Editing Pancreatic cancer (section)

== '''Staging''' ==

* Tissue to confirm. If biopsies inadequate, repeat them.
** EUA - best approach - se/sp >90%
** Percutaneous biopsy - quite good sp/se, and low rates of seeding
* At a minimum, good quality CT C/A/P including pancreatic protocol, before considering any intervention including stenting
* Staging laparoscopy for those at high risk of unidentified metastatic disease (tumours >3cm, CA 19-9 >100U/mL, equivocal CT, or body/tail tumours) to prevent non-therapeutic laparotomies. Also consider it for those with significant constitutional symptoms but no known metastases. Yield is 6% (changing management).
* Then stage and classify into resectable, borderline resectable or unresectable

'''Exocrine pancreatic cancer TNM staging AJCC UICC 8th edition'''
{| class="wikitable"
|'''Primary tumor (T)'''
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|'''T category'''
|'''T criteria'''
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|TX
|Primary tumor cannot be assessed
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|T0
|No evidence of primary tumor
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|Tis
|Carcinoma ''in situ''.

This includes high-grade pancreatic intraepithelial neoplasia (PanIn-3), intraductal papillary mucinous neoplasm with high-grade dysplasia, intraductal tubulopapillary neoplasm with high-grade dysplasia, and mucinous cystic neoplasm with high-grade dysplasia.
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|T1
|Tumor ≤2 cm in greatest dimension
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|T1a
|Tumor ≤0.5 cm in greatest dimension
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|T1b
|Tumor >0.5 and <1 cm in greatest dimension
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|T1c
|Tumor 1 to 2 cm in greatest dimension
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|T2
|Tumor >2 and ≤4 cm in greatest dimension
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|T3
|Tumor >4 cm in greatest dimension
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|T4
|Tumor involves the celiac axis, superior mesenteric artery, and/or common hepatic artery, regardless of size
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|'''Regional lymph nodes (N)'''
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|'''N category'''
|'''N criteria'''
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|NX
|Regional lymph nodes cannot be assessed
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|N0
|No regional lymph node metastasis
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|N1
|Metastasis in one to three regional lymph nodes
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|N2
|Metastasis in four or more regional lymph nodes
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|'''Distant metastasis (M)'''
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|'''M category'''
|'''M criteria'''
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|M0
|No distant metastasis
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|M1
|Distant metastasis
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|'''Prognostic stage groups'''
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|-
|'''When T is...'''
|'''And N is...'''
|'''And M is...'''
|'''Then the stage group is...'''
|-
|Tis
|N0
|M0
|0
|-
|T1
|N0
|M0
|IA
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|T1
|N1
|M0
|IIB
|-
|T1
|N2
|M0
|III
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|T2
|N0
|M0
|IB
|-
|T2
|N1
|M0
|IIB
|-
|T2
|N2
|M0
|III
|-
|T3
|N0
|M0
|IIA
|-
|T3
|N1
|M0
|IIB
|-
|T3
|N2
|M0
|III
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|T4
|Any N
|M0
|III
|-
|Any T
|Any N
|M1
|IV
|}

* '''Resectability''' (based on international consensus definitions 2017, Isaji et al). ''Note encasement is >180 degree involvement; abutment is <180 degree involvement.''
** '''Resectable''' - localised to pancreas, with no evidence of SMV or PV involvement, and a preserved fat plane surrounding SMA and coeliac artery branches
** '''Borderline resectable''' - one or more of the following:
*** '''Venous involvement'''
**** Reconstructable SMV or PV encasement
**** Reconstructable SMV or PV abutment with contour irregularity/narrowing of the vein, or thrombosis of the vein
*** '''Arterial involvement'''
**** SMA or CHA abutment
*** '''Biological''' - CA19-9 > 500, or regional lymph nodes on biopsy or PET
*** '''Performance status 2 or more'''
** '''Unresectable''' - metastasis, including lymph node metastasis outside the field of resection, ascites, or vascular involvement beyond the above.
*** SMA or CHA encasement
*** Contact with coeliac artery or RHA/LHA
*** Occlusion of SMV, PV, or SMV-PV without suitable vessels for reconstruction above and below
**
* Most present with locally advanced or metastatic disease - about 80%