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
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.