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PANCREATIC CANCER STAGES

On the surface this would seem to be a fairly straight forward question, but as there exists the controversy of competing stage nomenclatures for pancreatic cancer stages, it is not as simple as one might think. In fact, in the U. S., universal agreement on a standardized staging system does not exist. The fundamental problem is that the stages system for exocrine cancer of the pancreas as put forth by, for example, the American Joint Committee on Cancer (“AJCC”) is felt to be somewhat impractical by certain experts. This classification rests on knowing the status of the TNM (that is Tumor, lymph Nodes and distal Metastasis).

Under this classification (roughly) Stage I pancreatic cancer includes tumors which have not spread into certain proscribed sensitive areas and which have no involved regional nodes or distal metastasis. Stage II pancreatic cancer includes tumors which have spread into the duodenum, bile duct, or “peripancreatic” tissues AND which have no involved regional nodes or distal metastasis. Stage III pancreatic cancer includes tumors which may have OR may not have spread into these aforementioned areas and which have involved regional nodes, but which show no evidence of distal metastasis. Stage IVA pancreatic cancer includes tumors which have spread into the stomach, spleen, large bowel OR the adjacent large vessels AND which have involved regional nodes, but show no evidence of distal metastasis. And Stage IVB pancreatic cancer includes pancreatic tumors of any kind with node status of any kind AND with evidence of distal metastasis.islandblocks300

Leaving aside that fact that this stage classification may not completely comport with similar nomenclature for pancreatic cancer by the International Union Against Cancer (Union Internationale Contre le Cancer), in practice, though referred to, this classification is rarely used in its pure form as the stages do not fully match treatment options for pancreatic cancer or even patient prognosis, and very often the true lymph-node status cannot be fully determined without surgery (which most people with pancreatic cancer do NOT receive).

For doctors and patients then, staging is USUALLY based on sophisticated radiologic studies. And for these cases, a clinical/radiographic stage classification for pancreatic cancer has been proposed which attempts to more closely follow prognosis and clinical decision making in regard to the actual treatment options for pancreatic cancer. This three stage classification (potentially resectable, locally advanced and advanced) of pancreatic cancer involvement, is based on radiological findings, and is not directly referent to the TNM status.

In this proposed classification, potentially “resectable pancreatic cancer” stage (or Local) is defined roughly as that including no evidence of extra-pancreatic involvement of the tumor, demonstration of fully patent superior mesenteric / portal veins and showing no evidence of encroachment (“encasement”) by the tumor on the arterial celiac axis or the superior mesenteric artery. The “locally advanced pancreatic cancer” stage is that which demonstrates evidence of arterial encroachment (celiac axis or superior mesenteric artery) or venous occlusion (superior mesenteric / portal veins). And the advanced “pancreatic cancer stage” includes evidence of metastatic spread (typically to the liver, peritoneum or lungs).

There are other terms in use and still other stage classifications. Of course, this makes for a messy kind of communication, although in practice oncologists seem to be able to speak with one another without apparent misunderstanding. It is possible and even likely perhaps, over time, assuming the great strides in the sophistication and power of radiographic techniques continue to move forward, the future will further free these staging classifications of pancreatic cancer from their strictly surgical origins and enable a more uniformly agreed upon stage nomenclature.

ABSTRACTS:

The following are descriptions of titles of abstracts of medical journal articles that may be interesting or useful to those who are interested in further information about this topic.These abstracts can be searched Here.


  • 1-Jun-16 –  Node stage system for cancer of the pancreas 
  • 1-Jan-16 – Is there a difference between radiographic and surgical stage in locally advanced 
  • 4-Feb-14 – Staging of NE Tumors:  does the Ki-67 Marker have a Place?
  • 1-Feb-14 – Comparison of AJCC, ENETS, and  Novel Ki-67 Stage Schemas for Pancreatic Islet Cell Tumors
  • 1-Feb-14 – Stanford Physicians Propose a Novel TNM Staging System for Pancreatic Neuroendocrine Tumors
  • 1-Dec-13 – Using Pancreatic Cancer Tissue Grading for Prognostic Purpose
  • 1-Jan-13 – Staging of Cancer of the Pancreas Via Laparoscope
  • 1-Dec-12 – Contrast EUS for Staging of Pancreatic Cancer
  • 1-Nov-12 – Various Stage Nomenclatures for Pancreatic Cancer
  • 1-Sep-12 – MRI for the Diagnosis and Staging of Pancreatic Cancer
  • 1-Sep-12 – Experimental Staging with Fluorescent Laparascopy for Pancreatic Cancer in Mice
  • 1-Aug-12 – PET/CT for Staging Cancer of the Pancreas
  • 1-May-12 – Radiography for Staging in Pancreatic Cancer
  • 1-Mar-12 – Surgical Exploration Affects Pancreatic Cancer Stage
  • 1-Dec-11 – Novel Minimal Surgery for Staging Purposes
  • 1-Sep-08 – PET / CAT Scan in the Staging of Pancreatic cancer

Our science board is composed of:

James Abbruzzese, MD Chief, Medical Oncology Duke University

Markus Büchler, MD Chairman, Surgery Heidelberg University, Germany

Ralph Hruban, MD Director, GI / Liver Pathology Johns Hopkins University

Eileen O’Reilly, MD Associate Director for Clinical Research – Memorial Sloan-Kettering Cancer Center

Margaret Tempero, MD Chief, Medical Oncology University of California at San Francisco

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Pancreatic Cancer Blog

One of the observations that physicians often made when the standard of care treatment typically consisted of the chemotherapy drug agent of gemcitabine alone, was that many patients with pancreatic cancer (ductal adenocarcinoma of the pancreas) seemed to feel better after the initiation of treatment… More Here

 

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