胰腺癌2022.v1-NCCN（英文版）

NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines?)PancreaticAdenocarcinomaersionFebruaryNCCNGuidelinesforPatients?availableat/patientsVersion1.2022,02/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:52:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dex*MargaretA.Tempero,MD/Chair??UCSFHelenDillerFamilyComprehensiveCancerCenternterMDnterMDchiganentereCenterAlB.BensonIII,MD?RobertH.LurieComprehensiveCancerCenterofNorthwesternUniversityngramCancerCenternaBCardinngramCancerCenterE.GabrielaChiorean,MD?FredHutchinsonCancerResearchCenter/SeattleCancerCareAlliancefHopeVincentChungfHopecalCenterBrianCzito,MD§DukeCancerInstituteoradoChiaroMDoradoenterMaryDillhoff,MD,MS?TheOhioStateUniversityComprehensiveCancerCenter-JamesCancerHospitalandSoloveResearchInstituteTimothyR.Donahue,MD?UCLAJonssonComprehensiveCancerCenterEfratDotan,MD?FoxChaseCancerCenterCristinaR.Ferrone,MD?MassachusettsGeneralHospitalCancerCenteresPanelDisclosuresChristosFountzilas,MD?RoswellParkComprehensiveCancerCenterJeffreyHardacre,MD?CaseComprehensiveCancerCenter/UniversityHospitalsSeidmanCancerCenterandClevelandClinicTaussigCancerInstituteWilliamG.Hawkins,MD?SitemanCancerCenteratBarnes-JewishHospitalandWashingtonUniversitySchoolofMedicineEdwardJ.Kim,MD,PhD?UCDavisComprehensiveCancerCentertytenterAndrewH.Ko,MD?UCSFHelenDillerFamilyComprehensiveCancerCenterrcerHospitalrcerHospitalonsinleLoConteonsineCancerCenterAndrewM.Lowy,MD?UCSanDiegoMooresCancerCenterMoravektworkJorgeObando,MD¤stitutePatricioM.Polanco,MD?UTSouthwesternSimmonsComprehensiveCancerCenterSushanthReddy,MD?O’NealComprehensiveCancerCenteratUABMarshaReyngold,MD,PhD§MemorialSloanKetteringCancerCenterCourtneyScaife,MD?HuntsmanCancerInstituteattheUniversityofUtahJeanneShen,MD≠StanfordCancerInstituteMarkJ.Truty,MD,MS?MayoClinicCancerCenterAbramsonCancerCenterattheAbramsonCancerCenteratthensylvaniaandWomensnMWolpinandWomensenterBethMcCulloughRN,BSMaiNguyen,PhDosticInterventional¤GastroenterologyosticInterventional¤Gastroenterology?Hematology/Hematologyoncology?Medicaloncology≠Pathology￥Patientadvocacy§Radiotherapy/Radiationoncology?Surgery/Surgicaloncology*DiscussionsectionwritingcommitteeUCSFHelenDillerFamilyComprehensiveCancerCenterAmolK.Narang,MD§TheSidneyKimmelComprehensiveCancerCenteratJohnsHopkinsVersion1.2022,02/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.anelMembersryofGuidelinesUpdatespicionofPancreaticCancerEvidenceofDilatedPancreaticandorBileDuctPANCanelMembersryofGuidelinesUpdatespicionofPancreaticCancerEvidenceofDilatedPancreaticandorBileDuctPANCeaseNoMetastasesPANCeryPANCanceTherapyPANCPANCPrinciplesofDiagnosis,Imaging,andStaging(PANC-A)PancreaticCancerRadiologyReportingTemplate(PANC-A,5of8)PANCBfiningResectabilityStatusatDiagnosisPANCCofCriteriaforResectionFollowingNeoadjuvantTherapy(PANC-C,2of2)PrinciplesofSurgicalTechnique(PANC-D)PathologicAnalysis:SpecimenOrientation,HistologicSections,andReporting(PANC-E)PrinciplesofSystemicTherapy(PANC-F)CGSupportiveCarePANCHounselingPANCIdexlievesthatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.FindanNCCNMemberInstitution:/home/member-institutions.ofEvidenceandsusAllrecommendationsotherwisedNCategoriesofEvidenceandConsensus.NCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.TheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualstancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanywayTheNCCNbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.?2022.Version1.2022,02/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.UPDATESVersion1.2022,02/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:52:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexeNCCNGuidelinesforPancreaticAdenocarcinomafromVersionincludeGlobalchanges?Changed"Germlinetesting"to"Genetictestingforinheritedmutations."