If the tumour touches or surrounds blood vessels, does that mean it cannot be operated on?

Not necessarily. Whether the tumour can be removed surgically depends on which vessels are involved and to what extent, as well as whether a safe and complete resection can be achieved. This is why disease is classified as resectable, borderline resectable or locally advanced. In borderline cases, assessment by an experienced multidisciplinary team is particularly valuable.

Is immunotherapy used for pancreatic cancer?

For the great majority of patients, immunotherapy is not an established treatment when used on its own. It can, however, be particularly valuable in a small subgroup of tumours with specific biological features, such as MSI-H/dMMR. Appropriate molecular testing can therefore identify treatment options that would not be apparent from the histological diagnosis alone.

Pancreatic Cancer

Diagnosis · Staging · Resectability · Systemic Treatment · Molecular Testing

Pancreatic cancer requires accurate staging and multidisciplinary assessment from the outset. The treatment strategy depends primarily on whether the tumour can be removed surgically, the extent of the disease, the patient’s general condition and—in selected cases—the tumour’s molecular or inherited characteristics.

What Needs to Be Known Before Treatment Is Selected?

Precise anatomical location and extent of the tumour
Relationship of the tumour to the major surrounding blood vessels
Presence or absence of metastatic disease
Histological confirmation where required
General condition and comorbidities
Molecular and germline testing where clinically relevant

How Is Surgical Resectability Assessed?

Resectable

The tumour can be removed surgically on the basis of the extent of the disease and its relationship to the major blood vessels. The treatment strategy includes surgery and systemic treatment, with their sequence determined through multidisciplinary assessment.

Borderline Resectable

The tumour is in close contact with, or has limited involvement of, important vascular structures. Systemic treatment is often given first, followed by reassessment of whether surgical resection is feasible.

Locally Advanced

There are no distant metastases, but the local extent of the tumour does not initially allow safe surgical resection. Systemic treatment is the principal approach, and the possibility of surgery may be reassessed in selected cases.

Metastatic Disease

The disease has spread to other organs. Treatment is mainly systemic and is selected according to the patient’s general condition, previous treatment and, where relevant, the molecular characteristics of the disease.

Reassessment After Neoadjuvant Treatment Requires Specialist Expertise

Assessment of resectability depends not only on selecting the appropriate imaging investigation, but also on specialist interpretation. After neoadjuvant treatment, fibrosis and treatment-related changes on CT may mimic residual disease or vascular invasion. Reassessment should therefore preferably be performed by a radiologist experienced in pancreatic imaging and discussed within a multidisciplinary tumour board.

How Are Diagnosis and Staging Performed?

The initial assessment has two principal aims: to confirm the diagnosis where required and to define the local extent of the disease and the possible presence of metastases accurately. The quality and correct interpretation of imaging directly affect treatment planning.

1. Pancreatic-Protocol CT of the Chest, Abdomen and Pelvis

Multiphase contrast-enhanced CT is the principal investigation for diagnosis and staging. A dedicated pancreatic protocol assesses the extent of the primary tumour and its relationship to the major blood vessels, while imaging of the chest, abdomen and pelvis assesses for metastatic disease. Image quality and specialist radiological interpretation are critical when assessing resectability.

2. MRI — When It Adds Information

MRI is used selectively, for example when indeterminate liver lesions require better characterisation or when CT does not adequately answer a specific clinical question.

3. Endoscopic Ultrasound & Biopsy

Endoscopic ultrasound (EUS) provides detailed imaging of the pancreas and, where histological confirmation is required, allows ultrasound-guided tissue sampling. Histological confirmation is particularly important before systemic or neoadjuvant treatment.

4. Laboratory Tests & CA 19-9

Laboratory tests complement the clinical and imaging assessment. CA 19-9 may be used as an adjunctive marker for initial assessment and follow-up, but it is not a diagnostic test on its own and must be interpreted in the appropriate clinical context.

How Is Pancreatic Cancer Treated?

The treatment strategy is determined by resectability, the extent of the disease, the patient’s general condition and the response to previous treatment. Management may therefore involve surgery, systemic treatment or a combination of different approaches.

