Pancreatic Cancer: Diagnosis & Staging

Getting an accurate diagnosis and determining the size and extent (also called the stage) of a pancreatic cyst or tumor is an essential first step toward getting the most-effective treatment. At Memorial Sloan-Kettering, radiologists, pathologists, surgical oncologists, and other members of your multidisciplinary cancer care team use a variety of sophisticated tests to obtain accurate information about a tumor and determine the best treatment approach.

Diagnostic Tests

When you come to Memorial Sloan-Kettering, your doctor will perform a comprehensive physical examination and review previous imaging and medical data from your primary care physician. We may recommend one or more of the following tests to make an accurate diagnosis and determine the stage of your disease:

Blood Tests

Although no blood test can detect pancreatic cancer at an early stage, several tests can give further evidence to support a diagnosis of pancreatic cancer. Doctors also use blood tests to monitor the progression of your disease and to track the effects of treatment.

• Liver (Hepatic) Function Test – This test is used to measure levels of bilirubin (a substance made by the liver) and liver enzymes. Pancreatic cancer is not the only cause of higher bilirubin levels, but an elevated measurement could indicate that you have a tumor that is blocking the bile duct.
• CA 19-9 – People with pancreatic cancer often have increased levels of this protein in their blood. However, because CA 19-9 also increases in people with pancreatitis and jaundice, it cannot be used alone to diagnose pancreatic cancer.
• CEA (Carcinogenic Antigen) – Levels of this protein in the blood typically increase in people with cancers of the gastrointestinal tract. However, like CA 19-9, CEA levels can also rise in response to noncancerous conditions such as pancreatitis.

Diagnostic Imaging

Your doctor may use one or more imaging tests to determine the extent of the tumor in the pancreas and whether cancer cells have spread to surrounding tissues or other parts of the body.

• CT – CT scans are used to identify the precise location and extent of a pancreatic tumor. Our doctors use a highly accurate method in which a contrast dye is injected before scanning to obtain a better image. This method reduces the amount of radiation that is required to obtain an image and provides almost as much information as more-invasive imaging methods.
• MRI – MRI is another imaging technology that provides complementary information to that seen in a CT scan.
• MRCP (Magnetic Resonance Cholangiopancreatography) – Doctors use this type of MRI to see inside the pancreatic ducts, the channels in the pancreas where tumors often begin.
• EUS (Endoscopic Ultrasound) – Doctors insert a thin scope through the mouth and into the stomach while the patient is under anesthesia. At the tip of the tube is a small ultrasound probe that bounces sound waves through the walls of the stomach and onto the pancreas. Because the stomach is located next to the pancreas, EUS provides highly detailed pictures of the pancreas. The endoscope used in EUS can also be used to remove pancreatic cells and fluid for a biopsy.
• ERCP (Endoscopic Retrograde Cholangiopancreatography) – As in EUS, an endoscope is passed through the mouth into the pancreatic duct. A contrast dye is injected through the endoscope before imaging, enabling the doctor to see if the pancreatic duct has narrowed or become blocked. Gastroenterologists may also use the endoscope to remove pancreatic cells for a biopsy and to guide placement of a bile duct stent to relieve jaundice.

Biopsy

If your physical exam, lab tests, and imaging studies suggest that you might have pancreatic cancer, your doctor may perform a biopsy to confirm the diagnosis. Most biopsies are obtained via EUS or ERCP as described above. Alternately, a radiologist inserts a thin needle into the abdomen while the patient is under anesthesia to remove a small amount of tissue and fluid from the pancreas.

After the tissue sample is taken, a pathologist then examines it closely to determine precisely what type of tumor it is, and if it is benign or malignant. Careful microscopic evaluation of tumor cells collected through a biopsy remains the gold standard for diagnosing pancreatic cancer. To an experienced pathologist, each of the approximately 20 types of pancreatic tumors has a different appearance under the microscope. Because each type of tumor responds differently to therapy, knowing which type of tumor you have will help your doctor select the most effective treatment option for you.

Biopsies are performed in Memorial Sloan-Kettering's Center for Image-Guided Interventions, where experts use highly precise imaging technologies to guide biopsy procedures. These advanced approaches now make it possible to investigate cysts and tumors in areas of the body that were impossible to reach safely in the past.

Laparoscopic Staging

Although sophisticated imaging techniques are useful in staging pancreatic tumors, these tests are not always accurate in determining whether surgery is the most appropriate treatment. For this reason, doctors often perform an exploratory surgery called a laparotomy as a part of the staging process. In this procedure, a surgeon makes an incision in the abdomen to view the extent of a pancreatic tumor and determine whether it can be removed successfully without posing undue risk to a patient.

Surgeons at Memorial Sloan-Kettering pioneered the use of a minimally invasive alternative to the laparotomy, called a laparoscopy. For this procedure, a surgeon inserts a laparoscope – a thin, lighted tube with a camera on its tip – through a tiny incision in the patient’s abdomen to view the pancreas and surrounding organs. Studies have suggested that laparoscopic staging can identify inoperable pancreatic tumors in up to 15 percent of patients who were thought to have resectable (operable) tumors.⁽¹⁾ Recovery from laparoscopy is much shorter than with open surgery, allowing patients to begin treatments such as chemotherapy without delay.

Stages of Pancreatic Cancer

Following your diagnostic tests, your doctors will determine whether you have a benign cyst, a precancerous lesion, or a malignant tumor. If your tumor is malignant, the doctor will use information from your diagnostic tests to determine the stage of your cancer. The stage of the cancer is a measure of the extent to which the tumor has grown in the pancreas and has spread to other sites in the body. This information helps your doctors to determine the treatment approach that would be best for you.

Pancreatic cancer can be assigned one of the following four stages:

• Stage I – The tumor is less than 2 cm in diameter and is completely contained within the pancreas.
• Stage II– The tumor has begun to grow outside of the pancreas, but has not invaded a major blood vessel. Stage II pancreatic cancer may have spread to nearby lymph nodes, but not to distant sites.
• Stage III – The tumor is growing outside of the pancreas, and has moved into nearby large blood vessels or major nerves.
• Stage IV – The cancer has spread to other parts of the body, such as the liver or the peritoneum (inner lining of the abdomen).