Adjuvant Therapy for Resected Pancreatic Adenocarcinoma
1. Adjuvant gemcitabine or adjuvant TS-1 are both reasonable options postsurgical resection for PDAC.
2. Adjuvant radiation therapy concurrent with fluoropyrimidine is not recommended routinely for these patients unless resection margin is positive.
3. A full restaging scan should be performed prior to start of adjuvant chemotherapy to rule out any metastases.
Borderline Resectable Pancreatic Adenocarcinoma
1. Neoadjuvant therapy can be considered in patients with borderline resectable pancreatic adenocarcinoma. There is insufficient evidence to recommend a specific regimen. Possible regimens for chemotherapy include FOLFIRINOX or gemcitabine-based combination chemotherapy. Subsequent chemoradiation can be considered after initial chemotherapy.
2. Participation in clinical trials recommended if available.
Locally Advanced Pancreatic Adenocarcinoma (LAPC)
1. Chemotherapy alone or fluoropyrimidine-based chemoradiotherapy are reasonable options.
2. Chemotherapy regimens recommended as per metastatic setting.
3. Upfront chemoradiotherapy can be considered for patients with poorly controlled pain from local disease.
4. Participation in clinical trials recommended if available.
Metastatic Pancreatic Adenocarcinoma (PDAC)
1. Best supportive care ought to be considered for patients with poor performance status.
2. Systemic chemotherapy is recommended for patients with good performance status. First-line chemotherapy with FOLFORINOX or combination gemcitabine and abraxane is preferred.
3. In the second-line setting, the recommendation is fluoropyrimidine-based chemotherapy if previously treated with gemcitabine-based therapy or gemcitabine-based therapy if previously treated with fluoropyrimidine-based therapy.
4. After second-line therapy, participation in clinical trials is recommended if available.