How Pancreatic Cancer Is Diagnosed

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The diagnosis of pancreatic cancer relies on several tools. A medical history focused on symptoms and risk factors, along with a physical exam, is the first step. Imaging tests, which may include a specialized abdominal CT scan, endoscopic ultrasound, MRI, and/or ERCP, can visualize the tumor. Blood tests can help identify the causes of jaundice and may detect tumor markers. Depending on the preliminary findings, a biopsy may or may not be needed before surgery. After diagnosis, staging is done to determine the most appropriate treatments for the disease.

Talk to your doctor and make an appointment to be seen right away if you develop symptoms of pancreatic cancer. Screening may be recommended based on your risk factors.

The American Gastroenterological Association recommends screening for people who are at high risk of pancreatic cancer, including those who have a first-degree family history and certain genetic diseases and mutations. Screening includes genetic testing and counseling and should begin at age 50 or at an age that's 10 years younger than the initial age of family onset.

pancreatic cancer diagnosis
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Labs and Tests

Your physical examination may show signs consistent with pancreatic cancer, but these changes can also occur with some other medical conditions.

Your skin and eyes may show evidence of jaundice (yellowish discoloration of the skin and the whites of the eyes). Your abdominal examination may identify a. mass, enlargement of your liver, or ascites (build-up of fluid in the abdomen).

Your doctor might also observe that you appear malnourished or that you seem to have lost weight.

Blood test abnormalities are not specific to pancreatic cancer, but they can sometimes be helpful in making a diagnosis when combined with imaging tests. 

Tests may include:

  • Liver function tests, which are sometimes elevated
  • A complete blood count (CBC) may show thrombocytosis (high platelet count)
  • A bilirubin test may show elevations in both conjugated and total bilirubin, which is consistent with obstruction from a pancreatic tumor pushing on the common bile duct

Blood sugar can be elevated with pancreatic cancer, which can cause insulin resistance or diabetes.

Individuals who experience a sudden case of pancreatitis (inflamed pancreas), have a higher risk of developing pancreatic cancer. Sudden-onset pancreatitis will show elevations in serum amylase and serum lipase in screening tests.

Tumor Markers

Tumor markers are proteins or substances secreted by cancer cells that can be detected with tests such as blood tests or biopsies. Carcinoembryonic antigen (CEA) is elevated in roughly half of those who are diagnosed with pancreatic cancer. CEA is also elevated in several other types of conditions as well. 

Another marker, CA 19-9, can be helpful in following the course of pancreatic cancer treatment, but it's not always elevated with this kind of cancer, and it can be elevated with other conditions too.

Neuroendocrine Tumor Blood Tests

Neuroendocrine tumors, which are rare, can develop in several different organs in the body, including the pancreas. These tumors involve endocrine cells, and they produce hormones or other proteins that can be detected with blood tests.

Pancreatic Cancer Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

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Imaging

Imaging tests are usually the primary method of visualizing a pancreatic mass.

CT Scan

Computerized tomography (CT), which uses X-rays to create a cross-section of a region of the body, is often the mainstay of diagnosis. For evaluating possible pancreatic cancer, a multiphase helical CT scan or pancreatic protocol CT scan is often recommended.

A CT scan can be helpful both for characterizing the tumor (determining its size and location in the pancreas) and looking for any evidence of spread to lymph nodes or other regions.

Endoscopic Ultrasound (EUS)

Ultrasound uses sound waves to create an image of the inside of the body. A conventional (transcutaneous) ultrasound is not usually used to evaluate possible pancreatic cancer, because intestinal gas can make visualization of the pancreas difficult.

Endoscopic ultrasound can be a valuable procedure in making the diagnosis of pancreatic cancer. During this invasive test, an endoscope (a flexible tube with an ultrasound probe at its end) is inserted through the mouth and threaded down into the stomach or small intestine so that the images can be taken from inside the body.

This test allows doctors to get a very good look at the pancreas.

This procedure is done with conscious sedation, and it is usually tolerated well. The test may be more accurate than CT for assessing the size and extent of a tumor but isn't as useful for finding metastases (distant spread of the tumor) or determining if the tumor involves blood vessels.

CT may be more effective than endoscopic ultrasound in determining whether cancer has spread to the superior mesenteric artery, which is important in choosing treatment.

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive test that involves endoscopy plus X-rays in order to visualize the bile ducts. ERCP can be a sensitive test for finding pancreatic cancer, but it is not accurate for differentiating the disease from other problems, such as pancreatitis.

MRI

Magnetic resonance imaging (MRI) uses magnets rather than X-rays to create an image of internal structures. MR cholangiopancreatography (MRCP) is used primarily for people whose diagnosis is unclear based on other studies, or if a person has an allergy to the contrast dye used for CT.     

Octreoscan

A test called an octreoscan or somatostatin receptor scintigraphy (SRC) may be done if there's concern about a neuroendocrine tumor of the pancreas.

Before an octreoscan, a radioactive protein tracer is injected into a vein. If a neuroendocrine tumor is present, the tracer will bind to cells in the tumor. Several hours later, a scan (scintigraphy) is done that picks up radiation that is being emitted. If present, neuroendocrine tumors will light up on the image.

PET Scan

PET scans, often combined with CT (PET/CT), may occasionally be done, but are not used often for diagnosing pancreatic cancer.

Before this test, a small amount of radioactive sugar is injected into a vein. A scan is done after the sugar has had time to be absorbed by cells. Actively growing cells, such as cancer cells, will light up, in contrast to areas of normal cells or scar tissue.

Biopsy

A biopsy (sample of tissue) is usually needed to confirm the diagnosis of pancreatic cancer. This test is also used to look at the molecular characteristics of the tumor. In selected cases, surgery can be done without a biopsy.

