Clinical Practice Guidelines for Pancreatic Cancer 2022 from the Japan Pancreas Society: a synopsis
Japan Pancreas Society · 2023 · Japan
Source and licence
- Authors
- Takuji Okusaka, Masafumi Nakamura, Masahiro Yoshida et al.
- Title
- Clinical Practice Guidelines for Pancreatic Cancer 2022 from the Japan Pancreas Society: a synopsis
- Journal
- International Journal of Clinical Oncology, 2023
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC10066137
Licence statement of the original publication
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This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Diagnosis or D
- StatementFurther investigations are recommended in patients with new-onset diabetes and diabetes exacerbation, considering the possibility of pancreatic cancer.
- StatementFollow-up observation is recommended in consideration of the possible development of pancreatic cancer in patients with chronic pancreatitis.
- StatementScrutiny and follow-up observation are recommended in view of the possibility of concomitant pancreatic cancer in patients with intraductal papillary mucinous neoplasms.
- StatementGenetic testing is recommended for individuals who have not yet developed the disease, but have a suspected hereditary risk of development of pancreatic cancer based on the family history, medical history, etc.
- StatementCancer gene panel testing using tumor tissue is recommended in patients with unresectable pancreatic cancer.
- StatementCancer gene panel testing using liquid biopsy is recommended in patients with unresectable pancreatic cancer.
- Statement• Germline genetic testing (still not approved for health insurance coverage for pancreatic cancer) is recommended for the purpose of further assessing the risk of carcinogenesis in patients with pancreatic cancer and their relatives.
- StatementGenetic consultation is recommended.
- StatementTransabdominal ultrasonography is recommended as a first-step diagnostic tool in patients with suspected pancreatic cancer.
- StatementAbdominal MRI is recommended as a diagnostic tool in patients with suspected pancreatic cancer.
- StatementEndoscopic ultrasonography is recommended as a diagnostic tool in patients with suspected pancreatic cancer, especially as it is more sensitive than other imaging modalities for the diagnosis of pancreatic cancer.
- StatementEndoscopic retrograde cholangiopancreatography is especially recommended for the diagnosis of pancreatic duct stenosis, which is difficult to differentiate from inflammatory lesions by other imaging modalities, or of pancreatic duct stenosis, which could be a manifestation of early pancreatic cancer.
- StatementPositron emission tomography is not recommended as a diagnostic or qualitative diagnostic tool in patients with suspected pancreatic cancer.
- StatementEUS-guided fine-needle aspiration or biopsy is recommended for the histopathological diagnosis of mass lesions in the pancreas.
- StatementIn patients presenting with a mass lesion in the pancreas, transabdominal ultrasound-guided biopsy is recommended as a diagnostic procedure.
- StatementNeedle biopsy is recommended for the diagnosis of genetic abnormalities in patients with pancreatic cancer.
- StatementEndoscopic retrograde cholangiopancreatography with pancreatic fluid cytology is recommended in patients with certain pancreatic duct findings and no mass lesions. However, particular attention should be paid to the possible precipitation of acute pancreatitis by endoscopic retrograde cholangiopancreatography.
- StatementContrast-enhanced MRI is recommended for pancreatic cancer staging and for assessment of its resectability, especially for the detection of liver metastasis.
- StatementWhen contrast-enhanced CT cannot definitively determine the disease stage/resectability, addition of EUS is recommended, because EUS is superior to contrast-enhanced CT for diagnosing T-factor/N-factor/vascular invasion.
- StatementPositron emission tomography is recommended in patients with suspected distant metastasis, as PET is more specific than CT for the diagnosis of distant metastasis.
- StatementLaparoscopy is recommended for evaluating the disease stage in pancreatic cancer patients, because it is useful for identifying small metastases on the surface of the liver and peritoneal metastases.
- StatementAssessment of the preoperative nutritional status and body composition is recommended in patients with pancreatic cancer, because these variables have been shown to contribute to prediction of the long-term prognosis and postoperative complications in patients undergoing surgery for pancreatic cancer.
Operation or O
- StatementSurgical treatment for pancreatic cancer is recommended at high-volume facilities.
- StatementSurgical treatment is not recommended as the first-line therapy in pancreatic cancer patients with a positive peritoneal lavage cytology.
- StatementIt is not yet clear whether combined portal vein resection for pancreatic cancer might improve the prognosis in patients with pancreatic cancer. However, when curative resection is expected, combined portal vein resection is recommended.
- StatementProphylactic extended lymph node and nerve plexus dissection is not recommended in patients with pancreatic cancer, because it has not been shown to contribute to prolong survival.
