The study of pancreatic cancer, which is slow to progress, has seen a major update in the guidelines. CSCO guide!

The 2020 CSCO pancreatic cancer diagnosis and treatment guide is coming out. Let's take a look at the updated key points! On July 3-4, 2020, BOC and best of ASCO 2020 China (BOA) was successfully held online. Experts and scholars from all over the country discussed and shared research results online through the Internet, witnessing the update of major guidelines in the field of cancer.during the meeting, Professor Li Qi from the first people's Hospital Affiliated to Shanghai Jiaotong University interpreted the update points of the guidelines for diagnosis and treatment of pancreatic cancer of the Chinese society of Clinical Oncology (CSCO) in 2020.compared with other solid tumors, the diagnosis and treatment of pancreatic cancer is more difficult, and the research progress is relatively slow. However, CSCO pancreatic cancer diagnosis and treatment guidelines have been updated many times this year, which will help clinicians.among them, 12 and 10 new notes, 10 contents and 1 and 10 references were updated.Table 1 content update points mainly include pathological diagnosis of pancreatic cancer, surgical treatment of resectable pancreatic cancer, adjuvant chemotherapy of resectable pancreatic cancer, treatment principle of locally advanced pancreatic cancer, treatment principle of metastatic pancreatic cancer and diagnosis and treatment process of pancreatic cancer.Professor Li Qi focused on the diagnosis of pancreatic cancer and adjuvant chemotherapy for resectable pancreatic cancer.in many solid tumors, precise therapy based on gene detection and biomarkers has been widely used.before the interpretation of the guidelines, Professor Li Qi briefly summarized the precise treatment under the guidance of gene detection and biomarkers: Patients with metastatic pancreatic cancer with MSI-H / mismatch repair defect (dmmr) can benefit from the treatment of pabolizumab; patients with metastatic pancreatic cancer with positive ntrk fusion gene can benefit significantly from larotrectinib treatment; and ntrk fusion gene can benefit from the treatment of ntrk fusion gene Patients with positive metastatic pancreatic cancer can benefit significantly from entrectinib treatment; patients with BRCA or PALB2 mutations benefit more from platinum containing regimen; patients with hr-ddr mutation benefit more from platinum containing regimen.1 update of pathological diagnosis of pancreatic cancer: in terms of pathological diagnosis of pancreatic cancer, BRCA1 / 2, PALB2, ntrk gene detection, dmmr and MSI detection were increased to the level I experts' recommendation; level II experts recommended the addition of embryo lines and treatment-related somatic mutation gene detection; class III experts recommended the addition of second-generation sequencing (NGS) for multi gene detection to assess the tumor mutation load (TM B) To find out whether there are potential therapeutic targets.Table 2: if there is BRCA1 / 2 or PALB2 gene mutation, platinum containing chemotherapy can be considered; for patients with ntrk gene fusion, targeted ntrk can benefit patients; for patients with dmmr or MSI, immunotherapy may benefit patients.2 adjuvant chemotherapy for resectable pancreatic cancer, there are few updated contents in the guidelines, only the order of chemotherapy options is adjusted.the recommended order of level II experts was adjusted as follows: 1. Gemcitabine (GEM) combined with capecitabine (CAP) (type 1A evidence); 2. Mfolfirinox (type 1A evidence); 3. Gemcitabine monotherapy (type 1A evidence); 4. S-1 single drug (type 1A evidence).espac-4 study published in Lancet in 2017 showed that gemcitabine combined with capecitabine has more significant benefits than gemcitabine monotherapy, and can prolong the overall survival (OS) (28.8% vs 16.3%).based on this study, gemcitabine combined with capecitabine is recommended for pancreatic cancer patients with good physical fitness (grade I expert recommended, class a).3 neoadjuvant chemotherapy for resectable pancreatic cancer, there are many controversies about neoadjuvant chemotherapy for resectable pancreatic cancer. The reason is that once the neoadjuvant chemotherapy is ineffective, it may lead to disease progression and increase the difficulty of treatment.according to the European study of pact-15, if gemcitabine combined with epirubicin, cisplatin and capecitabine was used preoperatively, the progression free survival (PFS), disease-free survival (DFS) and OS of the patients were improved after three treatment cycles. However, the toxicity of the combination of the four drugs was relatively high, and its feasibility was still to be discussed Medium.neoadjuvant chemoradiotherapy