Pancreatic cancer

American Joint Committee on Cancer TNM staging system (8th Edition)[71]Exocrine and endocrine pancreas. In: Amin MB, Edge S, Greene F, et al, eds. AJCC cancer staging manual. 8th ed. New York, NY: Springer; 2017.

The American Joint Committee on Cancer (AJCC) staging system describes the extent of disease based on the following anatomic factors: size and extent of the primary tumor (T); regional lymph node involvement (N); and presence or absence of distant metastases (M). Nonanatomic prognostic factors (e.g., tumor grade, biomarkers) may be used to supplement the staging of certain cancers.

Clinical stages

Resectable disease: there are no universally accepted criteria for resection, and decisions about resectability should be made by a multidisciplinary team. Based on clinical experience, resectable pancreatic cancer can be defined as a tumor without evidence of involvement of the superior mesenteric artery (SMA), common hepatic artery (CHA), or celiac axis (CA); a patent superior mesenteric-portal venous confluence (or <180° contact without vein contour irregularity), and no evidence of distant metastases.[1]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: pancreatic adenocarcinoma [internet publication]. https://www.nccn.org/guidelines/category_1 ​​[72]Al-Hawary MM, Francis IR, Chari ST, et al. Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association. Gastroenterology. 2014 Jan;146(1):291-304. http://www.ncbi.nlm.nih.gov/pubmed/24355035?tool=bestpractice.com

Borderline resectable disease: criteria for borderline resectable tumors include superior mesenteric vein (SMV) or portal vein (PV) impingement, <180° tumor abutment on SMA, abutment or encasement of hepatic artery (if reconstructible), SMV occlusion of a short segment and reconstructible, or, in tumors in the tail of the pancreas, SMA or celiac encasement <180°.[1]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: pancreatic adenocarcinoma [internet publication]. https://www.nccn.org/guidelines/category_1 ​​[72]Al-Hawary MM, Francis IR, Chari ST, et al. Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association. Gastroenterology. 2014 Jan;146(1):291-304. http://www.ncbi.nlm.nih.gov/pubmed/24355035?tool=bestpractice.com

Locally advanced unresectable disease: tumors involving nearby structures to an extent that renders them unresectable despite the absence of evidence of metastatic disease, and solid tumor contact of >180° with the SMA or CA, or with CA and aortic involvement; and an unrecontructible SMV or PV due to tumor involvement or occlusion. Metastasis to a regional lymph node beyond the field of resection is considered unresectable.[1]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: pancreatic adenocarcinoma [internet publication]. https://www.nccn.org/guidelines/category_1 ​​[72]Al-Hawary MM, Francis IR, Chari ST, et al. Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association. Gastroenterology. 2014 Jan;146(1):291-304. http://www.ncbi.nlm.nih.gov/pubmed/24355035?tool=bestpractice.com

Metastatic disease: evidence of distant metastasis (to liver, lung, or bone).[71]Exocrine and endocrine pancreas. In: Amin MB, Edge S, Greene F, et al, eds. AJCC cancer staging manual. 8th ed. New York, NY: Springer; 2017.[72]Al-Hawary MM, Francis IR, Chari ST, et al. Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association. Gastroenterology. 2014 Jan;146(1):291-304. http://www.ncbi.nlm.nih.gov/pubmed/24355035?tool=bestpractice.com

Extent of resection

R1: microscopic disease left behind after surgical removal (the surgeon does not know at the time of the operation but is informed by the pathologist).

R2: macroscopic disease left behind after surgical removal (the surgeon is aware at the end of the operation that a part of the tumor was left behind, and this is confirmed by the pathologist).