Map of Pancreatica Walks and Runs

Pancreatic Cancer Diagnosis

Signs and Symptoms

Generally, the diagnosis of early pancreatic cancer is very difficult. The most common symptoms of cancer of the pancreas include loss-of-appetite, weight loss, abdominal discomfort and nausea. As these are all fairly non-specific symptoms, there is often delay in getting to the final diagnosis. The most common physical sign of pancreatic cancer is jaundice, with or without associated itching. Proceeding to a medical evaluation often requires a high index of suspicion by the patient or by medical personnel who are experienced with the presentation of early pancreatic cancer.

Laboratory

Often lab results in pancreatic cancer show a high bilirubin (yellowish bile pigment found in the serum) and elevated liver function enzymes. The CA 19-9 marker, a Lewis blood group-related mucin, is frequently elevated in pancreatic cancer, but its use as a sole agent in the screening for or diagnosis of cancer of the pancreas is not presently a fully accepted practice. High CA 19-9 levels may tend to be associated with (but do not always indicate) larger sized tumors and with a decreased likelihood of surgical resectability. The use of this marker is more universally accepted as a running measure within a particular individual (after diagnosis), to help reflect the stability, response, or progression of pancreatic cancer to treatment.

Staging Studies

The main reason for the diagnostic staging of pancreatic cancer is to try to chart the best course for treatment, especially to help decide whether a patient is a candidate for surgical resection. There is a great deal of flux and controversy in these areas of diagnoses; there are institutional and even geographical variations in considered opinions as to the correct approaches in regard to these diagnosis / staging techniques. Also, there may be great variability in the experience level of the operators and evaluators of a given diagnostic procedure – thus (perhaps rightfully) coloring the institution’s approach at recommending which diagnostic studies are used. In the context of these understandings, the following brief overview will try and point out some strengths and weaknesses of certain of the current diagnosis staging procedures.

Generally, in the U.S., the dynamic spiral (or helical) CT scan with IV and oral contrast media enhancement is considered to be the procedure of choice for the diagnosis / staging of pancreatic cancer. With the latest equipment and with experienced operators and evaluators, this approach at diagnosis can detect up to 90-95% of cancer of the pancreas. Specific pancreatic cancer tumors that are greater than ½ to one inch in diameter can usually be detected. These CTs can predict unresectability about 90% of the time; but are less accurate at predicting surgical resectability. Its diagnostic strength in this regard is related to its ability to demonstrate pancreatic extension involving local arteries. This technique is less reliably able to show subtle local vein involvement, to detect or diagnose small liver metastasis or to pick up lymph node involvement in pancreatic cancer.

Transabdominal ultrasound is a more popular diagnostic procedure for pancreatic cancer outside of the U.S. where operators are more experienced and generally the patient-population may be less obese – a big problem in imaging structures through the abdomen. In experienced hands, with a thin patient and with good equipment, this ultrasound approach can often diagnose or detect smaller pancreatic cancer tumors than are even found by the CT procedure.

Two other ultrasound procedures are of note. The endoscopic ultrasound (ultrasound through a tube which is placed down the esophagus) can be very good at finding small tumors in the pancreas. And laparoscopic ultrasound (ultrasound through a small tube placed through the abdomen into the region of the pancreas) is sensitive at finding liver and peritoneal involvement in pancreatic cancer, without having to resort to full surgery.

Pre-operative angiography (viewing contrast dye placed in select arteries) is recommended by some surgeons for pancreatic cancer diagnosis and staging, although the introduction of spiral CT has provided a competing option.

CT or ultrasound-guided percutaneous biopsy (via needle) can retrieve a bit of pancreatic tumor tissue for histologic (microscopic) viewing without requiring full pancreatic cancer surgery. There exists some concern about the risk of inadvertent “seeding” of the tumor into the peritoneum with this technique, but some experts feel that the potential risks outweigh the potential harm in selected cases.

Often an institution will have a coordinated approach at the diagnosis and staging of pancreatic cancer. For example, a spiral CT procedure might be done first. If it appears that there is a pancreatic cancer tumor and that it might be resectable, the next step might be a diagnostic laparoscopy (for direct visualization) – with perhaps a peritoneal wash (to check for malignant pancreatic cancer cells in the peritoneum) and with or without a laparoscopic ultrasound exam. If evidence of unresectability is found, a percutaneous biopsy might be done, to fully establish the diagnosis of the type of pancreatic cancer and to help with medical treatment planning. If no evidence of unresectability is found, then a full abdominal surgery might typically ensue to further evaluate the clinical status with an aim of the diagnosis of pancreatic cancer – and if finally so indicated to proceed with the most appropriate surgical procedure.

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