- StatementMinimally invasive pancreaticoduodenectomy is recommended in patients with invasive ductal carcinoma who are candidates for pancreaticoduodenectomy, but only at facilities specializing in the treatment of pancreatic cancer.
- Statement• Laparoscopic distal pancreatectomy is recommended in patients with invasive ductal carcinoma who are candidates for distal pancreatectomy, but only at facilities specializing in the treatment of pancreatic cancer.
- StatementContinued regular long-term surveillance of pancreatic cancer patients is recommended, even in patients surviving for more than 5 years after resection.
- StatementPerioperative pancreatic enzyme replacement therapy is recommended in pancreatic cancer patients with suspected/confirmed pancreatic exocrine insufficiency.
- StatementSurgical treatment is recommended even in elderly patients with pancreatic cancer who are 80 years of age or older, when curative resection is expected.
- StatementTotal pancreatectomy is recommended to achieve curative resection in patients with pancreatic cancer.
Adjuvant or A
- StatementCombined gemcitabine + S-1 therapy is recommended as preoperative neoadjuvant therapy in patients with resectable pancreatic cancer.
- Statement• Postoperative adjuvant chemotherapy is recommended in patients with pancreatic cancer who have received macroscopic radical resection.
Operation or O
- StatementIn patients with borderline resectable pancreatic cancer, it is recommended that reassessment be performed prior to surgery to determine if the cancer can be curatively resected, by evaluating the therapeutic efficacy of preoperative neoadjuvant therapy.
- Statement• Distal pancreatectomy with celiac artery resection is recommended.
Adjuvant or A
- StatementAs neoadjuvant therapy for borderline resectable pancreatic cancer, Chemoradiotherapy is recommended.
- StatementPostoperative adjuvant chemotherapy is recommended for patients with borderline resectable pancreatic cancer.
Treatment of locally advanced disease or L
- Statement• Chemoradiotherapy is recommended.
Radiation or R
- Statement• For patients with locally advanced, unresectable pancreatic cancer scheduled to receive chemoradiotherapy, concurrent use of fluoropyrimidine with radiotherapy is recommended.
- StatementIn patients with locally advanced, unresectable pancreatic cancer scheduled to receive radiotherapy, elective nodal irradiation for the para-aortic lymph nodes is not recommended.
- StatementGemcitabine hydrochloride monotherapy is not recommended as induction chemotherapy prior to chemoradiotherapy in patients with locally advanced, unresectable pancreatic cancer.
- StatementRadiotherapy alone or chemoradiotherapy for the primary lesion is recommended for unresectable pancreatic cancer patients with pain.
- StatementIncreased radiation dose using high-precision radiotherapy is recommended in patients with locally advanced, unresectable pancreatic cancer.
- StatementIt is not possible to make a clear recommendation at this time about the need for inducing hyperthermia in combination with chemoradiotherapy in patients with locally advanced, unresectable pancreatic cancer.
Chemotherapy or C
- Statement• Combined fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) therapy is recommended.
- Statement• Second-line chemotherapy is recommended for unresectable pancreatic cancer patients who are refractory to first-line therapy.
- StatementAs first-line chemotherapy for elderly patients with advanced pancreatic cancer in consideration of the performance status and comorbidities, Combined gemcitabine hydrochloride + nab-paclitaxel therapy is recommended.
Operation or O
- StatementResection of the primary lesion after multidisciplinary treatment is recommended as one of the treatment options for patients with locally advanced pancreatic cancer in whom the disease was judged as being unresectable at the first examination, if the treatment is successful and the cancer becomes resectable.
Adjuvant or A
- StatementAdjuvant chemotherapy after primary lesion resection is recommended for patients with locally advanced, unresectable pancreatic cancer at the time of initial examination.
Chemotherapy or C
- StatementAs first-line chemotherapy for pancreatic cancer patients with distant metastases, 14. FOLFIRINOX therapy is recommended.
- Statement• Second-line chemotherapy is recommended for patients with unresectable pancreatic cancer who are refractory to first-line therapy.
- StatementAs first-line chemotherapy in elderly patients with advanced pancreatic cancer, in consideration of the performance status and comorbidities, Combined gemcitabine hydrochloride + nab-paclitaxel therapy is recommended.
- Statement• Use of a platinum-containing regimen is recommended for pancreatic cancer patients with pathological germline variants of BRCA1/2.
Operation or O
- Statement• Surgical resection of the remnant pancreas is recommended in patients with postoperative metastases/recurrences.
- StatementIn pancreatic cancer patients with distant metastasis that cannot be resected at the time of first diagnosis, it is not clear whether surgical treatment should be performed, even if response to multidisciplinary treatment is obtained at the primary site and/or distant metastasis.
