Pancreatic Cancer: Diagnosis

Detecting and diagnosing pancreatic cancer can be difficult, especially because the symptoms are not always obvious, often develop gradually, and can be mistaken for other conditions.

At times, pancreatic tumors are found incidentally when a patient is being evaluated forfor another medical condition. If pancreatic cancer is suspected, there are a variety of tests a doctor may perform including blood tests, imaging studies, and/or a biopsy the tumor.

A physical exam will focus on the patient’s abdomen. The doctor will check for masses or fluid buildup in the areas near the pancreas, stomach, liver, and gallbladder, and examine skin and eyes for signs of jaundice. Since cancer can also spread to lymph nodes above the collarbone and other locations in the body, the physician may examine these areas for swelling or other signs of metastasis. Urine and stool tests may also be ordered. The patient’s history will be taken, to pinpoint any risk factors and find out if any family members have been diagnosed with pancreatic cancer.

Currently, there is no simple blood test to detect early pancreatic cancer. However, certain blood tests can support a diagnosis and help the doctor determine the best course of treatment.

Hepatic Function This test measures the levels of bilirubin and liver enzymes in the blood. If there is a tumor blocking the bile duct, the bilirubin levels may increase, causing jaundice.

CA 19-9 Tumor Marker This test measures a substance that is released into the bloodstream by the tumor or by the body, in response to tumor cells. CA 19-9 is a tumor marker commonly associated with pancreatic cancer but is not elevated in every patient with pancreatic cancer.

Carcinoembryonic Antigen (CEA) This test measures a protein in the blood that may also function as a tumor marker. The CEA test is best used to determine disease progression and treatment effectiveness.

Non-invasive Imaging studies may be ordered as well. These tests help determine if there is a mass in the pancreas and these tests are critical in determining if the patient is a suitable surgical candidate

Abdominal Ultrasound This machine uses sound waves to examine the body's internal organs, including the pancreas, gallbladder, liver, kidneys, spleen, stomach, and intestines.

Computed Tomography (CT) Scan An X-ray machine linked to a computer takes a series of detailed cross-sectional pictures. These "slices" are then linked together to create a detailed 3-dimensional reconstruction of the body. Unlike regular X-ray images that can only show bone, CT images can also show soft tissue and blood vessels

Magnetic Resonance Imaging (MRI) This machine uses radio waves and powerful magnets to produce images of the body. Like a CT scan, an MRI can provide detailed 3-dimensional cross-sectional images of the pancreas.

Magnetic Resonance Cholangiopancreatography (MRCP) This special kind of MRI enables the physician to visualize the bile and pancreatic ducts in a non-invasive way. This is particularly helpful since tumors typically arise in the ducts.

Positron Emission Tomography (PET) scan creates images based on the metabolic activity of cells in the body. A small amount of radio-labeled glucose is injected into the bloodstream. The glucose is taken up and metabolized by the tissues. Since cancer cells metabolize more glucose than normal cells, they usually "light up" more brightly on the PET scans.

Once cancer is suspected on the basis of a non-invasive test or if a person has unexplained jaundice, a physician may order one of the following invasive tests

Endoscopic Ultrasound EUS provides detailed images of the pancreas and surrounding tissues including the liver, blood vessels, and lymph nodes, using high frequency sound waves. When the sound waves bounce off of the internal organs, they send echoes to a computer that translates this information into a visual image on a monitor. 

EUS involves passing a thin, lighted tube, called an endoscope, through the mouth then into your stomach and duodenum. An ultrasound probe attached to the tip of the endoscope can get very close to the pancreas and its surrounding organs, producing detailed pictures of even the smallest tumors. This imaging test is usually performed on an outpatient basis.

The real-time needle guidance provided by the EUS procedure enables the physician to biopsy a suspicious cyst or suspected tumor in a process called Fine Needle Aspiration (FNA). This is safer than obtaining a biopsy through the stomach. To learn more about biopsy procedures, click here

Endoscopic Retrograde Cholangiopancreatography (ERCP) allows the physician to visualize the bile and pancreatic ducts. The study is most often performed when a patient exhibits symptoms of jaundice, which can indicate presence of a mass narrowing or blocking the ducts.
ERCP is an outpatient procedure. A physician passes an endoscope (a long, thin, lighted tube) through the patient’s mouth, through the stomach, and into the duodenum. A tube called a catheter is threaded through the endoscope directly to the pancreatic and bile ducts. Dye is injected through the catheter and an X-ray is taken.

If the physician finds a blockage, or stricture (narrowing), a stent can be placed in the obstructed duct. This device that helps hold the duct open to allow bile and pancreatic juices to flow properly.

Spyglass Direct Visualization System Physicians at NewYork-Presbyeterian/Columbia University Medical Center are among the first in the nation to use the SpyGlass Direct Visualization System, the latest technology to visualize and evaluate pancreatic ducts. This device enables physicians to view hard-to-access ducts with greater clarity.

Three kinds of biopsies may be performed to evaluate the suspected diagnosis of pancreatic cancer.

Fine Needle Aspiration (FNA) or Core Biopsy is a method to directly sample the suspicious lesion without a surgical procedure. FNA biopsy of the pancreas may be performed percutaneously (through the skin) or guided by EUS. When the percutaneous approach is used, a local anesthetic is applied to the skin and a long thin needle is inserted through the abdominal wall and into the pancreas. Imaging from a CT or ultrasound is used to guide the needle placement to ensure tumor cells are gathered.

In EUS guided FNA, the physician uses live ultrasound images to guide needle placement through an endoscope directly into a suspicious mass. The EUS-guided approach is used most frequently and is usually well tolerated and provides accurate results regarding the diagnosis. This procedure should be performed by an experienced endoscopist.

Brush Biopsy In this approach, a small brush is inserted through the endoscope during an ERCP procedure and directly into the bile or pancreatic duct. Cells rub off onto the brush and are then examined under a microscope. However, the chance of getting a conclusive diagnosis by this method is lower compared to FNA.

Laparoscopy In this procedure, a small camera attached to a thin, lighted tube is inserted directly into the abdominal cavity through a small incision. It is performed with the patient under general anesthesia. This means the patient is completely asleep during the procedure and does not respond to verbal or physical prompts. By manipulating the camera, the doctor can directly view the pancreas and its surrounding organs. A tissue biopsy can be taken by passing a pair of forceps through the laparoscope.

These tests help the physician determine the stage of the tumor and whether or not it can be surgically removed.