Screening and diagnosis

Classification and risk stratification

Perioperative care

Quality improvement

Patient education

Nonpharmacologic interventions

Therapeutic procedures

Respiratory support

Follow-up and surveillance

Specific circumstances

Preventative measures

Medical management

Surgical interventions

Inpatient care

Diagnostic procedures

Diagnostic investigations

Insufficient evidence to make a recommendation.

Strongly favor this test or intervention.

The Eastern Cooperative Oncology Group (ECOG) performance status calculator is designed to evaluate a patient's functional ability and categorize it into a specific score from 0 to 5. This quantitative measure helps clinicians make informed decisions about treatment based on the patient's capacity for daily activities and self-care. Here's how it operates:

The user provides input by selecting the description that best matches the patient's current condition from a list of predefined options. These options encapsulate various levels of activity and ability:

- A patient who is "Fully active, able to carry on all pre-disease performance without restriction" is assigned a score of ECOG PS 0. This indicates that the patient is not limited in any capacity by their disease.
- If a patient is "Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, such as light housework, office work," they receive an ECOG PS 1. This means the patient can perform some self-care and work activities but faces restrictions with strenuous tasks.
- "Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours" corresponds to an ECOG PS 2. This reflects moderate impairment, where the patient is active for the majority of the day but not capable of work activities.
- A patient who is "Capable of only limited self-care, confined to bed or chair more than 50% of waking hours" gets an ECOG PS 3. This score denotes significant limitation, as the patient is mobile for less than 50% of the time and requires assistance for most activities.
- With "Completely disabled, cannot carry on any self-care, totally confined to bed or chair," the patient is categorized as ECOG PS 4, indicating severe impairment and complete dependency.
- Finally, if the patient is "Dead," they are assigned an ECOG PS 5.

These score assignments help standardize assessments, providing an objective measure of a patient's status which can be pivotal in guiding medical decisions and evaluating treatment options.

The Eastern Cooperative Oncology Group (ECOG) performance status, also known as the ECOG score, is a widely used tool in oncology to assess a patient's level of functioning in terms of their ability to care for themselves, daily activity, and physical ability (walking, working, etc.). It is applicable to patients with cancer of any type and at any stage.

The ECOG score ranges from 0 to 5, with 0 indicating fully active and able to carry on all pre-disease activities without restriction, and 5 indicating death. The score is used to determine a patient's prognosis, assess how a disease is progressing, and to determine appropriate treatment strategies. It is also often used in clinical trials to assess eligibility and to monitor patient progress.

There are no specific exclusion criteria for the use of the ECOG score, but it is important to note that it is a subjective measure and may not fully capture a patient's functional status. It is also less useful in patients with fluctuating or rapidly changing conditions.

Eastern Cooperative Oncology Group performance status (ECOG score)

The TNM classification system for exocrine pancreatic cancer assesses the stage of cancer by evaluating three types of input: tumor size and local extent (T), lymph node involvement (N), and distant metastasis (M). Each of these classifications has specific criteria, and the combination of these classifications determines the cancer stage.

Inputs:
The tumor classification options are: Tx (Primary tumor cannot be assessed), T0 (No evidence of primary tumor), Tis (Carcinoma in situ), T1 (Tumor <= 2 cm), T2 (Tumor > 2 cm but <= 4 cm), T3 (Tumor > 4 cm), T4 (Involvement of major arteries). The lymph node classification options are: Nx (Cannot be assessed), N0 (No metastasis), N1 (Metastasis in 1-3 nodes), N2 (Metastasis in >= 4 nodes). The metastasis classification options are: M0 (No distant metastasis) and M1 (Distant metastasis).

Output:
The result provides the stage of pancreatic cancer, ranging from Stage IA to Stage IV, or indicates if the stage cannot be fully assessed.