?Changed"Geneprofiling"to"Molecularprofiling."?Changed"MSI/MMRstatusand/orgeneprofiling"to"molecularprofiling."?Bulletremoved:Microsatelliteinstability(MSI)and/ormismatchrepair(MMR)testingonavailabletumortissue.?Changed"cancers"to"adenocarcinoma."?Changed"carcinoma"toadenocarcinoma."spRevisedfootnotes:?Footnotea:Multidisciplinaryreviewshouldideallyinvolveconsiderinvolvingexpertisefromdiagnosticimaging,interventionalendoscopy,medicaloncology,radiationoncology,surgery,pathology,geriatricmedicine,geneticcounseling,andpalliativecare(seePrinciplesofPalliationandSupportiveCare[PANC-H]).Considerconsultationwitharegistereddietitian.SeeNCCNGuidelinesforOlderAdultOncologyandNCCNGuidelinesforPalliativeCare.(AlsopagePANC-10)?Footnoteg:GermlineGenetictestingforinheritedmutationsisrecommendedforanypatientwithconfirmedpancreaticcancer,usingcomprehensivegenepanelsforhereditarycancersyndromes.Geneticcounselingisrecommendedforpatientswhotestpositiveforapathogenicmutation(ATM,BRCA1,BRCA2,CDKN2A,MLH1,MSH2,MSH6,PALB2,PMS2,STK11,andTP53)orforpatientswithapositivefamilyhistoryofcancer,especiallypancreaticcancer,regardlessofmutationstatus.OkurV,etal.ColdSpringHarbMolCaseStud2017;3(6):a002154.SeeDiscussionandNCCNGuidelinesforGenetic/FamilialHighRiskAssessment:Breast,Ovarian,andPancreatic.(AlsopagesPANC-2throughPANC-4,PANC-6throughPANC-8,andPANC-10)?Footnotei:Tumor/somaticgenemolecularprofilingisrecommendedforpatientswithlocallyadvanced/metastaticdiseasewhoarecandidatesforanti-cancertherapytoidentifyuncommonmutations.Considerspecificallytestingforpotentiallyactionablesomaticfindingsincluding,butnotlimitedto:fusions(ALK,NRG1,NTRK,ROS1,FGFR2,RET),mutations(BRAF,BRCA1/2,HER2,KRAS,PALB2),amplifications(HER2),microsatelliteinstability(MSI),and/ormismatchrepair(MMR)deficiency(detectedbytumorIHC,PCR,orNGS).Testingontumortissueispreferred;however,cell-freeDNAtestingcanbeconsiderediftumortissuetestingisnotfeasible.SeeDiscussionandPrinciplesofCancerRiskAssessmentandCounseling(PANC-I).(AlsopagesPANC-4,PANC-5A,andPANC-8throughPANC-10)pNewfootnotesadded:?Footnotef:ElevatedCA19-9doesnotnecessarilyindicatecanceroradvanceddisease.CA19-9maybeelevatedasaresultofbiliaryinfection(cholangitis),inflammation,orobstruction,benignormalignant.Inaddition,CA19-9willbeundetectableinLewisantigen-negativeindividuals(SeeDiscussion).(AlsopagePANC-7)?Footnoteh:Corebiopsyisrecommended,ifpossible,toobtainadequatetissueforpossibleancillarystudies.(AlsopagesPANC-4andPANC-6)UPDATESVersion1.2022,02/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:52:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexeNCCNGuidelinesforPancreaticAdenocarcinomafromVersioninclude?Treatment:pFirstcolumn,secondoptionrevised:EUS-guidedbiopsyifconsideringneoadjuvanttherapyandifnotpreviouslydoneandConsiderstentifclinicallyindicated.?FollowingEUS-guidedbiopsy,optionadded:Considerstaginglaparoscopy,inhigh-riskpatientsorasclinicallyindicated.–FollowingConsiderstaginglaparoscopy,bulletadded:Clinicaltrialpreferred.pSecondcolumn,bulletadded:Considerstaginglaparoscopy,inhigh-riskpatientsorasclinicallyindicated.?Footnotelrevised:High-riskfeaturesincludeimagingfindings,veryhighlymarkedlyelevatedCA19-9,largeprimarytumors,largeregionallymphnodes,excessiveweightloss,extremepain.ifnotpreviouslydone?FootnotesrevisedpFootnotep:EUS-guidedFNAandcorebiopsyatacenterwithmultidisciplinaryexpertiseispreferred.WhenEUS-guidedbiopsyisnotfeasible,CT-guidedbiopsycanbedone.?First-LineTherapypFollowingGoodperformancestatus,fourthoptionrevised:ChemoradiationorSBRTinselectedpatientswhoarenotcandidatesforcombinationinductionchemotherapy.?Newfootnotesadded:pFootnotek:SeePrinciplesofDiagnosis,Imaging,andStaging(PANC-A).pFootnoteq:Unlessbiliarybypasswasperformedatthetimeoflaparoscopyorlaparotomy.FirstcolumnrevisedBaselinepostoperativeCTchestabdomenandpelviswithcontrastunlesscontraindicatedCA9-9,andGermlinegenetictestingforinheritedmutations,ifnotpreviouslydone.nceviswithcontrastunlesscontraindicatedspRevisedfootnotes:?Footnotez:Adjuvanttreatmentshouldbeadministeredtopatientswhohaveadequatelyrecoveredfromsurgery;treatmentshouldbeinitiatedideallywithin12weeks.Ifsystemicchemotherapyprecedeschemoradiation,restagingwithimagingshouldbedoneaftereachtreatmentmodality.?Footnotebb:Patientswhohavereceivedneoadjuvantchemoradiationorchemotherapymaybecandidatesforadditionalchemotherapy(orchemoradiationifnonewasdeliveredneoadjuvantly)followingsurgeryandmultidisciplinaryreview.Theadjuvanttherapyoptionsaredependentontheresponsetoneoadjuvanttherapyandotherclinicalconsiderations.Totaldurationofsystemictherapyistypically6months.pNewfootnotexadded:BasedonLAP-07trialdata,thereisnoclearsurvivalbenefitwiththeadditionofconventionalchemoradiationfollowinggemcitabinemonotherapy.Chemoradiationmayimprovelocalcontrolanddelaytheneedforresumptiontherapy.(HammelP,etal.AMA2016;315:1844-1853.)(AlsoPANC-10)ContinuedUPDATESVersion1.2022,02/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:52:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexeNCCNGuidelinesforPancreaticAdenocarcinomafromVersioninclude?MaintenanceTherapy:pOptionsrevised:ContinuesystemictherapyorOlaparib(onlyforgermlineBRCA1/2mutations)orOthermaintenancetherapystrategiesSeePrinciplesofSystemicTherapy(PANC-F)orClinicaltrialorChemotherapyholiday.?Footnoteeadded:SeePrinciplesofStentManagement(PANC-B).?SubsequentTherapy:pFollowingGoodPS,optionsrevised:Clinicaltrial(preferred)orSystemictherapy,orpossibly,whichmayincludetargetedtherapyorimmunotherapy...?Footnotewadded:Chemoradiationshouldbereservedforpatientswhodonotdevelopmetastaticdiseasewhilereceivingsystemicchemotherapy.?Footnoteremoved:Ifconsideringchemoradiationduetopositivemargins,chemotherapyshouldbegivenpriortotheadministrationofchemoradiation.?Headerrevised:MetastaticDiseaseFollowingSurgery?RecurrenceTherapypFollowing≥6mofromcompletionofprimarytherapy,optionsrevised:Clinicaltrial(preferred)orRepeatsystemictherapypreviouslyadministeredorAlternateSsystemictherapy(notpreviouslyused)or...pFollowing<6mofromcompletionofprimarytherapy,optionsrevised:Clinicaltrial(preferred)orSwitchtogemcitabine-basedsystemicchemotherapy(iffluoropyrimidine-basedtherapypreviouslyused)orSwitchtofluoropyrimidine-basedsystemicchemotherapy(ifgemcitabine-basedtherapypreviouslyused)orAlternatesystemictherapy(notpreviouslyused)or...PANC-A1of8?Thirdbullet,firstsub-bulletrevised:MultidetectorcomputedtomographyCT(MDCT)angiography...PANC-A2of8?Thirdbulletrevised:EUS-guidedFNA/fine-needlebiopsy(FNB)ispreferabletoaCT-guidedFNAbiopsyinpatientswithresectablenon-metastaticdiseasebecauseofbetterdiagnosticyield,safety,andpotentiallylowerriskofperitonealseedingwithEUS-FNA/FNBwhencomparedwiththepercutaneousapproach...?Fourthbulletrevised:Diagnosticstaginglaparoscopytoruleoutmetastasesnotdetectedonimaging(especiallyforbodyandtaillesions)isusedinsomeinstitutionspriortosurgeryorchemoradiationneoadjuvanttherapy,orselectivelyinpatientswhoareathigherriskfordisseminateddisease...?Sixthbulletrevised:DuringERCP,commonbileductbrushingsmaybedoneifthereisnopriordefinitivediagnosis,andanEUS-guidedbiopsycanbedoneorrepeated.PANC-C1of2?BorderlineResectable,Pancreaticbody/tail,bulletremoved:SolidtumorcontactwiththeCAof>180°withoutinvolvementoftheaortaandwithintactanduninvolvedgastroduodenalarterytherebypermittingamodifiedApplebyprocedure(somepanelmemberspreferthesecriteriatobeinthelocallyadvancedcategory).?LocallyAdvanced,Head/uncinateprocess:pFirstbulletrevised:SolidtumorcontactwithSMA>180°withtheSMAorCA.pBulletremoved:SolidtumorcontactwiththeCA>180°UPDATESVersion1.2022,02/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:52:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexeNCCNGuidelinesforPancreaticAdenocarcinomafromVersionincludePANC-C2of2?Followingneoadjuvanttherapy:pFourthbulletrevised:Patientswhoinitiallypresentedwithresectableorborderlineresectable(BR)diseaseshouldbeexplorediftheircarbohydrateantigen(CA)19-9isatleaststableorhasdecreasedandradiographicfindingsdonotdemonstrateclearprogression.pSixthbulletrevised:Forpatientswhopresentedwithlocallyadvanceddisease(LAD),explorationforresectionshouldbeconsideredifthereisa>50%signiicantdecreaseinCA19-9levelandclinicalimprovement(ie,improvementinperformancestatus,pain,earlysatiety,weight/nutritionalstatus)indicatingresponsetotherapy.ForLAD,patientsshouldbecounseledthatthelong-termbenefit(ie,chanceforcure)isunknown.LADcasesshouldalwaysalwaysbehandledinhighlyspecializedcenters.PANC-D2of3?SurgeryforLocallyRecurrentPancreaticDuctalAdenocarcinomapSecondparagraphrevised:Thereisapotentialbenefitofre-resectionforpancreaticductaladenocarcinomarecurrencesinselectedsubgroupsofpatients.Thesepatientsshouldbecarefullyevaluatedinthemultidisciplinaryclinicwherefollowingadetailedrestagingassessment,amultimodalitytherapycareplanconsistingofneoadjuvantchemotherapy,possibleradiationtherapy,andpossiblesurgicalresectioncanbeformulated.PANC-D3of3?Reference6added:SerafiniS,SpertiC,FrizieroA,etal.Systematicreviewandmeta-analysisofsurgicaltreatmentforisolatedlocalrecurrenceofpancreaticcancer.Cancers(Basel)2021;13:1277.PANC-E2of5?HistologicSectioning:pFourthbulletrevised:PerthecurrentCAPprotocol...Tumorclearanceshouldbereportedwithmillimeteraccuracyforallmarginswheretumorisclose(within≤1.0cmorlessofthetumor)...Attachedorgansresectedwiththespecimenenblocrequireserialsectioningtoassessnotonlydirectextension,butmetastaticdepositsaswell.OneSectionthatdemonstratesdirectinvasionoftheorganand/oraseparatemetastaticdepositisrequired.pBulletremoved:Attachedorgansresectedwiththespecimenenblocrequireserialsectioningtoassessnotonlydirectextension,butmetastaticdepositsaswell.Onesectionthatdemonstratesdirectinvasionoftheorganand/oraseparatemetastaticdepositisrequired.PANC-E3of5?DistalPancreatectomy,secondbullet,firstsub-bulletrevised:ProximalPancreatic(transection)Margin:Afullenfacesectionofthepancreaticbodyalongtheplaneoftransection,ifthetumorisgrossly>1.0cmfromthismargin.Careshouldbetakenwhenplacingthesectionintothecassettetodocumenttheorientationofthesectionwithrespecttowiththetruemargin(eg,facingdownsothattheinitialsectionintotheblockrepresentsthetruesurgicalmargin,orfacingupsothattheinitialsectionrepresentsthesurfaceoppositethetruemargin).Morethanoneblockmaybeneeded.Ifthetumorisgrosslyclosetothemargin(eg,within≤1.0cmorless),radial(eg,perpendicular)sectionstothismarginarerecommendedformillimeter-levelaccuracyindocumentingthedistancetothemargintheentiremarginshouldbesubmittedforpathologicevaluationinamannerthatallowsformillimeter-levelaccuracyindocumentingthedistanceoftumorfromthismargin.Forexample,themargincanbeinkedandshaved/amputated,followedbyperpendicularsectioningwithrespecttotheinkandsubmissionoftheentiremarginforhistologicexamination.UPDATESVersion1.2022,02/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:52:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexeNCCNGuidelinesforPancreaticAdenocarcinomafromVersionincludePANC-E4of5?Secondbulletattopofpagerevised:Treatmenteffectshouldbeassessedandreportedbythepathologist,astumorviabilitymayimpactpostoperativetherapyoptions.Formoreinformationaboutpathologicanalysis,refertotheCAPCancerProtocolTemplateforcarcinomaofthepancreas.