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 with a multiphase CT scan of the chest, abdomen, and pelvis to assess the extent of disease, as recommended by the American Society of Clinical Oncology 1.

Initial Assessment

The initial assessment should include a thorough evaluation of the patient's performance status, symptom burden, and comorbidity profile, as these factors have significant implications for treatment tolerance and outcomes 1.

• A multiphase CT scan of the chest, abdomen, and pelvis is the primary imaging modality for assessing the extent of disease.
• Other staging studies should be performed only as dictated by symptoms.
• The goals of care, including a discussion of advance directives, patient preferences, and support systems, should be discussed with every patient and their caregivers 1.

Additional Evaluations

Additional evaluations, such as MRI with MRCP, endoscopic ultrasound, and laboratory tests, may be considered to further clarify the extent of disease and guide treatment decisions.

• MRI with MRCP may be useful for further clarification of liver lesions or biliary anatomy.
• Endoscopic ultrasound may provide additional staging information and allow for tissue sampling if not already performed.
• Laboratory tests should include complete blood count, comprehensive metabolic panel, CA 19-9 tumor marker, and coagulation studies.

Multidisciplinary Collaboration

Multidisciplinary collaboration is essential for formulating treatment and care plans, and disease management for patients with pancreatic cancer.

• A multidisciplinary tumor board evaluation is essential to determine surgical candidacy for potentially resectable disease.
• Multidisciplinary collaboration should involve a team of healthcare professionals, including medical oncologists, surgical oncologists, radiation oncologists, and palliative care specialists.
• Patients with pancreatic cancer should be offered information about clinical trials, including therapeutic trials, palliative care, biorepository/biomarker, and observational studies 1.

From the Research

Appropriate Workup for Pancreatic Cancer

After histopathologic diagnosis, the workup for pancreatic cancer involves several steps:

• Determining the extent of the disease, which can be categorized into resectable, borderline resectable, locally advanced, and metastatic disease 2
• Using high-quality computed tomography with intravenous contrast and a dual-phase pancreatic protocol to detect the tumor and determine surgical resectability 2
• Considering endoscopic ultrasound as a complementary staging modality, which can also provide diagnostic confirmation when combined with fine needle aspiration 2
• Evaluating the patient's condition and considering surgical resection, which represents the only chance for cure 2

Diagnostic Techniques

Various diagnostic techniques can be used, including:

• CT scans, which are the preferred modality due to wider availability, greater consistency in image quality, and lower cost 3
• MRI and PET/CT, which are usually reserved as problem-solving tools in select patients 3
• Artificial intelligence (AI), which has the potential to improve upon radiologists' detection of small early-stage tumors and provide imaging biomarkers to predict disease recurrence and patient survival 3

Histopathologic Diagnosis

The histopathologic diagnosis of pancreatic cancer involves:

• Distinguishing pancreatic ductal adenocarcinoma from other solid neoplasms and autoimmune pancreatitis using systematic workup and clear diagnostic criteria 4
• Detecting mucin-producing neoplasms in cystic pancreatic lesions, which can be precursors to pancreatic cancer, using molecular analyses 4
• Evaluating the pancreatic neck margin and analyzing unclear lesions of the liver during frozen section examination 4

Treatment Options

Treatment options for pancreatic cancer depend on the stage and extent of the disease:

• Surgical resection, which is the only potentially curative treatment, but can only be performed in a limited number of cases 2, 5
• Systemic chemotherapy combinations, including FOLFIRINOX and gemcitabine plus nab-paclitaxel, which remain the mainstay of treatment for patients with advanced disease 6, 2
• Neoadjuvant chemotherapy and/or radiation therapy, which can be used to downstage the disease and improve patient outcomes 3