Management of Pancreatic Mass

Initial Diagnostic Approach

The European Society for Medical Oncology recommends that clinical presentation suggesting pancreatic cancer should lead without delay to ultrasound of the liver, bile duct, and pancreas 2
When pancreatic malignancy is suspected from clinical symptoms and/or ultrasound findings, further imaging with CT, MRI/MRCP should be performed to accurately delineate tumor size, infiltration, and metastatic disease 2, 3
MD-CT or MRI plus MRCP should be used for staging; EUS can complement staging by providing information on vessel invasion and potential lymph node involvement 1
MD-CT of the chest is recommended to evaluate potential lung metastases 1
The American College of Radiology states that PET scan has no role in the diagnosis of pancreatic cancer 1

The European Society for Medical Oncology recommends that for patients who will undergo surgery with radical intent, a previous biopsy is not obligatory 1
Biopsy should be restricted to cases where imaging results are ambiguous, with EUS-guided biopsy being preferred 1, 4
Percutaneous sampling should be avoided in potentially resectable tumors due to limited sensitivity and risk of tumor seeding 2, 3

The American Society of Clinical Oncology recommends that radical surgery is the only curative treatment option 1, 5
Pancreaticoduodenectomy (with or without pylorus preservation) is the treatment of choice for tumors of the pancreatic head 2, 6
Distal resection of the pancreas (with splenectomy) is appropriate for localized carcinomas of the body and tail 2
Resectional surgery should be confined to specialist centers to increase resection rates and reduce hospital morbidity and mortality 2
Postoperatively, 6 months of gemcitabine or 5-FU chemotherapy is recommended 1

Patients may benefit from neoadjuvant chemotherapy or chemoradiotherapy to achieve downsizing of the tumor and potentially convert to resectable status 1
Patients who develop metastases during neoadjuvant chemotherapy or who progress locally are not candidates for secondary surgery 1

Patients with good performance status may be considered for FOLFIRINOX protocol 5, 7

The FOLFIRINOX protocol can be considered for patients ≤75 years with good performance status (0 or 1) and bilirubin ≤1.5 ULN 5, 7
Patients can be treated with a combination of gemcitabine and erlotinib, but erlotinib should only be continued if skin rash develops within the first 8 weeks 5, 7

Endoscopic stenting is the preferred procedure in unresectable patients 5, 7
Metal prostheses should be preferred for patients with a life expectancy of >3 months 5, 7
If a stent is placed prior to surgery, it should be of the plastic type and placed endoscopically 2
Self-expanding metal stents should not be inserted in patients likely to proceed to resection 2

Patients with severe pain must receive opioids, with morphine generally being the drug of choice 5, 7
Percutaneous or EUS-guided celiac plexus blockade can be considered for patients with poor tolerance to opioid analgesics 5, 7
Hypofractionated radiotherapy may improve pain control and reduce analgesic consumption in selected patients 5

For patients who have undergone resection with elevated preoperative CA19.9 levels, assessment of this marker should be performed every 3 months for 2 years 5, 7
Abdominal CT scan should be performed every 6 months 5, 7
Follow-up should be designed to avoid emotional stress and economic burden for the patient 5, 7

Delaying referral to specialist centers - this reduces resection rates and increases mortality 2
Using percutaneous biopsy techniques for potentially resectable tumors - this risks tumor seeding 1, 2
Inserting self-expanding metal stents in patients who may undergo resection - this complicates surgery 2
Performing extended lymphadenectomy - there is no evidence this is beneficial 1
Routine use of PET scan for staging - this is not currently recommended 1