1. Resectable Disease — Surgery & Adjuvant Treatment

When the tumour is resectable, surgical removal is a central part of treatment. Adjuvant chemotherapy is recommended after surgery for a total duration of approximately six months; for patients with good performance status, mFOLFIRINOX is a preferred option.

2. Borderline Resectable Disease — Treatment Before Surgery

In borderline resectable disease, initial systemic therapy is generally preferred over immediate surgery. After completion of treatment, the disease is reassessed and, provided there has been no progression and the overall clinical picture is favourable, the possibility of surgical resection is reconsidered.

3. Locally Advanced Disease — Systemic Treatment & Reassessment

When there are no distant metastases but the tumour is not initially resectable, management is based primarily on systemic treatment. The possibility of surgery should be reassessed periodically within a multidisciplinary team, as in selected patients it may become feasible following a good response to treatment.

4. Metastatic Disease — Individualised Systemic Treatment

In metastatic disease, systemic treatment is the principal approach. For patients with good performance status, current first-line options include FOLFIRINOX, NALIRIFOX or gemcitabine–nab-paclitaxel. The choice depends on fitness, comorbidities and the individual patient’s characteristics.

Treatment Is Not Determined by ‘Stage’ Alone

Two patients with the same anatomical extent of disease may require different strategies. Fitness, disease biology, response to treatment and—in some cases—molecular characteristics influence the final choice.

Molecular & Germline Testing

Why Does It Matter?

Germline and molecular testing are not performed because a therapeutic ‘target’ is expected to be found frequently. In pancreatic cancer, most currently actionable molecular alterations occur in relatively small subgroups of patients. The purpose of testing is to identify those cases in which the result may genuinely influence the treatment strategy.

When Can It Have Therapeutic Relevance?

When a clinically significant finding is detected, it may influence treatment selection or create additional treatment options. Such findings are relatively uncommon, and their significance depends on the specific gene, the type of alteration, the stage of the disease and the availability of approved treatments or clinical trials.

1. Germline Genetic Testing

Testing for inherited mutations looks for genetic alterations present in every cell of the body. In pancreatic cancer, this may include genes such as BRCA1, BRCA2, PALB2 and other cancer-predisposition genes. The absence of a strong family history does not exclude an inherited mutation.

2. Tumour Molecular Profiling

Tumour molecular profiling looks for alterations that have developed within the cancer cells. Most molecular alterations do not currently lead to a different treatment. In smaller subgroups of patients, however, therapeutically relevant findings may be identified, including BRCA1/2 alterations, MSI/dMMR or other rarer potentially actionable alterations.

3. When the Result Changes Management

In specific molecular subgroups, the result may influence the choice of systemic treatment. DNA-repair defects, such as BRCA1/2 mutations, are a characteristic example, while much rarer findings may create an opportunity for a specific targeted treatment. The significance of each finding must be assessed according to the level of evidence and the available treatment options.

Before and During Treatment: What Requires Prompt Management?

1. Jaundice and Biliary Obstruction

Jaundice—the yellowing of the skin and whites of the eyes—may be the first symptom of the disease or may develop during the initial assessment and treatment. When caused by biliary obstruction, it is essentially a mechanical problem that needs prompt management. Restoring bile flow—usually endoscopically with stent placement when indicated—may be necessary before systemic treatment can proceed safely.

2. Pain Control Should Not Wait for a Treatment Response

Pain control is an immediate treatment priority. There is no need to wait for chemotherapy to reduce the tumour and potentially improve symptoms. Analgesic treatment should be tailored to the patient’s needs from the outset; inadequately controlled pain can affect mood, appetite, sleep, quality of life and often adherence to treatment.

3. Nutrition and Pancreatic Function

Maintaining weight and muscle mass is not only a matter of quality of life. A patient who is adequately nourished and maintains a better functional status is more likely to be able to receive the planned anticancer treatment. Weight loss, diarrhoea, steatorrhoea or dyspepsia may also be associated with exocrine pancreatic insufficiency, requiring prompt assessment and, where indicated, pancreatic enzyme replacement therapy and structured nutritional support.

4. Psychological Support from the Outset

Diagnosis is often followed within days by investigations, biopsies, invasive procedures and treatment decisions. Amid this intensity, fear, anxiety and psychological distress can easily become secondary concerns. They should not. Psychological wellbeing, the patient’s support network and individual needs should be assessed from the outset and alongside the physical disease.