Computation:
The computations use specific conditions to determine the stage:

- Stage IA: T1 with no lymph node or distant metastasis (T1, N0, M0).
- Stage IB: T2 with no lymph node or distant metastasis (T2, N0, M0).
- Stage IIA: T3 with no lymph node or distant metastasis (T3, N0, M0).
- Stage IIB: Any of T1, T2, or T3 with 1-3 lymph node metastases and no distant metastasis (T1-3, N1, M0).
- Stage III: Any of T1, T2, T3, or T4 with >= 4 lymph node metastases or involvement of major arteries and no distant metastasis (T1-4, N2, M0).
- Stage IV: Any tumor and lymph node classification with distant metastasis (any T, any N, M1).
- If the input conditions do not match these scenarios, the stage cannot be fully assessed, or if no selections are made for the inputs, a prompt to select inputs is returned.

The precise combinations of T, N, and M classification inputs determine the output stage, and if no match is found, the output suggests further assessment is needed.

The calculator in question is the TNM Classification for Exocrine Pancreatic Cancer. TNM stands for Tumor, Node, Metastasis, a system used to classify the extent of cancer spread. This specific classification is used for patients diagnosed with exocrine pancreatic cancer.

The TNM Classification for Exocrine Panicreatic Cancer is used to stage the disease, which is crucial for determining the most appropriate treatment plan and predicting patient prognosis. The 'T' in TNM refers to the size and extent of the main tumor, 'N' refers to the number of nearby lymph nodes that have cancer, and 'M' refers to whether the cancer has metastasized (spread) to other parts of the body.

This classification system is not applicable to patients with endocrine pancreatic cancer or other types of cancer. It is also less useful in cases where the cancer is inoperable or the patient is not a candidate for surgery due to other health conditions.

TNM classification for exocrine pancreatic cancer

The Karnofsky Performance Scale (KPS) provides a practical method to evaluate a patient's functional ability and the extent of care required based on their health status. The scale ranges from 0% to 100%, where higher percentages signify better functional capacity and health.

This tool involves selecting a descriptive statement that best reflects a patient's current condition from a predefined list. Each statement is connected to a specific KPS percentage that indicates the patient’s ability to perform daily activities and their dependency levels. Here’s how the assessment works:

- When a patient is described as "Normal, no complaints, no evidence of disease," this is assessed as KPS 100%. At this level, the individual can engage in all regular activities, including work, without needing special care.

- If a patient can "carry on normal activity" but exhibits "minor signs or symptoms of disease," they are scored at KPS 90%, indicating the capability to maintain routine activities without requiring special care.

- A description of "Normal activity with effort, some signs or symptoms of disease" aligns with KPS 80%. This suggests the patient can still carry out normal activities but might require some extra effort.

- When the condition reflects "Cares for self, unable to carry on normal activity or to do active work," it corresponds to KPS 70%. The patient can handle most personal needs independently but may need occasional assistance.

- "Requires occasional assistance but is able to care for most personal needs" is rated as KPS 60%, implying increased dependency on assistance though the patient remains mostly self-sufficient.

- At KPS 50%, for conditions described as "Requires considerable assistance and frequent medical care," the patient can live at home but needs considerable help with personal care.

- As the need for care intensifies, with descriptions like "Disabled, requires special care and assistance," the KPS drops to 40%. This marks a significant deterioration in self-care ability.

- "Severely disabled, hospital admission is indicated, death not imminent" corresponds to KPS 30%, highlighting a need for hospitalization without immediate life-threatening conditions.

- For those "Very sick," necessitating hospital admission and "active supportive treatment," the KPS is 20%, indicating critical care requirements.

- At KPS 10%, "Moribund" denotes an inability to care for oneself, with urgent need for hospital-level care and a poor prognosis.

- Lastly, "Dead" is considered as KPS 0%.

This scale is instrumental in providing a quick overview of a patient's ability to function independently and their need for medical support, thereby facilitating better care planning and resource allocation.

The Karnofsky Performance Status Scale (KPSS) is a clinical calculator used primarily in patients with cancer. It is a simple, numerical scale that measures a patient's functional status, ability to perform daily activities, and overall quality of life. The KPSS ranges from 0 (indicating death) to 100 (indicating perfect health). 

The clinical utility of the KPSS is to assess a patient's prognosis, determine appropriate treatment strategies, and monitor changes in a patient's condition over time. It is particularly useful in oncology for determining eligibility for certain treatments, such as chemotherapy or surgery, and for predicting survival outcomes. 

