Pancreatic Cancer

Question 1

What is defined as resectable pancreatic disease?

Answer 1

No arterial tumor contact w/celiac axis, SMA, and common hepatic artery. No contact with the PV or SMV or less than or equal to 180 contact of the vein

Question 2

What is the definition of borderline resectable pancreatic cancer in terms of artery encroachment?

Answer 2

Solid tumor contact with CHA w/o extension to the CA or hepatic artery bifurcation. Solid tumor contact w/SMA of less than or equal to 180. Distal/tail lesion having contact of CA of less than or equal to 180

Question 3

What is the definition of borderline resectable pancreatic cancer in terms of venous enchroachment?

Answer 3

Solid tumor contact with the SMV or PV of greater than 180 or you can have contact that is 180 or less but the contour of the vein is irregular or thrombosis in the vein is present. Solid tumor contact with the IVC.

Question 4

What are the tx options for a patient who has resectable or borderline disease?

Answer 4

So you can take them directly to surgery if they do not have high risk features or you can give neoadjuvant tx using mFOLFIRINOX or the regular regimen of this or Gem/Abraxane

Question 5

What are the neoadjuvant regimens that are preferred for BRCA 1/2 mutation?

Answer 5

mFOLFIRINOX (or not modified) or Gem/Cisplatin

Question 6

What are high risk features that would prompt you to give neoadjuvant chemo to a patient with resectable dx?

Answer 6

Very high CA 19-9, large primary tumor, large regional lymph nodes, equivocal or indeterminate image findings, excessive weight loss, extreme pain.

Question 7

For those patients who undergo surgery upfront, what adjuvant chemo options are preferred?

Answer 7

Gem/Capecitabine
mFOLFIRINOX, there are the preferred option. Other Cat 1 recs are Gemcitabine and 5-FU/leucovorin. Remember RT in the adjuvant setting was not assoc w/an OS benefit.

Question 8

What are the preferred options for patients who have locally advanced unresectable dx? What is the role of RT? This is for a PS of 0-1

Answer 8

mFOLFIRINOX (or unmodified is an option), Gem/Abraxne, NALIRIFOX. Ideally for those that can tolerate it, you give induction chemo followed chemo/RT or SBRT.

Question 9

What are the options for locally advanced pancreatic cancer for those with a PS of 2?

Answer 9

Capecitabine
Gemcitabine
Gem/Abraxane
For those who can tolerate you then do chemo/RT after chemo or SBRT.

Question 10

What are the preferred first line options for metastatic pancreatic cancer?

Answer 10

FOLFIRINOX (modified or not modified), Gem/Abraxne, NALIRIFOX

Question 11

I want to emphasize the targeted options available for use in locally advanced and metastatic disease.

Answer 11

dMMR/MSI-H, TMB-H-Pembro
BRAFV600E-Dabrafenib/Trametinib (CAT2B for metastatic)
NTRK-Larotrectinib/Entrectinib, Repotrectinib
RET-Selpercatinib

Question 12

What is the role of Olaparib in metastatic pancreatic cancer?

Answer 12

You give it as maintenance therapy after you have given them upfront chemo and they had a decent response. It says you can give Rucaparib also for BRCA 1/2 and PALB2 mutations.

Question 13

What are the options for 2nd line tx for locally advanced/metastatic pancreatic cancer? Remember that whatever backbone they didn’t receive e.g. fluoropyrimide if it was given w/prior Gem, that backbone is an option and vice versa

Answer 13

Just remember all of the targeted therapies available if positive testing and not given previously.
If given prior gem/fluoropyrimidine-give 5-FU/Liposomal Irinotecan/Leucovorin

Question 14

What are the preferred options for chemo/RT?

Answer 14

Cape/concurrent RT
Continuous infusion 5-FU/RT
Gem is an option, but not preferred