Under what circumstances do you give chemotherapy for a nondiagnostic pancreas biopsy that is suspicious for adenocarcinoma?

Assuming it is a localized pancreatic abnormality and no "metastases," I would not give chemotherapy as such. If anything, I would consider surgical removal, which will also give the exact diagnosis. To start, chemotherapy is not curative (maybe if it were a lymphoma!). There may be some way of doing a liquid biopsy with one of the new cancer detection tests, but I would do surgery if I am convinced this is highly suspicious. A number of benign and rare cancer conditions can mimic pancreatic ade...

I am a purist of sorts here, and I would say in my practice, "almost never." My partners will treat patients with "suspicious cells" on pathology (but not atypical cells) based on this study, Long Term Follow-up of Atypical and Suspicious Pancreas Cytology.

Given that FOLFIRINOX is a higher-risk chemotherapy, I do not feel comfortable using it unless I have definitive pathology.

I agree and disagree with my esteemed colleagues.

To me, it depends a lot on the rest of the clinical context. Is the patient exhibiting any of the common symptoms of pancreatic cancer (pain, weight loss, new-onset DM)? Is there vascular encasement making surgery impossible? Is there an elevated CA 19-9 in the absence of biliary obstruction? These factors, along with a "suspicious" histopathology, would generally lead our multidisciplinary group to recommend neoadjuvant chemotherapy.

We certainl...