American College of Radiology
ACR Appropriateness Criteria®

Resectable Pancreatic Cancer

Variant 1: 78-year-old man with resected well-differentiated adenocarcinoma of the pancreatic head, pT1N0M0 with negative margin of resection, and no evidence of perineural invasion. Postoperative CA19-9=80. Karnofsky performance status (KPS) of 80.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Observation May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
5-FU May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
Gemcitabine Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Multiagent chemotherapy May be appropriate 4 n/a 0 0 0 0 0 0 0 0 0
Chemoradiation therapy followed by adjuvant chemotherapy May be appropriate 4 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy followed by chemoradiation therapy followed by chemotherapy May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy × 4–6 months followed by chemoradiation therapy May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
45 Gy/1.8 Gy May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
54 Gy/1.8 Gy May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
59.4 Gy/1.8 Gy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
AP/PA photons Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
4–5 field photon 3-D conformal plan Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Tumor bed alone May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Tumor bed + nodal basin Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Variant 2: 65-year-old woman with resected moderately-differentiated adenocarcinoma of the pancreatic head, pT2N1M0 with negative margin of resection, 1 of 15 lymph nodes involved, and no evidence of perineural invasion. Postoperative CA19-9=120. KPS 80.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Observation Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
5-FU Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Gemcitabine Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Multiagent chemotherapy May be appropriate 4 n/a 0 0 0 0 0 0 0 0 0
Chemoradiation therapy followed by adjuvant chemotherapy May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy followed by chemoradiation therapy followed by chemotherapy Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy × 4–6 months followed by chemoradiation therapy Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
45 Gy/1.8 Gy May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
54 Gy/1.8 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
59.4 Gy/1.8 Gy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
AP/PA photons Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
4–5 field photon 3-D conformal plan Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Tumor + nodal basin Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Tumor alone Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Tumor + nodal basin Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Variant 3: 70-year-old man with resected poorly-differentiated adenocarcinoma of the pancreatic head, pT3N0M0 with a positive uncinate margin of resection, and postoperative CA19-9=140. KPS 80.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Observation Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
5-FU May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Gemcitabine Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Multiagent chemotherapy May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Chemoradiation therapy followed by adjuvant chemotherapy May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy followed by chemoradiation therapy followed by chemotherapy Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy × 4–6 months followed by chemoradiation therapy Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
45 Gy/1.8 Gy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
50.4 Gy/1.8 Gy Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
54 Gy/1.8 Gy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
59.4 Gy/1.8 Gy May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
AP/PA photons Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
4–5 field photon 3-D conformal plan Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Tumor bed alone May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Tumor bed + nodal basin Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Variant 4: 65-year-old woman with resectable moderately-differentiated adenocarcinoma of the pancreatic head, cT2N0M0, and preoperative CA19-9=140. KPS 90.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Upfront Surgery Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Neoadjuvant chemoradiation therapy followed by surgery May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Neoadjuvant chemotherapy followed by surgery May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Neoadjuvant chemotherapy followed by chemoradiation therapy followed by surgery May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Standard fractionation 45–50 Gy/1.8 Gy fx Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Hypofractionation 2.4–3 Gy/fx 30–36 Gy Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
AP/PA photons Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
4–5 field photon 3-D conformal plan Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Tumor alone May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Tumor + nodal basin Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Tumor + nodal basin Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Please refer to the supporting documentation for a more complete discussion of the concepts and their definitions below.
Final Tabulations:
A histogram of the number of panel members who rated the recommendation as noted in the column heading (ie, 1, 2, 3, …etc.)
Disagree:
The variation of the individual ratings from the median rating indicates panel disagreement on the final recommendation.
References:
Lists the references associated with the recommendation
SQ:
Study Quality (1, 2, 3, 4, Good M or Inadequate M) of the references listed.
RRL:
Information on the Relative Radiation Level (RRL) designations can be found here.