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Diagnosis

How Is Pancreatic Cancer Diagnosed?

Pancreatic cancer can be difficult to diagnose early, as symptoms frequently do not develop until the later stages of the disease. Patients who are experiencing any of the symptoms of pancreatic cancer should see their physician, who will perform a series of diagnostic exams and tests. The results of these exams and tests will also help the patient and his or her physician decide the best treatment options.

Imaging Tests and Procedures

Several types of imaging tests and procedures are used to diagnose pancreatic cancer. The patient’s physician may request one or more of the following:

Computed Tomography (CT) Scan

CT scans use x-ray equipment and computer processing to produce 2-dimensional images of the body. The patient lies on a table and passes through a machine that looks like a large, squared-off donut. Doctors order CT scans when they want to see a two-dimensional image of the body to look for tumors and examine lymph nodes and bone abnormalities. If contrast dye is used to improve the computer image, the patient may need to avoid eating or drinking for 4 to 6 hours before the test. Patients should tell their provider before the test if they have any allergies or kidney problems.

Magnetic Resonance Imaging (MRI)

This test uses a magnetic field, radiofrequency pulses, and a computer to produce detailed images of body structures in multiple places. You may be asked to drink a contrast solution for better imaging, and you will most likely lie on a moving table as pictures are taken. MRI is a more detailed tool than x-ray and ultrasound and for certain organs or areas of the body, it provides better images than CT. MRI may not be recommended if you have a pacemaker or other metal implant.

Ultrasound

Diagnostic ultrasound, also called sonography or diagnostic medical sonography, is an imaging method that uses high-frequency sound waves to produce images of structures within the body. The images can provide valuable information for diagnosing and treating a variety of diseases and conditions. Most ultrasound examinations are done using a sonar device outside the body, though some ultrasound examinations involve placing a device inside the body.

Positron Emission Tomography (PET) scan

A PET scan is used to detect cellular reactions to sugar. Abnormal cells tend to react and "light up" on the scan, thus helping physicians diagnose a variety of conditions. For the PET scan, a harmless chemical, called a radiotracer, is injected into your blood stream. Once it has had time to move through your body, you will lie on a table while a scanner follows the radiotracer and sends three-dimensional images to a computer screen. Patients are generally asked to wear comfortable clothing and refrain from eating for 4 hours before the scan. Tell your doctor if you are pregnant or breastfeeding. Patients with diabetes should discuss diet guidelines with their physician for the hours leading up to the scan.

Endoscopic Retrograde Cholangiopancreatography (ERCP)

During an ERCP, the gastroenterologist uses an endoscope, a long, thin, flexible tube with a light and camera at the end, through the esophagus, the stomach, and the first part of the small intestine, called the duodenum. Once the endoscope reaches the papilla, which is the opening of the common bile duct, the physician injects dye through these ducts, enabling x-rays to be taken. A physician may recommend an ERCP if the patient is experiencing abdominal pain or develops jaundice.

Endoscopy

You will receive an intravenous sedative and pain medication. Once comfortable, the physician will then examine the area using an endoscope—a lighted tube with a small camera at the end. The physician will be able to view any abnormalities and take a tissue samples (biopsies) if necessary.

Blood Tests

Blood tests may be performed for a variety of reasons. For example, if a patient has jaundice, a blood test may be done to check the patient’s liver function to see what may be causing it.

Blood tests may also be used to check for levels of the tumor markers CA 19-9 and CEA (carcinoembryonic antigen) in the blood. These tumor markers may be elevated in patients with pancreatic cancer.

Other blood tests check for organ function. These tests can help a physician determine whether a patient is able to undergo major surgery.

Biopsy

Any suspicious mass of tissue or tumor is subject to a biopsy, or removal of cells from the mass. This is the only technique that can confirm the presence of cancer cells. The doctor will use a general or local anesthetic depending on the location of the mass, and then remove a sample of tissue to send to the lab. The sample is sent to a pathologist, a physician who is an expert at identifying diseased cells in tissue samples. Very often, a few stiches are used to help the area heal, and tenderness is felt for a short period of time.

Staging

Staging is used to determine the extent of the cancer. The most common system used to stage pancreatic cancer is the American Joint Committee on Cancer’s TNM system. The TNM system takes into account the size of the primary tumor (T), whether cancer is present in nearby lymph nodes (N), and whether the cancer has metastasized (spread) to other organs or tissues in the body (M). View TNM staging for pancreatic cancer here.

The three categories are combined to determine the overall stage of the cancer. This is called stage grouping.

Stage Grouping for Pancreatic Cancer

Stage I: The cancer is only present in the pancreas.

Stage II: The cancer has invaded nearby tissues but has not invaded nearby blood vessels. The cancer may have spread to the lymph nodes.

Stage III: The cancer has invaded nearby blood vessels.

Stage IV: The cancer has spread to other organs in the body.
(National Cancer Institute 2010)

The grade of the cancer—how the cells appear under a microscope—also plays an important role in determining the extent of the cancer. Cancers are graded on a scale of G1 (the cells appear relatively normal) to G3 (or G4) (the cells appear very abnormal).

For treatment purposes, physicians may group pancreatic cancers into the following four categories:

  • Resectable: The entire cancer can be surgically removed.
  • Borderline resectable: Surgeons may be able to remove the entire cancer, even though it may have spread to nearby blood vessels. Sometimes a trial of chemotherapy is performed to try to shrink the tumor prior to surgery.
  • Locally advanced (unresectable): The cancer is still local, but it cannot be entirely removed.
  • Metastatic: The cancer has spread to distant sites in the body.
    (American Cancer Society 2015a)

Patients are encouraged to discuss cancer staging and treatment options with their physicians.

Gastroenterology/Hepatobiliary Tumor Board

The results of the diagnostic tests are discussed at the Gastroenterology/Hepatobiliary Tumor Board. During this weekly meeting, the entire multidisciplinary team comes together to discuss new cases and develop individualized treatment plans for each patient.

References

American Cancer Society. 2015a. Pancreatic Cancer Overview. PDF.

-----2015b. “What are the risk factors for pancreatic cancer?” Last modified January 9, 2015.
http://www.cancer.org/cancer/pancreaticcancer/detailedguide/pancreatic-cancer-risk-factors

American Joint Committee on Cancer. 2009. Pancreas Cancer Staging. 7th ed. PDF. https://cancerstaging.org/references-tools/quickreferences/Documents/PancreasSmall.pdf

National Cancer Institute. 2010. What You Need To Know About™ Cancer of the Pancreas. Bethesda: National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services. http://www.cancer.gov/publications/patient-education/pancreas.pdf

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