What is the appropriate workup for pancreatic cancer after histopathologic (tissue examination) diagnosis?

From the Guidelines

After a histopathologic diagnosis of pancreatic cancer, a comprehensive workup should be initiated immediately to determine disease stage and guide treatment planning, with a multiphase CT scan of the chest, abdomen, and pelvis as the primary imaging modality, as recommended by the American Society of Clinical Oncology 1. The workup should include:

• A multiphase CT scan of the chest, abdomen, and pelvis to assess the extent of disease, as this is the preferred imaging modality for staging pancreatic cancer 1
• Laboratory tests, such as complete blood count, comprehensive metabolic panel, CA 19-9 tumor marker, and coagulation studies, to evaluate the patient's overall health and detect any potential complications
• Endoscopic ultrasound may be performed for additional staging information and potential biopsy confirmation if not already done, as it provides additional staging information and is highly accurate and reliable for determining malignancy 1
• PET-CT scanning may be considered for evaluating metastatic disease in selected cases, although its role is still unclear and it is not a substitute for high-quality, contrast-enhanced CT 1
• Genetic testing of the tumor for mutations in genes like BRCA1/2, PALB2, and microsatellite instability should be performed to guide potential targeted therapies
• A multidisciplinary tumor board discussion involving surgical oncology, medical oncology, radiation oncology, gastroenterology, and pathology is essential to develop an individualized treatment plan based on disease stage, patient performance status, and molecular profile, as recommended by the National Comprehensive Cancer Network 1 This comprehensive approach ensures proper staging and identification of patients who may benefit from surgical resection, neoadjuvant therapy, or palliative treatments, and is in line with the most recent and highest quality guidelines available 1.

From the Research

Diagnostic Workup for Pancreatic Cancer

After histopathologic diagnosis, the following steps are taken for the workup of pancreatic cancer:

• High-quality computed tomography (CT) with intravenous contrast using a dual-phase pancreatic protocol is typically the best method to detect a pancreatic tumor and determine surgical resectability 2
• Endoscopic ultrasound (EUS) is an increasingly used complementary staging modality that also allows for diagnostic confirmation when combined with fine-needle aspiration 2, 3
• EUS is useful in determining local vascular invasion and obtaining tissue diagnosis, while fluoro-deoxyglucose/positron emission tomography (FDG-PET) is useful in identifying metastatic disease 3

Staging of Pancreatic Cancer

The National Comprehensive Cancer Network (NCCN) guidelines define resectability criteria based on tumor involvement of the arteries and veins and triage patients into resectable, borderline resectable, locally advanced, and metastatic categories 4

• Patients with resectable disease are eligible for upfront surgical resection, while patients with high-stage disease are treated with neoadjuvant chemotherapy and/or radiation therapy with hopes of downstaging the disease 4
• Artificial intelligence (AI) has the potential to function as 'second readers' to improve upon the radiologists' detection of small early-stage tumors, which can shift more patients toward surgical resection of potentially curable cancer 4

Treatment Options for Pancreatic Cancer

Systemic chemotherapy combinations, including FOLFIRINOX and gemcitabine plus nab-paclitaxel, remain the mainstay of treatment for patients with advanced disease 5, 2

• Combination chemotherapy remains standard of care for metastatic pancreatic cancer, with both FOLFIRINOX and gemcitabine plus a taxane improving overall survival compared to gemcitabine alone 5
• The effects of radiotherapy were uncertain, as only one low-quality trial was included in the study 5