatment if jaundice is combined. 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, so it is recommended that these practices be completed in a larger clinic.
(3) Scope of lymph node dissection for radical pancreatic head cancer and pancreatic body tail cancer
For the grouping of lymph nodes in pancreatic cancer, the current domestic and foreign literature and guidelines mostly use the grouping of the Japanese Pancreatic Association as the naming standard, as shown in Figure 1.
3. Judgment criteria of the cut edge
In the previous literature, the presence or absence of tumor cells on the surface of the incisional margin was used as a criterion for judging R0 or R1 resection, and with this criterion, there was no statistically significant difference in prognosis between R0 and R1 resected patients, and R0 resected patients still had 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 R0 or R1 resection. Using 1 mm as the judgment principle, there was a statistically significant difference between the prognosis of R0 and R1 patients. Due to the anatomical location of pancreatic cancer and the proximity to surrounding blood vessels, most patients with pancreatic cancer are resected for R1. If the cut edge is positive by visual judgment, it is R2 resection.
4. Standardized detection of pancreaticoduodenectomy specimens
Standardized testing of pancreaticoduodenectomy specimens is advocated. Under the premise of protecting the integrity of the specimen, the surgical and pathological physicians should cooperate to mark and describe the following cut edges of the specimen to reflect the status of the cut edges objectively and accurately.
5.Palliative treatment
The purpose of palliative treatment is to relieve biliary and digestive tract obstruction, improve the patient’s quality of life and prolong the life span. About 2/3 of pancreatic cancer patients have jaundice. For unresectable pancreatic cancer patients with obstructive jaundice, endoscopic stenting via 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. For patients with duodenal obstruction who cannot be endoscopically placed with stents, percutaneous external drainage via hepatic puncture can be used, or drainage tubes can be placed into the duodenum through the papillae for internal and external drainage, or stents can be placed into the duodenum to relieve gastrointestinal obstruction.
6.Postoperative adjuvant therapy
Postoperative adjuvant chemotherapy for pancreatic cancer is effective in preventing or delaying tumor recurrence and can significantly improve the prognosis of patients compared with the control group, so it should be actively implemented. Fluorouracil or gemcitabine monotherapy is recommended for postoperative adjuvant chemotherapy, while combination chemotherapy can be considered for patients in good physical condition. Adjuvant therapy should be started as early as possible, with 6 cycles of chemotherapy recommended.
7.Treatment of unresectable locally progressive or metastatic pancreatic cancer
For unresectable locally progressive or metastatic pancreatic cancer, aggressive chemotherapy can help to relieve symptoms, prolong survival and improve quality of life. Depending on the patient’s physical status, options include: gemcitabine monotherapy, fluorouracil monotherapy, gemcitabine fluorouracil analogues, gemcitabine + albumin-bound paclitaxel, FOLFIRINOX regimen, etc. Gemcitabine combined with molecular targeted therapy is also a viable option. Alternative drugs such as oxaliplatin can be used for those with tumor progression.
8.Postoperative follow-up of pancreatic cancer patients
Patients after resection should be followed up once every 3-6 months for 2 years after surgery. Laboratory tests include tumor markers, routine blood and biochemistry, and imaging tests include ultrasound, X-ray and abdominal CT.