A fine needle biopsy (a procedure in which a thin needle is directed through the skin in the abdomen and into the pancreas to extract a sample of tissue) is most often done using ultrasound or CT guidance.

There is some concern that this type of biopsy could "seed" the tumor, resulting in the spread of cancer along the line where the needle is introduced.

It's not known how often seeding occurs, but according to a 2017 study, the number of case reports of seeding due to endoscopic ultrasound-guided fine-needle aspiration has been rapidly increasing.

As an alternative approach, a more invasive procedure—laparoscopy—may be used to obtain a biopsy, especially if a tumor could potentially be completely resectable (able to be removed) during laparoscopic surgery. During a laparoscopy, several small incisions are made in the abdomen and a narrow instrument is inserted to obtain the biopsy sample.

Differential Diagnoses

There are a number of conditions that may mimic the symptoms of pancreatic cancer or result in similar findings on blood tests and imaging.

Doctors will work to rule out the following before making a diagnosis:

  • Bile duct stricture is an abnormal narrowing of the bile duct. It may be caused by gallstones or gallstone surgery, but may also be caused by pancreatic cancer.
  • Acute or chronic pancreatitis, an inflammation of the pancreas, can cause similar symptoms but does not cause a mass to develop. Between 7 and 14% of those diagnosed with pancreatic cancer also present with acute pancreatitis.
  • Bile duct stones in the bile duct can cause symptoms of obstructive jaundice and can often be seen on ultrasound. Like bile duct strictures, however, they may be present along with pancreatic cancer.
  • Ampullary carcinoma
  • Gallbladder cancers can appear very similar to pancreatic cancers and may be differentiated with CT or MRI.
  • Gallstones (cholelithiasis)
  • Gastric or duodenal ulcers
  • Abdominal aortic aneurysm 
  • Pancreatic lymphoma
  • Gastric lymphoma
  • Liver cancer
  • Bile duct cancer 

Staging

Determining the stage of pancreatic cancer is extremely important when it comes to deciding whether cancer can be surgically removed or not. Staging can also assist in estimating the prognosis of the disease.

There are several staging systems used for pancreatic cancer. The simplest of these defines cancer as resectable, borderline resectable, or nonresectable.

pancreatic cancer stage at diagnosis
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TNM Staging

Doctors use a system called TNM staging to determine the stage of a tumor.

T stands for tumor. A tumor is given a number from T1 to T4 based on the size of the tumor, as well as other structures the tumor may have invaded.

For a primary pancreatic tumor:

  • T1: Tumor confined to the pancreas and less than 2 centimeters (cm).
  • T2: Tumor confined to the pancreas and more than 2 cm but no more than 4 cm.
  • T3: Tumor confined to the pancreas and is bigger than 4 cm.
  • T4: Tumor has spread outside the pancreas and into nearby blood vessels.

N stands for lymph nodes. N0 would mean that a tumor has not spread to any lymph nodes. N1 means that the tumor has spread to nearby lymph nodes.

M stands for metastases. If a tumor has not spread, it would be described as M0, meaning no distant metastasis. If it has spread to distant regions (beyond the pancreas) it would be referred to as M1.

Based on TNM, tumors are given a stage between 0 and 4.

There are also substages:

  • Stage 0: Stage 0 is also referred to as carcinoma in situ and refers to cancer that has not yet spread past the basement membrane, which is a lining of the pancreas. These tumors are not invasive and should be completely curable if fully treated at this stage.
  • Stage 1: Stage 1 (T1 or T2, N0, M0) pancreatic cancers are confined to the pancreas and are less than 4 cm (about 2 inches) in diameter.
  • Stage 2: Stage 2 tumors (either T3, N0, M0 or T1-3, N1, M0) are no larger than 4 cm and may have spread to no more than three lymph nodes.
  • Stage 3: Stage 3 tumors (T4, any N, M0) have spread to nearby blood vessels or to no more than four lymph nodes.
  • Stage 4: Stage 4 tumors (Any T, any N, M1) can be any size. While they may or may not have spread to lymph nodes, they have spread to distant sites such as the liver, the peritoneum (the membranes that line the abdominal cavity), the bones, or the lungs.

Frequently Asked Questions

  • Can a blood test tell me whether I have pancreatic cancer?

    There isn’t a specific blood test for pancreatic cancer, but certain blood tests can help contribute to the diagnosis and guide treatment. These tests check:

  • How do doctors get an image of the pancreas to check for cancer?

    Several types of imaging tests may be used to diagnose pancreatic cancer: CT scans help determine if cancer is present and has spread and may guide a biopsy. MRIs are used for those who can’t undergo CT scans or when other tests are inconclusive. Ultrasounds may be done from outside the abdomen or via an endoscope that’s inserted into the digestive tract.

  • Why is pancreatic cancer usually found so late?

    It’s difficult to diagnose pancreatic cancer early because the organ is deep in the abdomen. It can’t be felt in a physical exam, imaging tests don’t catch small lesions, and there isn’t a single blood test that can detect it. Most cases of pancreatic cancer aren’t diagnosed until stage 4 when it’s metastasized.  

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Article Sources
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Additional Reading
  • Pancreatic Cancer Diagnosis. American Society of Clinical Oncology. Cancer.Net. Updated 12/2016.

  • Kikuyama, M., Kamisawa, T., Kuruma, S. et al. Early Diagnosis to Improve the Poor Prognosis of Pancreatic Cancer. Cancers. 2018. 10(2):.pii: E48. doi:10.3390/cancers10020048.

  • Current and Emerging Therapies in Pancreatic Cancer, Springer Verlag, 2017.