investigations and diagnosis

Last edited 05/2020 and last reviewed 05/2022

  • full blood count
    • may reveal a normochromic anaemia or thrombocytosis or both
    • raised serum bilirubin, alkaline phosphatase and γ‑glutamyltransferase in obstructive jaundice (serum aspartate aminotransferase (AST) and serum alanine aminotransferase (ALT) may also be raised to a lesser extent)
    • may be impaired glucose tolerance or diabetes
  • tumour markers
    • carbohydrate 19-9 (CA19-9) - also known as sialylated Lewis (a) antigen
    • although most widely used serum tumor marker it is not specific for pancreatic cancer (a sensitivity of 80% and specificity of 73% for pancreatic cancer
    • is a useful to assess response to treatment and as a surveillance tool after treatment
  • imaging
    • initial examination
      • abdominal ultrasound –
        • double duct sign - bile duct dilation (>7 mm, or >10 mm if previous cholecystectomy) with pancreatic duct dilation (>2 mm) may be a sign of pancreatic cancer
        • other findings - liver metastases and ascites
    • further evaluations
      • triple phase computed tomography  preceded by non-contrast computed tomography
        • best method for detecting pancreatic neoplasms and assessing resectability
      • endoscopic ultrasound
        • useful especially for small tumours (<3cm)
        • can detect involvement of loco regionl lympnodes
        • also used to guide  fine needle aspiration (FNA) for cytological evaluation of lesions in which there is diagnostic uncertainty
      • positron emission tomography (PET) combined with CT (PET-CT)
        • it is more sensitvie in detecting pancreatic cancer and extra hepatic metastasis
      • MRI combined with magnetic resonance cholangiopancreatography (MRCP)
      • endoscopic retrograde cholangiopancreatography (ERCP)
        • is an effective way of confiming pancreatic adenocarcinoma with sensitivity of 90-95%
        • an invasive procedure whith 5-10% isk of significant complications hence reserved for  therapeutic procedure for biliary obstruction or for the diagnosis of unusual pancreatic neoplasms

NICE state that with respect to diagnosis of pancreatic cancer:

  • Diagnosis:

    • People with obstructive jaundice
      • if obstructive jaundice and suspected pancreatic cancer, offer a pancreatic protocol CT scan before draining the bile duct.
      • if the diagnosis is still unclear, offer fluorodeoxyglucose-positron emission tomography/CT (FDG-PET/CT) and/or endoscopic ultrasound (EUS) with EUS-guided tissue sampling.
      • take a biliary brushing for cytology if:
        • endoscopic retrograde cholangiopancreatography (ERCP) is being used to relieve the biliary obstruction and
        • there is no tissue diagnosis

    • People without jaundice who have pancreatic abnormalities on imaging
      • a pancreatic protocol CT scan should be offered to people with pancreatic abnormalities but no jaundice.
      • if the diagnosis is still unclear, offer FDG-PET/CT and/or EUS with EUS-guided tissue sampling.
      • if cytological or histological samples are needed, offer EUS with EUS-guided tissue sampling

Reference:                        

Related pages:

CA199