Pancreatic Cancer Workup
Begin with a pancreatic protocol CT scan of the chest, abdomen, and pelvis combined with baseline CA 19-9 measurement, liver function tests, and family history assessment as the primary diagnostic approach. 1
Initial Imaging Strategy
- Multiphasic contrast-enhanced CT (pancreatic protocol) is the first-line imaging modality, including late arterial and portal venous phases, with >90% positive predictive value for determining unresectability 1
- Chest CT with contrast is mandatory to assess for metastatic disease 1
- Abdominal ultrasound is useful for initial examination when patients present with abdominal pain or jaundice, though accuracy for diagnosing pancreatic tumors is only 50-70% 2, 3
- If jaundice is present from an obstructive head tumor, obtain imaging BEFORE biliary drainage or stenting to avoid artifacts 1
- Imaging should be performed within 4 weeks before starting treatment 1
Laboratory Workup
- Obtain baseline CA 19-9 (if no cholestasis present) for prognostic information and treatment monitoring 1
- CA 19-9 demonstrates 83% sensitivity and is the most clinically useful tumor marker 1, 4
- Critical caveat: CA 19-9 is undetectable in Lewis antigen-negative patients (5-10% of population) and is elevated in cholestasis, making it unreliable for screening or initial diagnosis 1
- Elevated CA 19-9 >500 IU/ml indicates worse prognosis and should prompt consideration of neoadjuvant therapy before surgery 1
- Liver function tests are mandatory 1
- Complete blood counts are required 1
Advanced Imaging When Needed
- MRI with MRCP should be used when CT is inconclusive, contraindicated, or for evaluating cystic lesions 2, 1
- Endoscopic ultrasound (EUS) should be considered to evaluate small lesions not visible on CT and can complement staging by providing information on vessel invasion and lymph node involvement 2, 1
- ERCP is indicated only if clinical suspicion remains high despite negative CT imaging, or to relieve bile duct obstruction 2, 1
- In the preoperative setting, ERCP and biliary stenting should only be performed if surgery cannot be done expeditiously 2
Tissue Diagnosis Strategy
The approach to biopsy depends on resectability status:
- For resectable masses in surgical candidates, proceed directly to surgery without preoperative biopsy 1
- For unresectable or metastatic disease, biopsy confirmation is mandatory before initiating systemic therapy 1
- EUS-guided fine needle aspiration is the preferred biopsy method with highest accuracy and lowest risk of tumor seeding 1
- Avoid percutaneous biopsy in surgical candidates due to risk of tumor seeding 2, 1
- If metastatic lesions are present, biopsy these under ultrasound or CT guidance 2, 1
Staging Evaluation
- Use the TNM staging system developed by the AJCC-UICC 2
- Staging laparoscopy should be considered to exclude clinically occult intra-abdominal and lymph node metastases, particularly for left-sided large tumors, high CA 19-9 levels, or when neoadjuvant treatment is considered 2, 1
- Laparoscopy may detect small peritoneal and liver metastases changing therapeutic strategy in <15% of patients 2
Molecular Testing
- Obtain KRAS and BRCA testing for all patients 1
- For metastatic disease with KRAS wild-type tumors, assess microsatellite instability (MSI) status, NTRK fusion status, and other rare actionable fusions 1
- Patients with family history or high-risk features should undergo genetic counseling 1
- BRCA1, BRCA2, or PALB2 mutations indicate potential platinum therapy sensitivity 1
Tests to Avoid
- PET scan has no role in the diagnosis or routine staging of pancreatic cancer 2
- Bone scan should not be ordered for routine staging, as only a few patients present with bone involvement at diagnosis 2, 1
Multidisciplinary Review
- Consultation should involve expertise from diagnostic imaging, interventional endoscopy, medical oncology, radiation oncology, surgery, and pathology before finalizing treatment decisions 1