Pancreas
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Pancreas (ICD‐O‐3 C25) Rules for Classification The classification applies to carcinomas of the exocrine pancreas and/or high‐grade neuroendocrine carcinomas. Well‐differentiated neuroendocrine tumours of the pancreas are classified as shown on page 102. There should be histological or cytological confirmation of the disease. The following are the procedures for assessing T, N, and M categories. T categories Physical examination, imaging, and/or surgical exploration N categories Physical examination, imaging, and/or surgical exploration M categories Physical examination, imaging, and/or surgical exploration
C25.0 C25.1 C25.2 C25.3
Head of pancreasa Body of pancreasb Tail of pancreasc Pancreatic duct
Notes a Tumours of the head of the pancreas are those arising to the right of the left border of the superior mesenteric vein. The uncinate process is considered as part of the head. b Tumours of the body are those arising between the left border of the superior mesenteric vein and left border of the aorta. c Tumours of the tail are those arising between the left border of the aorta and the hilum of the spleen.
Regional Lymph Nodes The regional lymph nodes for tumours in the head and neck of the pancreas are the lymph nodes along the common bile duct, common hepatic artery, portal vein, pyloric, infrapyloric, subpyloric, proximal mesenteric, coeliac, posterior, and anterior pancreaticoduodenal vessels, and along the superior mesenteric vein and right lateral wall of the superior mesenteric artery. The regional lymph nodes for tumours in body and tail are the lymph nodes along the common hepatic artery, coeliac axis, splenic artery, and splenic hilum, as well as retroperitoneal nodes and lateral aortic nodes.
Digestive System
Anatomical Subsites
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Digestive System Tumours
TNM Clinical Classification T – Primary Tumour TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ*
T1 Tumour 2 cm or less in greatest dimension T1a Tumour 0.5 cm or less in greatest dimension T1b Tumour greater than 0.5 cm and less than 1 cm in greatest dimension T1c Tumour greater than 1 cm but no more than 2 cm in greatest dimension T2 Tumour more than 2 cm but no more than 4 cm in greatest dimension T3 Tumour and more than 4 cm in greatest dimension T4 Tumour involves coeliac axis, superior mesenteric artery and/or com mon hepatic artery Note * Tis also includes the ‘PanIN–III’ classification.
N – Regional Lymph Nodes NX N0 N1 N2
Regional lymph nodes cannot be assessed No regional lymph node metastasis Metastases in 1 to 3 regional lymph node Metastases in 4 or more regional lymph node
M – Distant Metastasis M0 No distant metastasis M1 Distant metastasis
pTNM Pathological Classification The pT and pN categories correspond to the T and N categories. For pM see page 8. pN0 Histological examination of a regional lymphadenectomy specimen will ordinarily include 12 or more lymph nodes. If the lymph nodes are negative, but the number ordinarily examined is not met, clas sify as pN0.
Pancreas
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Stage – Pancreas Stage 0 Stage IA Stage IB Stage IIA Stage IIB Stage III Stage IV
Tis T1 T2 T3 T1, T2, T3 T1, T2, T3 T4 Any T
N0 N0 N0 N0 N1 N2 Any N Any N
M0 M0 M0 M0 M0 M0 M0 M1
Prognostic Factors Grid – Pancreas
Prognostic factors
Tumour related
Host related
Environment related
Essential
Distant metastases
ECOG status
Post‐resection residual disease or margin status (R0, R1, R2)
Additional
Lymph node metastases CA19‐9 level
Postoperative morbidity
Adjuvant therapy
New and promising
hENT1 expression
Modified Glasgow prognostic score (C‐reactive protein [CRP] and albumin) Neutrophil‐to‐ lymphocyte ratio (NLR)
Pathological response to neoadjuvant therapy
Source: UICC Manual of Clinical Oncology, Ninth Edition. Edited by Brian O’Sullivan, James D. Brierley, Anil K. D’Cruz, Martin F. Fey, Raphael Pollock, Jan B. Vermorken and Shao Hui Huang. © 2015 UICC. Published 2015 by John Wiley & Sons, Ltd.
Digestive System
Prognostic risk factors for pancreatic cancer