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Pancreatic Cancer
Diagnosis

It is important to note that pancreatic cancer is not just one disease. There are many types of pancreatic tumors, each with its own unique prognosis and treatment recommendations. Currently, there is no screening exam of proven value for detecting pancreatic cancer in the general population.

In making a diagnosis of pancreatic cancer, your doctor may conduct the following tests.

Medical History and Physical Examination

A series of tests may be necessary to make a definite diagnosis. Your doctor will first start by asking about your medical history and any physical complaints or symptoms, specifically recent weight loss, pain and changes in appetite, bowel patterns or skin color. The doctor will then complete a thorough physical exam, which will include palpation and observation of the chest and abdomen.

Lab Tests

Blood specimens may be collected and less commonly, urine or stool samples. Of particular interest to the doctor is the level of "bilirubin" and "liver enzymes" in a patient's blood, which measures liver and pancreas function.

Another blood test commonly performed is CA19-9 (carbohydrate antigen 19-9). CA19-9 is referred to as a "tumor marker," which is a chemical substance in the body that may be found at higher levels if cancer is present.

An elevated CA 19-9 test by itself is not used to make the diagnosis of pancreatic cancer, as it can be elevated in a variety of other conditions, such as pancreatitis or cirrhosis of the liver, and some people with pancreatic cancer do not show this marker at all.

CA 19-9 can be used as a tool, however, to help evaluate the effectiveness of a cancer therapy by comparing the levels before and during treatment.

Additional Diagnostic Tests

The following tests may also be conducted to make a definite diagnosis:

  • Ultrasound — Ultrasound uses a machine that emits high-frequency sound waves to create images of the organs inside the body. An abdominal ultrasound examines the liver, gallbladder, spleen, pancreas and kidneys, and can help identify abnormal structures or tissue.
  • Computed Tomography (CT) Scan — This is a non-invasive method of examining internal organs that captures a series of thin X-ray images of the inside of the body. CT scans can help detect tumors and determine whether it has spread to other parts of the body, such as the liver.

    There are different types of CT scans and special techniques that can be done to create more detailed images of the pancreas. At UCSF, we offer a three-dimensional CT scan, often referred to as a "spiral" or "helical" scan, which creates extremely detailed images of the pancreas and nearby blood vessels and structures to help determine treatment decisions.
  • Endoscopic Ultrasound (EUS) — This is a procedure that allows a specially trained doctor, typically a gastroenterologist, to view the esophagus, stomach and the first portion of the small intestine, as well as adjacent organs including the liver and pancreas.

    While the patient sleeps, a thin, flexible tube called an endoscope is passed through the mouth into the stomach and small intestine. On the end of the tube is an ultrasound probe that emits sound waves that create images of the abdominal organs.

    If unusual masses are detected, the doctor may collect a specimen of tissue at the time of the procedure during a biopsy. The use of EUS can decrease the likelihood that a patient will need to go to the operating room for surgery.
  • Endoscopic Retrograde Cholangiopancreatography (ERCP) — This procedure uses an endoscope — a long, flexible, lighted tube connected to a computer and TV monitor. Your doctor will guide the endoscope through your stomach and into the small intestine. ERCP combines two imaging techniques: "endoscopy," the direct visualization of internal structures and "fluoroscopy," a live action X-ray method. These two techniques allow the doctor to view images of the liver, gall bladder and pancreas ducts, which can help detect a narrowed or blocked duct.

    Further tests, such as a biopsy, can pinpoint the cause of a narrowed or blocked duct. If a duct is narrowed or blocked by a tumor, a plastic or metallic stent can be placed across the blockage. The stent is designed to expand and reopen the duct to allow bile juices to flow freely.
  • Magnetic Resonance Cholangiopancreatography (MRCP) — MRCP uses radio waves and a powerful magnet linked to a computer to visualize the biliary and pancreatic ducts in a non-invasive manner. These pictures can show the difference between normal and diseased tissue and can also detect bile duct obstruction.

    MRCP may be performed in patients who cannot have an endoscopic retrograde cholangiopancreatography (ERCP) or may also prevent unnecessary invasive procedures.
  • Biopsy — A biopsy allows a doctor to collect a small amount of tissue. A pathologist then uses a microscope to examine the tissue and identify the types of cells collected.

    Tissue can be collected at the time of an endoscopic ultrasound or endoscopic retrograde cholangiopancreatography. A biopsy also can be performed under guidance of a CT scan. If necessary, a biopsy can be performed at the time of open surgery of the abdomen.

    There are two methods frequently used to collect tissue for a biopsy. A fine needle aspiration (FNA) utilizes a very narrow needle. A core needle biopsy uses a larger needle. Both methods have advantages and risks.

    If cancer is suspected to have spread, or metastasized, it is preferable to biopsy the tumor than the pancreas itself. A specially trained doctor will determine the best method to use. It is also important to note that if all of your other test results suggest cancer, you may not need a biopsy before you have treatment.

Staging

If you are diagnosed with pancreatic cancer, your doctor will evaluate the stage or extent of your disease. Staging is a careful attempt to determine the size and location of the cancer and whether it has spread to other parts of the body.

The stage of a cancer is a description of the extent of a cancer at a specific point in time. This information helps your doctor develop the best and most effective treatment plan for your condition. The stage may be determined at the time of diagnosis or after more tests are performed.

There are two forms of a staging system for cancer:

  • Clinical staging involves a doctor's exam and imaging tests such as a computed tomography (CT) scan.
  • Pathologic staging depends on findings from surgery. However, most patients with pancreatic cancer do not have surgery. Doctors will develop a treatment plan according to the extent of disease.

Stages of Pancreatic Cancer

  • Localized and Resectable — The cancer is confined to the pancreas and is resectable, meaning that in most cases, it can be surgically removed. After surgical removal, most patients receive additional treatment such as cancer drugs or radiation therapy.
  • Locally Advanced and Unresectable — When cancer cannot be removed entirely by surgery, it is termed unresectable. Although the cancer has not yet spread to distant organs, the involvement of local structures, usually major blood vessels, make surgical removal technically impossible.

    In some cases, surgery might be done to relieve symptoms or problems caused by the cancer. Treatment generally includes drugs and sometimes radiation.
  • Metastatic — The cancer has spread to distant organs. In this case, surgery might be done to relieve symptoms or problems caused by the cancer. More often, drug therapy is used.

Reviewed by health care specialists at UCSF Medical Center.