As with any patient complaint, begin with a detailed history and a focused physical exam.
The following are important aspects of a history for suspected pancreatic cancer:undefined
- History of presenting complaint (onset, duration, alleviating/aggravating factors, associated symptoms, etc)
- Complete medical history, including discussion of comorbid illnesses (ex. diabetes, chronic pancreatitis)
- Risk factor assessment, including tobacco and alcohol use, lifestyle, and family history
- Review of systems to assess for constitutional symptoms or other findings indicative of metastases
A physical exam should be done to find clinical signs of pancreatic cancer. A focused abdominal exam is appropriate, with emphasis on palpation of an epigastric or right upper quadrant mass (may or may not be tender) and other findings such as hepatomegaly or ascites. Extra-abdominal physical findings should also be assessed such as jaundice of the skin and/or membranes and weight loss (cachexia).
Absence of clinically significant findings on physical exam does not rule out the diagnosis of pancreatic cancer. If the history is suspicious for pancreatic cancer, initial diagnostic testing, such as laboratory investigations and imaging, are initiated.
Laboratory investigations may include:
- CBC, electrolytes, Cr/BUN
- Liver enzymes (ALT, AST, ALP, GGT) and bilirubin
- Serum lipase
- Tumour marker CA19-9
The imaging modality chosen will depend on the patient’s presenting symptoms:
A summary of these modalities can be found in the table below.
If a patient presents with painless jaundice, the imaging modality of choice is often a transabdominal ultrasound of the right upper quadrant to assess for causes of biliary-pancreatic disease. Ultrasound is beneficial in this case because of its wide availability and low-cost to the health care system. It also has a high sensitivity for detecting masses in the head of the pancreas and biliary tract dilation, both important findings to assess for in a patient presenting with jaundice.
If a patient presents with epigastric pain and weight loss, a transabdominal ultrasound of the epigastrium and right upper quadrant may be done initially. However, because these clinical findings are more sinister, the imaging modality of choice is typically a CT scan due to its higher sensitivity for detecting small masses (<3cm) and its ability to detect metastatic disease.
The “positive” findings of pancreatic cancer on transabdominal US include a hypoechoic mass, dilatation of the pancreatic duct, and dilatation of the bile duct. Note that these findings are typically in keeping with a mass in the head of the pancreas. Masses in the body/tail of the pancreas are harder to detect by US due to lack of biliary dilatation and bowel gas obstructing the view.
If a transabdominal U/S is considered positive, the presence of a mass needs to be confirmed by a CT scan and disease extent needs to be assessed. The CT scan alone may provide enough information about the disease and resectability that surgical intervention can be carried out without a biopsy to confirm the diagnosis of pancreatic cancer. However, if there is uncertainty about the diagnosis or resectability, a biopsy +/- additional procedures may be carried out. Biopsies can be done through endoscopic ultrasound guidance or percutaneously.
If a transabdominal U/S is negative despite clinical suspicions of pancreatic cancer, a CT scan must be done. If the patient has signs of cholestasis (elevated ALP, GGT, bilirubin), an ERCP may be done instead to assess for choledocholithiasis. If either is found to be negative, no additional testing is required and the physician must consider an alternative diagnosis for the patient’s symptoms.
It is important to remember that although this module presents a pancreatic mass as pancreatic cancer, there is a differential diagnosis of a pancreatic mass. This is presented in the table below.