What is the recommended workup for suspected pancreatic cancer?

Recommended Workup for Suspected Pancreatic Cancer

The initial diagnostic workup for suspected pancreatic cancer should begin with a pancreatic protocol CT scan, followed by appropriate staging procedures and multidisciplinary review to determine resectability and treatment options. 1

Initial Diagnostic Evaluation

First-line Imaging

• Pancreatic protocol CT scan: This is the preferred initial imaging modality for suspected pancreatic cancer 1
  • Should be performed with thin, submillimeter axial sections using dual-phase pancreatic protocol
  • Images should be obtained in both pancreatic and portal venous phases of contrast enhancement
  • Provides clear distinction between hypodense lesions and normal pancreatic tissue
  • Allows visualization of important arterial and venous structures for assessing vascular invasion

Laboratory Tests

• Liver function tests to assess for biliary obstruction 1
• CA 19-9 level as a baseline tumor marker (note: limited utility in presence of cholestasis) 1
• Family history should be obtained to identify potential hereditary syndromes 1

Secondary Diagnostic Procedures

If Mass is Identified on Initial Imaging

1. Chest CT (preferred) or chest X-ray to evaluate for potential lung metastases 1
2. Endoscopic ultrasound (EUS) should be considered to:
   • Confirm primary site involvement 1
   • Perform fine needle aspiration (FNA) if tissue diagnosis is needed 1
   • Evaluate vascular involvement and lymph nodes 1
   • Particularly valuable for small lesions (<2 cm) 2

If No Mass is Identified on Initial Imaging

• MRI with MRCP (magnetic resonance cholangiopancreatography) 1
  • Superior for detecting isoattenuating tumors (5-17% of cases) 1
  • More sensitive than CT for small liver metastases 1
  • Particularly useful when CT is inconclusive or contraindicated 1

Tissue Acquisition

When to Obtain Tissue Diagnosis

• Mandatory for unresectable disease or when preoperative/neoadjuvant treatment is planned 1
• Not necessary for surgical candidates with clearly resectable disease on imaging 1
• Required for patients receiving palliative therapy 1

Preferred Methods for Tissue Acquisition

• EUS-guided fine needle biopsy is preferred for localized disease 1
  • Safer than percutaneous approaches
  • Higher sensitivity for small lesions
• Percutaneous biopsy of the most accessible site for metastatic disease 1
• Avoid transperitoneal techniques in potentially resectable tumors 1

Additional Staging Procedures

For Borderline or Locally Advanced Disease

• Staging laparoscopy may be considered:
  • Before resection in left-sided large tumors 1
  • When neoadjuvant treatment is planned 1
  • Can detect small peritoneal and liver metastases in up to 25% of patients 1

For Selected Cases

• PET-CT is not routinely recommended but may be considered:
  • For patients who will receive local cancer treatment (surgery or radiotherapy) 1
  • To help differentiate between benign and malignant lesions in ambiguous cases 2

Common Pitfalls and Caveats

1. Isoattenuating tumors (5-17% of cases) may be missed on standard CT 1
2. Chronic pancreatitis can mimic pancreatic cancer and may require additional functional imaging 2
3. Failure to obtain histological confirmation does not exclude malignancy and should not delay appropriate surgical treatment in highly suspicious cases 1
4. New-onset diabetes without predisposing factors may be an early warning sign of pancreatic cancer 1
5. Unexplained acute pancreatitis should prompt evaluation for underlying pancreatic cancer 1

Multidisciplinary Approach

After completing the diagnostic workup, multidisciplinary review is essential, involving expertise from:

• Diagnostic imaging
• Interventional endoscopy
• Medical oncology
• Radiation oncology
• Surgery
• Pathology 1

This comprehensive evaluation will determine resectability status (resectable, borderline resectable, locally advanced unresectable, or metastatic) and guide appropriate treatment planning.