A study to image the pancreas is often the first step in making the diagnosis. This can be achieved through an MRI or CT scan of the abdomen that produces a detailed picture of the organ and adjacent structures.
The helical "spiral" CT scan is the state-of-the-art x-ray study, as it provides information about the nature and location of the tumor, as well as its resectability (chance that it can be surgically removed). Additional diagnostic procedures may be ordered if CT scan results are inconclusive. They include:
Endoscopic ultrasound (EUS)
An endoscope (a long, thin, illuminated optical instrument) is passed through the patient's mouth into the stomach. By using this instrument in combination with an ultrasound device mounted on its tip, it can be determined if the cancer has invaded adjacent large blood vessels or lymph glands. This procedure can also uncover smaller tumors than those currently detectable by CT scanning techniques. (more)
Endoscopic retrograde cholangiopancreatography (ERCP)
As in EUS (see above), an endoscope is passed through the patient's mouth. Then, through the endoscope, a narrower tube called a cannula is inserted into the pancreatic duct. In this way, pancreatic cells can be removed for analysis, and opaque dye can be injected to determine, by way of x-rays, if the duct has narrowed or become blocked. ERCP also can be used therapeutically for the placement of a biliary stent to relieve jaundice. (more)
A diagnostic procedure in which the abdominal cavity is examined by inserting a laparoscope (a miniature camera) through one or more small incisions in the abdominal wall. Laparoscopy is unnecessary in most cases where tumors are likely to be resectable. (more)
This is a test to confirm the diagnosis of pancreatic cancer, but it is not needed in most patients. One biopsy approach is fine needle aspiration (FNA) in which a long, thin needle is passed through the abdomen, into the pancreatic tumor, to remove tumor cells. Another method involves surgically removing a piece of pancreatic tissue. Many surgeons don't recommend these procedures for those patients with resectable tumors. However, in cases where a non-operative approach is appropriate, tissue diagnosis through biopsy may be advised. (more)
The Helical ("Spiral") CT Scan
The helical ("spiral") CT scan is the best overall study for diagnosis and preoperative staging. It provides information about the nature and site of the lesion (e.g., pancreatic vs. other periampullary tumors, bile duct tumors), its resectability (e.g., tumor is unresectable if liver metastases, vascular invasion present), and vascular anatomy. If the tumor is judged to be "resectable" on the basis of helical CT, at UCLA we have been able to resect in about 85% of cases.
Endoscopic ultrasound (EUS) is not likely to be used as a first line diagnostic study in most patients with pancreatic cancer. However, once the diagnosis is suspected, it can provide valuable information about whether the pancreatic cancer has invaded adjacent vessels like the superior mesenteric vein. This is important in decisions about resection, and whether the patient is a candidate for operation. EUS also may detect smaller tumors than those currently detectable by CT scanning techniques, and it permits accurate placement of biopsy needles (e.g., fine needle aspiration for cytologic examination by a pathologist) if there is need to establish the diagnosis.
Endoscopic Retrograde Cholangiopancreatography
Diagnostic endoscopic retrograde cholangiopancreatography (ERCP), is now not often used in the workup of patients with pancreatic tumors. In a patient who presents with obstructive jaundice, and some weight loss, and in whom the abdominal CT scan shows a mass in the head of the pancreas, ERCP provides little additional information that affects decisions about management.
In patients who will not be operated upon, therapeutic ERCP with the placement of a biliary stent to relieve the jaundice is also a useful technique.
Should jaundice be relieved before surgery?
We generally advise against the routine use of endoscopically placed stents to relieve jaundice before surgery. However, in cases where the bile duct is obstructed and the operation must be postponed for several weeks or more, or if the jaundice is very severe, preoperative decompression may be indicated.
Laparoscopy (limited examination of the abdomen using one or more small incisions and a TV camera to see the organs) may be indicated in some patients. Generally, we do not use laparoscopy in patients who appear to have resectable lesions on helical CT, and who are good candidates for resection.
We do use laparoscopy, in certain circumstances. Examples include some patients with pancreatic cancer and CT evidence of liver or other metastases, body or tail cancers, and some patients with ascites (fluid in the abdomen) who may have peritoneal metastases.
Preoperative cytological confirmation of the diagnosis using fine needle aspiration (FNA) is often attempted in patients with suspected pancreatic cancer. However, we advise against it in most individuals who are operative candidates. It is uncomfortable for the patient, and it adds additional time and expense to the workup. It is of little value to an experienced pancreatic surgeon who will usually perform a pancreatic resection if the clinical picture and operative findings suggest the diagnosis of cancer.
In contrast, FNA in order to confirm the diagnosis of pancreatic cancer is valuable when that knowledge will affect treatment, e.g., a non-operative approach will be recommended. Thus, we often will obtain it in cases where unresectable disease appears to be present (e.g., to confirm CT evidence of liver metastases), in many cases of cancer in the body or tail of the pancreas where the likelihood of resection for cure is very low, or when the patient is an unacceptable risk for operation and a tissue diagnosis is required. The technique is highly specific (99%) in the hands of an experienced cytopathologist. Although severe pancreatitis and seeding of the needle tract with cancer have been reported after FNA of pancreatic or other intra-abdominal tumors, this is quite rare. The overall complication rate is less than 1%, so our reluctance to obtain an FNA routinely in these patients is not because of the concern about complications.
Should the tumor be biopsied before the operation?
Experienced pancreatic surgeons usually do not require histological proof of malignancy before they are willing to perform a pancreatic resection. There are several reasons for this:
1. If the clinical picture and findings at operation are consistent with the diagnosis of cancer, then the chances that cancer is present are at least 90%.
2. In those cases where cancer is not present, the most likely diagnosis is chronic pancreatitis. Pancreaticoduodenectomy is an excellent procedure to treat this, as well.
3. The operation can be done safely, with operative mortality rates less than 5%, often between 1% - 2%. Nevertheless, it is important that the patient understands and agrees with this approach, and a full discussion should occur preoperatively, which should be documented in the records.