Pancreatic Adenocarcinoma Page 1 of 14 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women. Note: Consider Clinical Trials as treatment options for eligible patients CLINICAL DIAGNOSTIC WORK-UP AND TISSUE ACQUISITION PRESENTATION CT scan or ultrasound-guided biopsy of Yes metastatic disease if accessible Clinical suspicion of pancreatic cancer (e.g., jaundice) or evidence of dilated pancreatic Metastases? duct and/or bile duct stricture ● Multidisciplinary planning presentation Yes ● EUS with FNA No ● Liver function tests, CA 19-9 ● CT chest (preferred) or chest x-ray 1,2 Mass in ● Pancreatic CT scan protocol For treatment based 3 pancreas on ● Obtain family history on tissue confirmation 4 imaging? ● Lifestyle risk assessment and clinical staging, see Pages 2-5 No ● Multidisciplinary planning presentation Yes ● Liver function tests, CA 19-9 Biopsy ● CT chest (preferred) or chest x-ray or brushings ● EUS with FNA if mass visualized in pancreas positive? ● ERCP with brushings as clinically indicated No Surgical consult EUS = endoscopic ultrasound FNA = fine needle aspiration ERCP = endoscopic retrograde cholangiopancreatography 1 Pancreatic CT scan protocol: multiphasic cross sectional imaging and thin slices; consider MRI, PET and/or EUS if CT results are equivocal 2 For patients who cannot undergo contrast enhanced CT (allergy, renal issues, etc.) consider MRI as an alternative 3 Consider referral for genetic counseling for patients with a family history of cancer. Universal gerrmline testing recommended for eligible patients. 4 See Physical Activity, Nutrition, and Tobacco Cessation algorithms; ongoing reassessment of lifestyle risks should be a part of routine clinical practice Department of Clinical Effectiveness V6 Approved by the Executive Committee of the Medical Staff on 09/17/2019 Pancreatic Adenocarcinoma Page 2 of 14 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women. Note: Consider Clinical Trials as treatment options for eligible patients PRESENTATION TREATMENT POST-OPERATIVE ● Individualized second line systemic therapy ● Consider best supportive care as indicated Yes ● Pre-operative clinical trial Evidence (preferred) or of locally 3 Post-treatment ● Systemic therapy advanced and/or 4 restaging Adequate and uneventful post-operative ● Consider chemoradiation in metastatic 5 No recovery within 12 weeks : select patients disease? 6 ● Consider adjuvant chemotherapy based on See Resection duration and response to neoadjuvant surveillance 1 Resectable chemotherapy on Page 8 4 pancreatic cancer ● Consider chemoradiation if not previously and low-risk2 given clinical features Adequate and uneventful post-operative recovery within 12 weeks5: 8,9 ● Restaging CT scan ● CA 19-9 Resection7 ● Adjuvant gemcitabine or 6 fluorouracil-based chemotherapy 4 ● Consider chemoradiation following chemotherapy 1 Resectable is defined as: 4 See Appendix B – Chemoradiation and Stereotactic Body Radiation Therapy Regimens ● Patent superior mesenteric vein-portal vein (SMV-PV) confluence 5 If post-operative recovery is greater than 12 weeks, adjuvant therapy will be at the discretion of the treating provider ● No interface between tumor and superior mesenteric artery (SMA) or celiac 6 Typically FOLFIRINOX or GemCape or single agent gemcitabine (see Appendix A – Chemotherapy Regimens) ● No metastases 7 If patient exhibits all low-risk features and all other factors are favorable, primary resection can be considered 2 8 Low-risk features: For patients who cannot undergo contrast enhanced CT (allergy, renal issues, etc.) consider MRI as an alternative 9 ● No suspicion of metastatic disease Pancreatic CT scan protocol: multiphasic cross sectional imaging and thin slices; consider MRI, PET and/or EUS ● CA 19-9 less than or equal to 500 units/mL with normal bilirubin if CT results are equivocal ● Manageable and optimized comorbidities 3 Typically gemcitabine plus paclitaxel or FOLFIRINOX (see Appendix A – Chemotherapy Regimens) Department of Clinical