What is the best course of action for a patient with a pancreatic mass?

Management of Pancreatic Mass

For patients with a pancreatic mass, the best course of action is prompt referral to a specialist center for proper diagnostic workup, staging, and treatment planning, with radical surgery being the only potentially curative option for early-stage disease. 1

Initial Diagnostic Approach

• Clinical presentation suggesting pancreatic cancer should lead without delay to ultrasound of the liver, bile duct, and pancreas 1
• 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 1
• 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
• PET scan has no role in the diagnosis of pancreatic cancer 1

Tissue Diagnosis

• 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
• Percutaneous sampling should be avoided in potentially resectable tumors due to limited sensitivity and risk of tumor seeding 1
• Failure to obtain histological confirmation of suspected malignancy does not exclude the presence of a tumor and should not delay appropriate surgical treatment 1
• Tissue diagnosis should be obtained for patients selected for palliative therapy 1

Treatment Based on Staging

Resectable Disease (Stage I and some Stage II)

• Radical surgery is the only curative treatment option 1
• Pancreaticoduodenectomy (with or without pylorus preservation) is the treatment of choice for tumors of the pancreatic head 1
• Distal resection of the pancreas (with splenectomy) is appropriate for localized carcinomas of the body and tail 1
• Resectional surgery should be confined to specialist centers to increase resection rates and reduce hospital morbidity and mortality 1
• Postoperatively, 6 months of gemcitabine or 5-FU chemotherapy is recommended 1, 2, 3

Borderline Resectable Disease

• 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

Locally Advanced Unresectable Disease

• Gemcitabine is indicated as first-line treatment for locally advanced (nonresectable Stage II or Stage III) adenocarcinoma 2
• Patients with good performance status may be considered for FOLFIRINOX protocol 1

Metastatic Disease (Stage IV)

• Gemcitabine is indicated as first-line treatment for metastatic (Stage IV) adenocarcinoma 2
• The FOLFIRINOX protocol can be considered for patients ≤75 years with good performance status (0 or 1) and bilirubin ≤1.5 ULN 1
• 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 1

Palliative Management

Biliary Obstruction

• Endoscopic stenting is the preferred procedure in unresectable patients 1
• Metal prostheses should be preferred for patients with a life expectancy of >3 months 1
• If a stent is placed prior to surgery, it should be of the plastic type and placed endoscopically 1
• Self-expanding metal stents should not be inserted in patients likely to proceed to resection 1

Duodenal Obstruction

• Duodenal obstruction should be treated surgically 1
• Expandable metal stents may be used in some cases of proximal obstruction 1

Pain Management

• Patients with severe pain must receive opioids, with morphine generally being the drug of choice 1
• Percutaneous or EUS-guided celiac plexus blockade can be considered for patients with poor tolerance to opioid analgesics 1
• Hypofractionated radiotherapy may improve pain control and reduce analgesic consumption in selected patients 1

Follow-up After Treatment

• 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 1
• Abdominal CT scan should be performed every 6 months 1
• Follow-up should be designed to avoid emotional stress and economic burden for the patient 1

Common Pitfalls to Avoid

• Delaying referral to specialist centers - this reduces resection rates and increases mortality 1
• Using percutaneous biopsy techniques for potentially resectable tumors - this risks tumor seeding 1
• Inserting self-expanding metal stents in patients who may undergo resection - this complicates surgery 1
• Performing extended lymphadenectomy - there is no evidence this is beneficial 1
• Overlooking nutritional support - this is required for most patients with pancreatic cancer 4
• Routine use of PET scan for staging - this is not currently recommended 1