Pancreatic cancer, resectable

Typical sequence for Resectable disease; durations are protocol values (cycle counts and lengths, fraction schedules, guideline follow-up intervals), not averages of real patients. Your team's plan will differ in detail.

Phase by phase

1. 1. Diagnosis and staging

   weeks 0-4

   Pancreas-protocol CT, endoscopic ultrasound biopsy, CA19-9; germline testing for BRCA and other genes; biliary stent if jaundiced.

   CT (computed tomography)Germline (hereditary) testing
   Source
   Decision: Resectable, borderline or locally advanced?

   • Resectable: surgery first, then adjuvant chemotherapy
   • Borderline resectable: neoadjuvant FOLFIRINOX (and sometimes chemoradiotherapy) before an attempt at surgery
   • Locally advanced: chemotherapy, surgery only if the tumour shrinks
2. 2. Pancreatic resection

   weeks 2-4

   Whipple procedure (head) or distal pancreatectomy (body and tail); 1-2 weeks in hospital.

   Source
3. 3. Recovery

   weeks 3-15

   Chemotherapy starts once eating and weight are stable, within 12 weeks of surgery (PRODIGE 24 window).

   Source
4. 4. Adjuvant mFOLFIRINOX

   weeks 11-35

   Twelve 2-week cycles of oxaliplatin, irinotecan, fluorouracil and leucovorin; gemcitabine-based chemotherapy for those not fit for it.

   ⟳Oxaliplatin⟳Irinotecan (and liposomal irinotecan)⟳Fluorouracil (5-FU)⟳GemcitabineCytotoxic chemotherapy
   Source
5. 5. Surveillance

   from week 35, continues for years

   CA19-9 and CT every 3-6 months for 2 years, then every 6-12 months.

   CT (computed tomography)
   Source

Sources

• https://www.nejm.org/doi/full/10.1056/NEJMoa1809775
• https://www.nccn.org/guidelines/category_1