Initial Workup of Pancreatic Masses
All patients with suspected pancreatic cancer should undergo a dedicated pancreas protocol CT scan with intravenous contrast as the primary initial imaging modality. 1, 2
Primary Imaging: Pancreas Protocol CT
The pancreas protocol CT is the cornerstone of initial evaluation and must include specific technical parameters 1, 2:
- Dual-phase contrast-enhanced imaging with late arterial/pancreatic phase (40-50 seconds post-contrast) and portal venous phase (70 seconds post-contrast) 2
- Thin-slice acquisition using submillimeter axial sections with multiplanar reformations 1, 2
- Chest imaging included to evaluate for pulmonary metastases 1
This protocol achieves 70-85% accuracy in predicting resectability and provides critical assessment of vascular involvement (celiac axis, SMA, hepatic artery, SMV, portal vein, splenic vein) 1, 2.
When CT Findings Are Indeterminate or Negative
If CT shows no mass but clinical suspicion remains high (jaundice, weight loss, elevated CA 19-9, new-onset diabetes), proceed immediately to endoscopic ultrasound (EUS). 1, 3
EUS demonstrates superior sensitivity (98%) for detecting pancreatic lesions, particularly those <3 cm that CT may miss 3, 4. EUS should be performed with fine-needle aspiration (FNA) capability available 3.
Role of MRI with MRCP
MRI with MRCP is the preferred alternative when IV contrast is contraindicated (contrast allergy, severe renal dysfunction). 1, 2
MRI offers advantages over CT including 1:
- Superior soft-tissue contrast (sensitivity 96.8% vs 80.6% for CT) 1
- Better characterization of CT-indeterminate liver lesions 1
- Superior demonstration of ductal communication 1
However, CT remains preferred for routine initial evaluation due to easier interpretation and less operator dependence 1.
Essential Laboratory Evaluation
Obtain baseline laboratory tests at presentation 5:
- Liver function tests (bilirubin, AST, ALT, alkaline phosphatase) to assess biliary obstruction 5
- CA 19-9 tumor marker when malignancy is suspected 5
- Fasting glucose or HbA1c as new-onset diabetes can herald pancreatic cancer 1, 5
- Lipase or amylase if pancreatitis is in the differential 5
Tissue Diagnosis Timing
Do NOT perform CT-guided percutaneous biopsy if the lesion appears potentially resectable on imaging. 1
Percutaneous biopsy risks peritoneal seeding that could eliminate curative potential in otherwise resectable cases 1. Instead:
- Resectable disease: Proceed directly to surgical consultation without tissue diagnosis 1
- Borderline resectable or unresectable disease: Obtain tissue via EUS-FNA before initiating neoadjuvant or palliative chemotherapy 3
- Metastatic disease: Tissue diagnosis required before systemic therapy 1
Performance Status and Comorbidity Assessment
Document baseline ECOG performance status and comorbidity profile, as these directly impact treatment eligibility 1:
- ECOG 0-1 with favorable comorbidities: Eligible for aggressive regimens like FOLFIRINOX 1
- ECOG 0-1 with moderate comorbidities: Consider gemcitabine/nab-paclitaxel 1
- ECOG ≥2: Palliative care focus with possible single-agent therapy 1
Critical Pitfalls to Avoid
Do not rely on ultrasound alone for initial pancreatic mass evaluation. While ultrasound can identify masses with 80-95% sensitivity, bowel gas compromises interpretation in 20-25% of cases and provides inadequate staging information 1.
Do not skip chest imaging. Intrathoracic metastases alter management and must be excluded 1.
Do not delay multidisciplinary consultation. Management decisions should involve surgical oncology, medical oncology, radiation oncology, and gastroenterology from the outset 1.
Specific Clinical Scenarios
For incidentally discovered pancreatic cysts (rather than solid masses), MRI with MRCP is preferred over CT to assess for worrisome features (cyst size ≥3 cm, mural nodules, main duct dilation ≥7 mm) 1.
For patients with prior Roux-en-Y gastric bypass, standard EUS may be impossible; consider modified EDGE procedure for tissue acquisition if needed 6.