for resectable / borderline resectable pancreatic cancer has a long history. Several studies in the United States have indicated that the overall benefit of neoadjuvant chemotherapy to patients is not ideal. the preopanc study published in 2020 showed that compared with surgery alone, preoperative neoadjuvant chemoradiotherapy had no longer OS (16.0 months vs 14.3 months, P = 0.096), but the OS of patients who could achieve R0 resection after neoadjuvant chemoradiotherapy was significantly prolonged (35.2 months vs 19.8 months, P = 0.029). the study was added to the new guideline note. 4 treatment principles of borderline resectable pancreatic cancer, two research notes have been added. one of the newly added notes is a meta-analysis of 24 pancreatic cancer studies. a total of 313 patients with borderline resectable pancreatic cancer were enrolled in this study. They received neoadjuvant therapy with polfirinox regimen, with an average of 4-9 cycles. the results showed that 67.8% of cancer patients responded well to folfirinox, and the lesions could be completely resected by surgery, with a median OS of 22.2 months and PFS of 18.0 months. Professor Li Qi said that compared with gemcitabine monotherapy, folfirinox regimen has higher requirements for patients, and patients need to have better physical condition and be able to tolerate adverse reactions caused by drugs. in addition, the results of jaspac05 phase II clinical study from Japan suggest that preoperative S-1 combined with concurrent radiotherapy is feasible and effective, and can improve the resection rate of R0. since it is only a phase II clinical study, the feasibility is worth discussing, and the phase III clinical study is in progress. 5 treatment principle of metastatic pancreatic cancer. For the treatment of metastatic pancreatic cancer, the maintenance chemotherapy recommended by grade III experts should be changed to maintenance treatment, and it should be promoted to the level II expert recommendation. Table 3 treatment principles of metastatic pancreatic cancer, chemotherapy combined with electric field therapy was added in the recommendation of grade III experts, and the update was based on the phase II PANOVA study. the results suggest that the combination of ttfields and systemic chemotherapy is safe and tolerable for patients with advanced pancreatic cancer. of the 40 newly diagnosed, locally advanced or metastatic pancreatic cancer, 20 received continuous electric field therapy + gemcitabine, and 20 received electric field therapy + gemcitabine + albumin paclitaxel. the median PFS and OS were 8.3 months and 14.9 months respectively in patients with advanced pancreatic cancer treated with electric field therapy plus gemcitabine, while 3.7 months and 6.7 months were PFS and 6.7 months in gemcitabine plus gemcitabine alone control group; the median PFS was 12.7 months in the electric field therapy + gemcitabine + albumin paclitaxel group, but the median OS was not reached, while gemcitabine + albumin paclitaxel treatment group The median PFS of the control group was 5.5 months. based on the research, China's State Drug Administration has granted it the qualification of innovative medical devices for breakthrough new tumor treatment technology. in the first-line treatment of metastatic pancreatic cancer, a new level I expert recommended: platinum containing regimen (with BRCA1 / 2 germline mutation), and olapali maintenance therapy (class I a evidence) should be considered for patients without disease progression after treatment for more than 16 weeks. this update is based on the results of a polo study published at the American Society of Clinical Oncology (ASCO) annual meeting in 2019: for patients with metastatic pancreatic cancer who have received platinum containing chemotherapy regimen and their disease is under control, 16 weeks after treatment, the patients can significantly prolong their PFS, regardless of the platinum containing regimen, age and gender Benefit. Table 4 first line treatment of metastatic pancreatic cancer in the second-line treatment of metastatic pancreatic cancer, nano liposome irinotecan + 5-fluorouracil (5-FU) / calcium folinate (LV) was updated to class 1A evidence, and it was promoted to class I expert recommendation. from the napoli-1 study, it can be seen that nano liposome irinotecan + 5-FU / LV can significantly improve the survival of patients with metastatic pancreatic cancer. the results of napoli-1 Asian subgroup showed that nano liposome irinotecan + 5-FU / LV regimen significantly improved the survival of patients with metastatic pancreatic cancer in Asia, with a median OS extension of 5.2 months and a median PFS extension of 2.6 months. Table 5 second line treatment for metastatic pancreatic cancer