(BurgartLJ,ShiC,AdsayVN,etal.ProtocolfortheExaminationofSpecimensfromPatientswithCarcinomaofthePancreas.CollegeofAmericanPathologists.CancerProtocolTemplates;2020.BurgartLJ,ChoppWV,JainD,etal.ProtocolfortheExaminationofSpecimensfromPatientswithCarcinomaofthePancreas.CollegeofAmericanPathologists.CancerProtocolTemplates;2021.)PANC-E5of5?Referenceadded:DhallD,ShiJ,AllendeDS,JangK,etal.Towardsamorestandardizedapproachtopathologicreportingofpancreatoduodenectomyspecimensforpancreaticductaladenocarcinoma:Cross-continentalandcross-specialtysurveyfromthePancreatobiliaryPathologySocietyGrossingWorkingGroup.AmJSurgPathol2021;45:1364-1373.PANC-F1of9?GeneralPrinciples,newbulletadded:Squamous/adenosquamouscarcinomasaretreatedthesameasadenocarcinoma.Thereisnodatasupportingtheefficacyofanyoftherecommendedregimensforsquamous/adenosquamouscarcinomas.?NeoadjuvantTherapy(Resectable/BorderlineResectableDisease),bulletrevised:Thereislimitedevidencetorecommendspecificneoadjuvantregimensoff-study,andpracticesvarywithregardtotheuseofchemotherapyandradiation.Subsequentchemoradiationissometimesincluded.Whenconsideringneoadjuvanttherapy,consultationatahigh-volumecenterispreferred.Ifneoadjuvanttherapyisconsideredorrecommended,treatmentatorcoordinatedthroughahigh-volumecenterispreferred,whenfeasible.Participationinaclinicaltrialisencouraged.PANC-F2of9?Firstbulletrevised:TheCONKO-001trialdemonstratedsignificantimprovementsindisease-freesurvival(DFS)andoverallsurvival(OS)withuseofpostoperativegemcitabineasadjuvantchemotherapyversusobservationinresectablepancreaticadenocarcinoma.PANC-F3of9?LocallyAdvancedDisease(First-LineTherapy)pGoodPS,OtherRecommendedRegimens,newoptionadded:Gemcitabine+albumin-boundpaclitaxel+cisplatin(category2B)pGoodPS,UsefulinCertainCircumstances,secondbulletrevised:ChemoradiationorSBRT(inselectpatientswhoarenotcandidatesforcombinationinductionchemotherapy).spNewfootnoteaadded:FOLFIRINOXormodifiedFOLFIRINOXshouldbelimitedtothosewithECOG0-1.(AlsopagesPANC-F4of9andPANC-F6of9)pFootnotefrevised:FOLFIRINOXormodifiedFOLFIRINOXshouldbelimitedtothosewithECOG0-1.Gemcitabine+albumin-boundpaclitaxelisreasonableforpatientswithECOG0-2.5-FU+leucovorin+liposomalirinotecanisareasonablesubsequenttherapyoptionforpatientswithECOG0-2.(AlsopagePANC-F4of9)PANC-F4of9?MetastaticDisease(First-LineTherapy)pGoodPS,OtherRecommendedRegimens,newoptionadded:Gemcitabine+albumin-boundpaclitaxel+cisplatinpGoodPS,UsefulinCertainCircumstances,newoptionadded:Pembrolizumab(ifMSI-H,dMMR,orTMB-H[≥10mut/Mb])pPoorPS,UsefulinCertainCircumstances,firstoptionrevised:Pembrolizumab(onlyforifMSI-H,ordMMR,orTMB-H[≥10mut/Mb]tumors).UPDATESVersion1.2022,02/24/2022?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon3/14/20227:52:51AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.dexeNCCNGuidelinesforPancreaticAdenocarcinomafromVersionincludePANC-F5of9?MetastaticDisease(MaintenanceTherapy):pOtherRecommendedRegimens,Ifpreviousfirst-linegemcitabine+nabalbumin-boundpaclitaxel,firstoptionrevised:Gemcitabine+nabalbumin-boundpaclitaxelmodifiedschedule(category2B)pUsefulinCertainCircumstances,optionadded:Priorplatinum-basedtherapy:Rucaparib(forgermlineorsomaticBRCA1/2orPALB2mutations).?Footnotemadded:Forpatientswhodidnothavediseaseprogressionfollowingtheirmostrecentplatinum-basedchemot