There are no specific exclusion criteria for the use of the KPSS. However, it is less useful in patients with non-cancer illnesses or in those with cognitive impairment who may not be able to accurately self-report their functional status.

Karnofsky Performance Scale

This tool calculates the risk score for postoperative pancreatic fistula by evaluating four clinical factors related to the patient's condition and surgical experience. Each input factor is assigned a numerical score, and the sum of these scores determines the overall risk, which is then classified into a specific interpretation category ranging from negligible to high risk.

Inputs and their corresponding scoring:

1. Gland Texture:
   - Firm: 0 points
   - Soft: 2 points

2. Pathology:
   - Pancreatic adenocarcinoma or pancreatitis: 0 points
   - Ampullary, duodenal, cystic, islet cell: 1 point

3. Pancreatic Duct Diameter:
   - >= 5 mm: 0 points
   - 4 mm: 1 point
   - 3 mm: 2 points
   - 2 mm: 3 points
   - <= 1 mm: 4 points

4. Intraoperative Blood Loss:
   - <= 400 mL: 0 points
   - 401-700 mL: 1 point
   - 701-1,000 mL: 2 points
   - > 1,000 mL: 3 points

The total score is computed by summing the scores from each of the four inputs. Once the total score is calculated, it is interpreted according to the following scale:

- Score of 0: The risk of fistula is negligible.
- Score from 1 to 2: The risk of fistula is low.
- Score from 3 to 6: The risk of fistula is intermediate.
- Score of 7 or more: The risk of fistula is high.

The procedure collects the user's inputs for gland texture, pathology, pancreatic duct diameter, and intraoperative blood loss, assigns predefined scores to each based on the specified categories, and sums these scores to produce a total score. This total score is then matched against interpretation criteria to provide a risk assessment, which includes both the numerical score and a descriptive interpretation of the risk level. 

This system provides a structured approach to evaluate postoperative fistula risk, helping inform clinical decisions by categorizing risk into clearly defined levels based on standard inputs.

The calculator in question is the Risk Score for Postoperative Pancreatic Fistula (POPF). This scoring system is specifically designed for patients undergoing pancreatic surgery, particularly pancreaticoduodenectomy, distal pancreatectomy, and other pancreatic resections. The clinical utility of this calculator is to predict the likelihood of a patient developing a postoperative pancreatic fistula, a serious and potentially life-threatening complication. 

The risk score takes into account various factors including patient characteristics, disease characteristics, and operative details. It helps clinicians to stratify patients into low, moderate, and high-risk categories, thereby guiding postoperative management and potentially reducing morbidity and mortality.

Exclusion criteria for its use would include patients not undergoing pancreatic surgery, those with pre-existing pancreatic fistulas, or those with contraindications to surgery. It's also important to note that this risk score may not be applicable in cases where intraoperative findings or postoperative course significantly deviate from the norm.

Risk score for postoperative pancreatic fistula

The Modified Glasgow Prognostic Score (mGPS) is a key tool in predicting cancer outcomes, relying on the assessment of two biochemical markers: C-reactive protein (CRP) and albumin. This score helps to categorize the prognosis into three levels: good, intermediate, and poor.

To compute the mGPS:

- C-reactive protein is evaluated first. Two options are considered:  
  - If the CRP is less than or equal to 10 mg/L, it indicates lower systemic inflammation.
  - If the CRP is greater than 10 mg/L, it signifies higher inflammation levels.

- Albumin is the second marker, with two possibilities:  
  - An albumin level of less than 3.5 g/dL [35 g/L] suggests malnutrition or potential inflammatory conditions.
  - An albumin level equal to or greater than 3.5 g/dL [35 g/L] signifies a normal nutritional status and protein reserves.

The mGPS score is derived based on the following systematic interpretation:

- If CRP is <= 10 mg/L, regardless of the albumin level, the score is mGPS 0, corresponding to a good prognosis. This combination indicates a low level of inflammation, which is a favorable signal in cancer outcomes.
 
