Pancreatic Cancer Flashcards
What is defined as resectable pancreatic disease?
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
What is the definition of borderline resectable pancreatic cancer in terms of artery encroachment?
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
What is the definition of borderline resectable pancreatic cancer in terms of venous enchroachment?
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.
What are the tx options for a patient who has resectable or borderline disease?
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
High risk features-large tumors, large nodes, pain, high CA19-9, imaging that is indeterminate, excessive weight loss
What are the neoadjuvant regimens that are preferred for BRCA 1/2 mutation?
mFOLFIRINOX (or not modified) or Gem/Cisplatin
What are high risk features that would prompt you to give neoadjuvant chemo to a patient with resectable dx?
Very high CA 19-9, large primary tumor, large regional lymph nodes, equivocal or indeterminate image findings, excessive weight loss, extreme pain.
For those patients who undergo surgery upfront, what adjuvant chemo options are preferred?
Gem/Capecitabine
mFOLFIRINOX, those are the preferred options. Other Cat 1 recs are Gemcitabine and 5-FU/leucovorin. Remember RT in the adjuvant setting was not assoc w/an OS benefit. However NCCN does recommend to consider chemo+chemo/RT if they didn’t receive neoadjuvant tx or if they have a R1 resection after getting neo-adjuvant chemo
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
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.
What are the options for locally advanced pancreatic cancer for those with a PS of 2?
Capecitabine
Gemcitabine
Gem/Abraxane
For those who can tolerate you then do chemo/RT after chemo or SBRT.
What are the preferred first line options for metastatic pancreatic cancer? What are the preferred options for a BRCA mutation?
FOLFIRINOX (modified or not modified), Gem/Abraxne, NALIRIFOX
BRCA-FOLFIRINOX (Cat 1) or Gem/Cis
I want to emphasize the targeted options available for use in locally advanced and metastatic disease.
dMMR/MSI-H, TMB-H-Pembro
BRAFV600E-Dabrafenib/Trametinib (CAT2B for metastatic)
NTRK-Larotrectinib/Entrectinib, Repotrectinib
RET-Selpercatinib
What is the role of Olaparib in metastatic pancreatic cancer?
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.
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
Just remember all of the targeted therapies available if positive testing and not given previously.
If given prior gem therapy-give 5-FU/Liposomal Irinotecan/Leucovorin Cat 1
If received 5-FU/OX-give NALIRI w/5FU, Gem alone, or Gem/Abraxane
KRAS G12C: Adagrasib/Sotorasib
HER2 IH3+-TDXT
What are the preferred options for chemo/RT?
Cape/concurrent RT
Continuous infusion 5-FU/RT
Gem is an option, but not preferred
