What is the workup for a patient with a pancreatic mass?

From the Guidelines

For a patient with a pancreatic mass, I strongly recommend starting with a high-quality computed tomography (CT) scan of the chest, abdomen, and pelvis, using a pancreatic protocol with multiphase thin-section images and intravenous iodinated non-ionic contrast agent injection, as this is the main modality for diagnosing pancreatic cancer (PC) and assessing tumour location, size, and vascular involvement 1. The imaging work-up should aim to assess tumour characteristics, tumour-to-vessel contact, locoregional involvement, and the presence or absence of distant metastases.

• Key factors for high-quality CT include:
  • Multiphase thin-section images including pancreatic, arterial, and portal venous phases
  • Intravenous iodinated non-ionic contrast agent injection at 1.5 ml/kg and at a rate of 4-5 ml/s
• Diagnostic criteria for PC include direct signs such as a hypovascular tumour and indirect signs such as main pancreatic and/or common bile duct dilation, segmental atrophy of the parenchyma, and abnormalities in pancreatic contour. If CT is inconclusive, abdominal MRI can be used as an alternative, especially for isoattenuating tumours or when a contrast-enhanced CT is contraindicated, and should include T2-, fat suppressed T1-, and diffusion-weighted sequences, as well as magnetic resonance cholangiopancreatography (MRCP) 1. A biopsy is indicated for patients requiring differential diagnosis with benign chronic pancreatitis or a histological diagnosis, and EUS-guided fine-needle biopsy is preferred for localized disease, allowing tissue confirmation of malignancy 1. Additional diagnostic tools, such as endoscopic retrograde cholangiopancreatography (ERCP) and positron emission tomography (PET)-CT, may be considered in specific cases, but are not routinely recommended for the diagnosis of PC 1. It is essential to use standardized reporting templates for imaging reports, detailing tumour characteristics, tumour-to-vessel contact, locoregional involvement, and the presence or absence of distant metastases, to ensure accurate staging and treatment planning 1.

From the Research

Diagnostic Workup for Pancreatic Mass

The diagnostic workup for a patient with a pancreatic mass involves a combination of imaging techniques and procedures to determine the nature and extent of the mass.

• The initial evaluation typically starts with a helical CT scan, which provides the best overall assessment of patients with periampullary malignancies 2.
• If the CT scan shows a mass in the head of the pancreas that appears to be resectable, the patient should be prepared for surgery 2.
• If no mass is apparent on the CT scan, a diagnostic endoscopic retrograde cholangiopancreatography (ERCP) is indicated 2.
• Fine-needle aspiration (FNA) for cytology should be performed if microscopic proof of the diagnosis will avoid surgery 2.
• Laparoscopy is indicated when unresectability appears likely and cannot be confirmed in less invasive ways 2.

Imaging Techniques

Various imaging techniques are used in the diagnostic workup of a pancreatic mass, including:

• CT scan: provides high sensitivity and specificity for the diagnosis of pancreatic cancer, with a sensitivity between 76% and 92% 3.
• Endoscopic ultrasonography (EUS): has a sensitivity of around 98% for the detection of pancreatic lesions and is accepted to be the most sensitive technique for the detection of small pancreatic tumors (<2 cm) 3.
• Magnetic resonance imaging (MRI): provides an accuracy in the detection and staging of adenocarcinoma of 90-100% 3.
• Ultrasound: may be used as an initial imaging modality, but its sensitivity and specificity are lower compared to other techniques 2.

Diagnostic Approach

A multimodality approach is usually necessary in patients with clinical suspicion of pancreatic lesion 3.

• The EUS is required for the local evaluation of the relation of the lesion with vessels and for tissue acquisition 3.
• The CT scan and/or MRI is usually required for the local and distance staging in case of pancreatic cancer 3.
• A diagnostic flow-chart approach can be used to guide the diagnostic workup, taking into account the patient's symptoms, imaging findings, and other factors 4.