- If CRP is > 10 mg/L and albumin is >= 3.5 g/dL [35 g/L], the score is mGPS 1, associated with an intermediate prognosis. This combination suggests elevated inflammation yet with sufficient nutritional status, resulting in a moderate outlook.

- If CRP is > 10 mg/L and albumin is < 3.5 g/dL [35 g/L], the result is mGPS 2, indicating a poor prognosis. This reflects high inflammation levels coupled with low albumin, suggesting a more severe condition.

Here's a concise summary table for reference:

| C-reactive Protein | Albumin               | mGPS Score | Interpretation          |
|---------------------|-----------------------|-------------|-----------------------|
| <= 10 mg/L          | < 3.5 or >= 3.5 g/dL  | 0           | Good prognosis         |
| > 10 mg/L           | >= 3.5 g/dL           | 1           | Intermediate prognosis |
| > 10 mg/L           | < 3.5 g/dL            | 2           | Poor prognosis         |

This systematic approach enables healthcare providers to improve risk stratification in cancer patients, allowing for more tailored treatment planning.

The Modified Glasgow Prognostic Score (mGPS) is a clinical calculator used in the field of oncology to predict the prognosis of patients with cancer. It is applicable to a wide range of cancer types and stages, making it a versatile tool for clinicians. The mGPS is based on two simple, routinely measured inflammatory markers: C-reactive protein (CRP) and albumin levels. 

The clinical utility of the mGPS lies in its ability to stratify patients into different risk groups based on their inflammatory response to cancer. This can guide clinicians in making decisions about treatment strategies and follow-up plans. It can also provide valuable prognostic information to patients and their families.

There are no specific exclusion criteria for the use of the mGPS. However, it should be noted that the score may not be as accurate in patients with concurrent inflammatory or infectious conditions, as these can also affect CRP and albumin levels. Additionally, the mGPS may not be applicable to patients with rare types of cancer or those with very early or very advanced disease, as it has not been extensively validated in these groups.

Modified Glasgow Prognostic Score for cancer outcomes (mGPS)

Pancreatic cancer

Management of borderline resectable disease

Pancreatic biopsy

Diagnostic imaging

Imaging for staging

Technical considerations for radiotherapy

Technical considerations for radiotherapy (respiratory motion management)

Management of unresectable disease

Management of unresectable disease, definitive chemoradiotherapy

Management of advanced/metastatic disease

Management of advanced/metastatic disease (treatment duration)

Endoscopic ultrasound-guided fine needle aspiration

EUS-guided FNA (cystic lesions)

General principles

Clinical trials

Follow-up

Management of advanced/metastatic disease (palliative radiotherapy)

Technical considerations for radiotherapy (image guidance)

Indications for screening

Indications for screening, genetically susceptible individuals

Management of pain

History and physical examination

Technical considerations for radiotherapy (premedication)

Management of advanced/metastatic disease, targeted therapy

Management of advanced/metastatic disease (thromboprophylaxis)

EUS-guided FNA (solid lesions)

Genetic counseling

Management of biliary obstruction

Management of biliary obstruction (EUS-guided procedures)

Management of biliary obstruction, endoscopic stenting

Technical considerations for radiotherapy (treatment planning)

Management of advanced/metastatic disease, first-line therapy

Management of resectable disease

Management of resectable disease, surgical resection

Management of resectable disease, adjuvant chemoradiotherapy

Management of advanced/metastatic disease, second-line therapy

Genetic testing

Management of resectable disease, neoadjuvant chemoradiotherapy

Perioperative antibiotic prophylaxis

Endoscopic retrograde cholangiopancreatography

ERCP (cystic lesions)

Indications for screening, general population

Nutritional support

Indications for screening (family relatives)

General counseling

Management of unresectable disease (palliative radiotherapy)

Tumor markers

Management of advanced/metastatic disease, third-line therapy

Staging

Assessment of treatment response

Management of unresectable disease (neoadjuvant chemoradiotherapy)

ERCP (solid lesions)

Management of resectable disease (management of perioperative bleeding)

Lifestyle modifications

Updated 2024 ASGE guidelines for endoscopic evaluation and management of solid pancreatic masses


Pancreatic cancer

Guidelines

Key sources