Support is not always pharmacological. Family and close contacts have a central role, and specialist help should be sought promptly when psychological distress begins to affect daily life, sleep, functioning or the patient’s ability to engage with treatment.

Frequently Asked Questions

In some patients, yes. In borderline resectable or locally advanced disease, systemic treatment may be given first, followed by a new assessment of resectability. Reassessment is not based solely on a change in tumour size; imaging findings, the relationship to adjacent vessels, the biological response and the overall clinical picture should all be considered by an experienced multidisciplinary team.

No. CA 19-9 is a supportive biomarker and cannot, on its own, confirm or exclude pancreatic cancer. Cholestasis and biliary obstruction can substantially increase its level even without malignancy, so it needs to be interpreted with particular caution in patients with jaundice and, where possible, reassessed after biliary drainage has been restored. Conversely, a small proportion of people with a Lewis-negative phenotype produce very little CA 19-9, so the marker can remain low even when disease is present. CA 19-9 should therefore be interpreted alongside the clinical picture and imaging; when elevated at baseline, its trend may also be useful for monitoring the same patient over time.

Hereditary germline testing and molecular testing of the tumour are different investigations that answer different questions. In pancreatic cancer, germline testing can be relevant even without a strong family history, while tumour molecular testing is particularly useful in advanced disease. Most molecular alterations do not currently lead to a different treatment, but in small subgroups of patients a finding may be identified that affects treatment selection or has implications for the family.

These problems should not simply be left until the next treatment cycle or until a possible response to anticancer treatment occurs. Jaundice may indicate biliary obstruction and can require prompt restoration of bile drainage; pain should be treated from the outset; and rapid weight loss requires early nutritional assessment and evaluation for pancreatic insufficiency. Managing these problems is part of cancer care and may be necessary to allow systemic treatment to continue safely.

Scientific Sources

The information on this page is based on international clinical guidelines and contemporary evidence for the diagnosis and management of pancreatic cancer.

1. Conroy T, Pfeiffer P, Vilgrain V, et al. Pancreatic cancer: ESMO Clinical Practice Guideline for diagnosis, treatment and follow-up. Ann Oncol. 2023;34(11):987–1002. doi: 10.1016/j.annonc.2023.08.009. 2. Sohal DPS, Kennedy EB, Cinar P, et al. Metastatic Pancreatic Cancer: ASCO Guideline Update. J Clin Oncol. 2020;38(27):3217–3230. doi: 10.1200/JCO.20.01364. 3. Turner KM, Wilson GC, Patel SH, Ahmad SA. ASO Practice Guidelines Series: Management of Resectable, Borderline Resectable, and Locally Advanced Pancreas Cancer. Ann Surg Oncol. 2024;31(3):1884–1897. doi: 10.1245/s10434-023-14585-y. 4. Tung N, Ricker C, Messersmith H, et al. Selection of Germline Genetic Testing Panels in Patients With Cancer: ASCO Guideline. J Clin Oncol. 2024;42(21):2599–2615. doi: 10.1200/JCO.24.00662. 5. Mosele MF, Westphalen CB, Stenzinger A, et al. Recommendations for the use of next-generation sequencing (NGS) for patients with advanced cancer in 2024: a report from the ESMO Precision Medicine Working Group. Ann Oncol. 2024;35(7):588–606. doi: 10.1016/j.annonc.2024.04.005. 6. Muscaritoli M, Arends J, Bachmann P, et al. ESPEN practical guideline: Clinical Nutrition in cancer. Clin Nutr. 2021;40(5):2898–2913. doi: 10.1016/j.clnu.2021.02.005. Conroy T, Ducreux M; ESMO Guidelines Committee. ESMO Clinical Practice Guideline Express Update on the management of metastatic pancreatic cancer. ESMO Open. 2025;10(4):104528. doi: 10.1016/j.esmoop.2025.104528.

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With a new diagnosis of pancreatic cancer, particularly where there is a question about resectability, the choice of first treatment or reassessment after treatment, a comprehensive review of the medical record may help inform the treatment strategy.

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