Doctors use many tests to find, or diagnose, cancer. They also do tests to learn if cancer has spread to another part of the body from where it started. A biopsy is the only certain way to confirm a diagnosis of cancer. When performing a biopsy, the doctor takes a sample of tissue for testing in a laboratory.
In order to understand the best treatment options available for treatment of pancreatic cancer, it is important to first determine where the cancer has spread in the body. More advanced cancers may invade adjacent organs, such as the liver, bile ducts, and intestine or spread to lymph nodes, the lining of the abdominal cavity, or other organs in the body via the blood system. Pancreatic cancer cells have a propensity to spread via the blood to the liver and, less commonly, to the lungs.
Determining the extent of the spread or the stage of the cancer is of initial importance to determine whether the cancer can be removed surgically. Upon completion of the clinical “staging evaluation,” your physicians will determine whether the cancer can be removed by surgery.1 The most common surgical procedure is a “Whipple” procedure. During this procedure the surgeon removes a portion of the pancreas, duodenum, stomach, and the entire gallbladder. Recent clinical studies have suggested that surgery is underutilized in patients with early-stage cancer of the pancreas, and that there is an opportunity to improve care of pancreatic cancer patients in the United States by offering surgery to all appropriate patients with early-stage operable disease.2
Following surgical removal of pancreatic cancer, a final “pathologic” stage will be determined. If the cancer cannot be removed by surgery, then the results of the clinical staging evaluation will be used to assign a stage. The following diagnostic procedures may be used in the evaluation of pancreatic cancer.
Imaging tests: Tests such as X-rays, CT scans, magnetic resonance imaging (MRI) and positron emission tomography (PET) are used to help determine the stage and whether the cancer has spread.
Computed Tomography (CT) Scan: A CT scan is a technique for imaging body tissues and organs, during which X-ray transmissions are converted to detailed images, using a computer to synthesize X-ray data. A CT scan is conducted with a large machine positioned outside the body that can rotate to capture detailed images of the organs and tissues inside the body.
Magnetic Resonance Imaging (MRI): MRI uses a magnetic field rather than X-rays, and can often distinguish more accurately between healthy and diseased tissue than a CT. An MRI gives a better picture of cancer located near bone than does CT, does not use radiation, and provides pictures from various angles that enable doctors to construct a three-dimensional image of the cancer.
Positron emission tomography (PET): Positron emission tomography scanning is an advanced technique for imaging body tissues and organs. One characteristic of living tissue is the metabolism of sugar. Prior to a PET scan, a substance containing a type of sugar attached to a radioactive isotope (a molecule that emits radiation) is injected into the patient’s vein. The cancer cells “take up” the sugar and attached isotope, which emits positively charged, low energy radiation (positrons) that create the production of gamma rays that can be detected by the PET machine to produce a picture. If no gamma rays are detected in the scanned area, it is unlikely that the mass in question contains living cancer cells.
Endoscopic Retrograde Cholangiopancreatography (ERCP): Pancreatic cancers may cause blockage of the pancreatic and biliary ducts and produce jaundice. A gastroenterologist may attempt to relieve jaundice using a special procedure where a scope is passed through the stomach into the area of the blockage. An ERCP can also be used to sample (biopsy) any suspicious lesions in the area.
Endosonography: Endosonography refers to an ultrasound test performed through an endoscope. Ultrasound tests utilize sound waves to detect different densities of tissue, including cancer. Endoscopic ultrasound may be used to determine the size of the cancer and whether surrounding lymph nodes may be enlarged.
Gastroscopy: A gastroscopy is an examination performed through an endoscope, which is a flexible tube inserted through the esophagus that allows the physician to visualize, photograph and biopsy (sample) the cancer. All patients have a gastroscopy with a biopsy to determine the histology or appearance of the cancer under the microscope.
Laparoscopy: Laparoscopy is a procedure that involves the insertion of an endoscope through a small incision in the abdomen. Laparoscopy is an important tool for staging and has proven to be more reliable than CT scanning in detecting spread of cancer to the liver and the lining of the abdomen (peritoneum).
Stages of Pancreatic Cancer
In order to learn more about the most recent information available concerning the treatment of pancreatic cancer, click on the appropriate stage.
Stage I: Cancer is confined to the pancreas.
Stage II: Cancer may extend to the duodenum, bile ducts, or fat surrounding the pancreas, but does not invade any local lymph nodes.
Stage III: Cancer invades one or more of the local lymph nodes and has extended to major blood vessels.
Stage IV: Cancer has spread to the stomach, bowel, or distant locations in the body, which may include the liver, lungs, bones, or other sites.
Recurrent/Relapsed: The pancreatic cancer has been detected or returned (recurred/relapsed) following an initial treatment.
Genomic or Biomarker Testing-Precision Cancer Medicine
The purpose of precision cancer medicine is to define the genomic alterations in the cancers DNA that are driving that specific cancer so a targeted therapy can be designed to attack a specific mutation or other cancer-related change in the DNA programming of the cancer cells. Patients with pancreatic cancer should undergo genomic biomarker testing for the BRCA gene and other markers because pancreatic can be treated with novel precision cancer medicines.3,4
1 American Cancer Society: Cancer Facts and Figures 2017. Atlanta, Ga: American Cancer Society, 2017..
2 National failure to operate on early stage pancreatic cancer. Annals of Surgery. 2007;246:173-180.
3 Pancreatic Cancer Action. Facts and statistics. Accessed February 2019 from pancreaticcanceraction.org/about-pancreatic-cancer/medical-professionals/stats-facts/facts-and-statistics/