See in clinic and assess/ CA19-9 GP referral Emergency admission Clinical assessment/Suspicion of pancreatic/peri-ampullary tumour with or without jaundice Pancreatic protocol CT or MRI +/- ERCP Video-link PHNT No mets **Exception may be ampullary tumour with resectable met(s) SMDT Metastatic disease** No mets Consider EUS/CT/US Bx ONCOLOGY +/- PALLIATIVE CARE Check CA 19-9 **Locally advanced *Borderline resectable Resectable tumour No mass lesion on imaging Double duct sign +/- jaundice MRCP//EUS+/- CA19-9/+/-ERCP Not fit See in clinic and assess/ CA19-9 Consider resection/neo-adjuvant treatment/ See in clinic and assess. For Surgery Suspicious CPET testing Neo-adjuvant chemo-rad/EUS/CT biopsy / CA19-9 No evidence of malignancy Surgery Restage Histology No progression SMDT SMDT Progression Adjuvant chemo Local follow up *Borderline resectable tumours - venous involvement of SMV/PV with distortion or occlusion with normal vein above and below for safer replacement and anastomosis/ GDA encasement up to the hepatic artery, either shot segment encasement/ or abutment of common hepatic artery without extension to the coeliac axis/ Tumour abutment of the SMA not to exceed 180 degree circumference of the wall ** Locally advanced tumours - Unreconstructable SMV/PV occlusion Greater than 180 degree abutment of SMA, Coeliac axis involvement