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Investigations and diagnosis

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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  • 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:


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