Effectiveness V6 Approved by the Executive Committee of the Medical Staff on 09/17/2019 Pancreatic Adenocarcinoma Page 3 of 14 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women. Note: Consider Clinical Trials as treatment options for eligible patients PRESENTATION TREATMENT Follow metastatic section Staging Yes of this algorithm on Page 7 laparoscopy Yes positive for metastatic Elevated CA 19-9 Yes Is staging disease? and/or other clinical No laparoscopy indications of appropriate? metastatic disease 1 ● Pre-operative clinical trial preferred Resectable 3 4 ● Systemic chemotherapy with chemoradiation pancreatic No 4 Metastases? cancer and or SBRT in select patients 2 ● Restage after each treatment modality high-risk No clinical features Adequate and uneventful postoperative recovery within 12 weeks5: Resection Consider adjuvant chemotherapy6 Characterize/optimize based on duration and response to Comorbidities comorbidities; diet and neoadjuvant chemotherapy3 exercise recommended SBRT = stereotactic body radiation therapy 1 Resectable is defined as: 3 Typically gemcitabine plus paclitaxel or FOLFIRINOX (see Appendix A – Chemotherapy Regimens) See surveillance ● Patent superior mesenteric vein-portal vein (SMV-PV) confluence 4 See Appendix B – Chemoradiation and Stereotactic Body Radiation Therapy Regimens on Page 8 ● No interface between tumor and superior mesenteric artery (SMA) or celiac 5 If post-operative recovery is greater than 12 weeks, adjuvant therapy will be at the discretion of the treating provider ● No metastases 6 Typically FOLFIRINOX or GemCape or single agent gemcitabine (see Appendix A – Chemotherapy Regimens) 2 High-risk features: ● Suspicion of metastatic disease ● CA 19-9 greater than 500 units/mL with a normal bilirubin ● Reversible and optimizable comorbidities Department of Clinical Effectiveness V6 Approved by the Executive Committee of the Medical Staff on 09/17/2019 Pancreatic Adenocarcinoma Page 4 of 14 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson’s specific patient population, services and structure, and clinical information. This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care. This algorithm should not be used to treat pregnant women. Note: Consider Clinical Trials as treatment options for eligible patients PRESENTATION TREATMENT Borderline resectable pancreatic cancer1 For management of progressed/metastatic Clinical trial preferred disease for second line options, see Page 7 Yes ● Clinical trial (preferred) 2 Radiographic, ● Systemic therapy followed by 3 3 and/or biochemical, chemoradiation or SBRT (in Post-treatment and/or clinical select patients) if no evidence of restaging After resection, consider adjuvant evidence of disease 4 progression and/or metastatic progression? chemotherapy based on duration and disease on interval scanning Yes response to neoadjuvant therapy No Multidisciplinary planning presentation and consider Resection? surgical resection No For management of progressed/metastatic disease for second line options, see Page 7 1 MD Anderson Cancer Center’s definition for borderline resectable pancreatic cancer with or without high risk features: Based on anatomic considerations; a tumor abutment of less than or equal to 180° of circumference of superior mesenteric artery (SMA); short-segment encasement abutment of the common hepatic artery or gastroduodenal artery; short-segment occlusion of superior mesenteric vein (SMV) or superior mesenteric vein-portal vein (SMV-PV) and patent vessel above and below. High-risk features: ● Suspicion of metastatic disease ● CA 19-9 greater than 500 units/mL with a normal bilirubin ● Reversible and optimizable comorbidities 2 Typically gemcitabine plus paclitaxel or FOLFIRINOX (see Appendix A – Chemotherapy Regimens) 3 See Appendix B – Chemoradiation and Stereotactic Body Radiation Therapy Regimens 4 Typically FOLFIRINOX or GemCape or single agent gemcitabine (see Appendix A – Chemotherapy Regimens) Department of Clinical Effectiveness V6 Approved