American College of Radiology
ACR Appropriateness Criteria®

Borderline and Unresectable Pancreas Cancer

Variant 1: 65-year-old woman with no comorbidities presents with jaundice and an ECOG performance status of 1. Pancreas-protocol CT scan reveals a 2.5-cm mass in the pancreatic head with encasement of the celiac artery without evidence for nodal or distant metastasis. Biopsy at the time of metal stent placement revealed adenocarcinoma. Stent normalized the bilirubin and the CA 19-9 was 150. She has no pain.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Supportive care only Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Upfront Surgery Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
Systemic chemotherapy only May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy and if response or stable disease consider standard course RT with concurrent chemotherapy Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Upfront RT with concurrent chemotherapy May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy and if response or stable disease consider standard RT with concurrent chemotherapy +/- surgery if technically resectable May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Systemic chemotherapy and if response or stable disease consider SBRT +/- surgery if technically resectable May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Variant 2: 80-year-old man presents with severe abdominal pain and an ECOG performance status of 2. CT scan reveals a mass in the body of the pancreas with 360° encasement of the celiac axis and SMA, with evidence of regional lymph node metastasis without other distant metastasis; CA 19-9 is 1000.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Supportive care only May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Upfront Surgery Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
Systemic chemotherapy only Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Palliative RT alone May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy and if response or stable disease consider standard course RT with concurrent chemotherapy May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Upfront RT with concurrent chemotherapy May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy and if response or stable disease consider standard RT with concurrent chemotherapy +/- surgery if technically resectable Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Systemic chemotherapy and if response or stable disease consider SBRT +/- surgery if technically resectable May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Variant 3: 54-year-old healthy woman with an ECOG performance status of 0 presents with vague abdominal pain. CT scan notes a pancreatic head mass with no evidence for metastasis. The tumor abuts the celiac axis, although <180°.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Immediate surgery +/- adjuvant therapy Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Supportive care only Usually not appropriate 1 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy only with gemcitabine then consideration for surgery May be appropriate 4 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy only with FOLFIRINOX then consideration for surgery May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Planned combined 5-FU and standard fractionation RT to 45–50.4 Gy to gross tumor volume and regional nodes followed by surgery May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Planned combined full dose gemcitabine and hypo-fractioned RT to 30–40 Gy to gross tumor volume then consideration for surgery May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
FOLFIRINOX chemotherapy and if there is a response or stable disease RT + chemotherapy followed by surgery Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Gemcitabine chemotherapy and if there is a response or stable disease, RT + chemotherapy followed by surgery May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy and if response or stable disease consider SBRT with consideration for surgery May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Variant 4: Standard RT details in treating a locally advanced pancreatic cancer.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Treat the gross tumor volume only plus small margins (no expansion for prophylactic lymph nodes) Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Treat the gross tumor volume and limited prophylactic lymph nodes (ie, only immediately adjacent nodal regions to the GTV) Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Treat the gross tumor volume and full prophylactic lymph node coverage May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
3-D technique Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
IMRT only if needed for normal tissue constraints Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Respiratory gating May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
4-D CT with the utilization of a MIP Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Variant 5: Chemotherapy details in treating a locally advanced pancreatic cancer.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
FOLFIRINOX Usually appropriate 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
Gemcitabine and Nab-paclitaxel Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Infusional 5-FU Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Capecitabine Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
FOLFIRINOX Usually not appropriate 3 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
Gemcitabine and Nab-paclitaxel Usually not appropriate 3 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.