Radiation or R
- StatementRadiotherapy is recommended for the management of painful bone metastases in patients with advanced pancreatic cancer.
- Statement• Radiotherapy is recommended for the management of local recurrences and regional lymph-node metastases.
Supportive and palliative medicine or S
- StatementThe endoscopic transpapillary route is recommended for biliary drainage in patients with unresectable pancreatic cancer.
- Statement• Use of metallic stents is recommended in resectable or borderline resectable pancreatic cancer patients with obstructive jaundice.
- StatementUse of a covered metallic stent is recommended in unresectable pancreatic cancer patients with obstructive jaundice.
- StatementEndoscopic gastrointestinal stent insertion is recommended for unresectable pancreatic cancer patients with gastrointestinal obstruction. In patients with a prolonged life expectancy, surgical gastro-jejunal anastomosis is recommended.
- StatementThe endoscopic transgastrointestinal route for biliary drainage is recommended in facilities with personnel skilled in the procedure for managing obstructive jaundice in patients with pancreatic cancer complicated by gastric and duodenal obstruction.
- Statement• Use of metallic stents is recommended in pancreatic cancer patients with obstructive jaundice receiving chemotherapy.
Supportive & palliative medicine or Sp
- StatementProvision of systematic support by a multidisciplinary team consisting of multiple experts, such as a palliative care team, is recommended even from the early stages of treatment for patients with advanced pancreatic cancer and their families.
- Statement• Pain treatment with a non-opioid/opioid analgesic(s) is recommended for pancreatic cancer patients with cancer pain.
- StatementExercise therapy is recommended for patients with pancreatic cancer.
- StatementRehabilitation treatment, including exercise therapy, before surgery is recommended for pancreatic cancer patients scheduled to undergo surgery.
- StatementAdvance care planning is recommended for patients with advanced pancreatic cancer.
- Statement• Use of duloxetine is recommended for managing peripheral neuropathy associated with FOLFIRINOX therapy or combined gemcitabine hydrochloride + nab-paclitaxel therapy in patients with pancreatic cancer.
- Statement• Anticoagulant therapy with low-molecular-weight heparin to prevent new onset of venous thromboembolism is recommended in pancreatic cancer patients undergoing chemotherapy (not approved for health insurance coverage in Japan).
- Statement• Ghrelin receptor agonists are recommended for cachexia in patients with advanced pancreatic cancer.
- StatementNo clear recommendation for CART can be made at this time for abdominal bloating in advanced pancreatic cancer patients with malignant ascites.
- StatementCommunication skills’ training is recommended for physicians expected to participate in important cancer-related discussions.
Abstract
Objectives: Clinical Practice Guidelines for Pancreatic Cancer was first published in 2006 by the Japan Pancreas Society, and revised in 2009, 2013, 2016, and 2019. In July 2022, Clinical Practice Guidelines for Pancreatic Cancer was newly revised in Japanese.
Methods: For this revision, we developed an entirely new guideline according to the Minds Manual for Guideline Development 2020, which includes the concepts of GRADE—Grading Recommendations Assessment, Development, and Evaluation, to enable a better understanding of the current guidelines. Patients and the public were actively involved in both the development and implementation of the guideline.
Results: The guideline includes algorithms for diagnosis, treatment, chemotherapy, and precision medicine of pancreatic cancer, and addresses 7 subjects: diagnosis, surgical therapy, adjuvant therapy, radiation therapy, chemotherapy, stent therapy, and supportive & palliative medical care. It includes 73 clinical questions and 112 statements. The statements correspond to the clinical questions, evidence levels, recommendation strengths, and agreement rates.
Conclusions: This guideline represents the most standard clinical and practical management guideline available until date in Japan. This is the English synopsis of the Clinical Practice Guidelines for Pancreatic Cancer 2022 in Japanese, and is an attempt to disseminate the Japanese guideline worldwide to introduce the Japanese approach to the clinical management of pancreatic cancer.
Contents of the original publication
The section headings of the original.
- Introduction
- General outline of the revision process
- Notes on the use of the guidelines
- Algorithms
- Diagnosis or D
- Treatment
- Treatment of resectable disease or R
- Adjuvant or A
- Treatment of borderline resectable disease or B
- Operation or O
- Radiation or R
- Chemotherapy or C
- Operation or O
- Adjuvant or A
- Treatment of metastatic disease or M
- Chemotherapy or C
- Operation or O
- Radiation or R
- Supportive and palliative medicine or S
- Supportive & palliative medicine or Sp
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