Diagnostic Workup for Pancreatic Cancer

George Kim, MD:The diagnostic workup for patients with pancreatic cancer will start with how they present. So, for our patient, he presents with liver enzyme abnormality. His bilirubin must be greater than 3 mg/dL because he’s jaundiced. We’ll start with simple chemistry—complete blood count—seeing whether or not he’s anemic. Does he have leukocytosis in reaction to the tumor? And then, we’ll move on to additional blood work that might include tumor marker, CEA, and CA 19-9.

Just a note on CA 19-9, it’s not a great screening test. It depends on the patient having a Lewis antigen. If they don’t have a Lewis antigen, they will not express CA 19-9. So, many times, we’re left with the quandary of: “You’ve got a mass in the pancreas, lesions in the liver, but the CA 19-9 is normal.” It’s because the patient does not have a Lewis antigen, and so that’s why their CA 19-9 can be a little confusing. It’s not carcinoma, a known primary, it really is metastatic pancreatic cancer.

What other diagnostic studies are performed? Well, we move on to our imaging evaluations. We do a CAT scan ideally with IV and oral contrast. Sometimes you won’t see the mass in the pancreas and you’ll have to do a pancreas-dedicated CAT scan, which takes more slices through the pancreas and really delineates what is normal and what is abnormal in the pancreas. Many institutions will do MRIs; again, really getting a close look at the pancreas. And then, obviously, we’re looking at the liver, we’re looking at the lungs, and we’re also trying to look at the peritoneum for metastases.

Other imaging studies are PET scans. I think PET scans are useful in the very beginning, especially when we’re trying to find out if the patient is resectable and trying to find occult metastases. So, PET scans are useful in the diagnostic evaluation. It may not be so great in terms of restaging patients. Other diagnostic procedures are endoscopic ultrasounds, where our gastroenterologists get involved. They go down into the stomach, look at the pancreas, and are able to retrieve tissue. ERCPs are important for symptom relief and also to get some brushing. And then, we move on to other studies with more advanced evaluations, especially if we don’t have a diagnosis or we can’t get tissue. Ideally, if you do have a patient with metastatic liver disease, you go after a biopsy of a lesion in the liver. Those are most easily approachable from a percutaneous approach. And so, those are some of the diagnostic studies that we’ll do in the very beginning.

So, an additional diagnostic evaluation is whether or not to do a laparoscopic evaluation, and that’s really for patients who you’re considering to resect or potentially you believe have curable disease. That’s a great way for the surgeons to assess if there is a peritoneal disease that’s not picked up on imaging and enables us to really, fully stage the patient. And obviously, if there is something that they detect, they can go in and biopsy it.

Transcript edited for clarity.

March 2016

• A 63-year-old Caucasian male was admitted to the hospital from the emergency room with symptoms of epigastric pain that radiated toward the back, abdominal distention, vomiting, and jaundice
• Laboratory tests:
  • Bilirubin and liver enzymes; elevated
  • CBC values WNL
  • Hepatitis B, & C testing, negative
  • CEA: 34.2 ng/mL; CA 19-9 > 12000 U/mL
• Performance status, 1
• CT reveals 3.5 cm × 3.7 cm mass in the head of the pancreas and multiple liver nodules; also, indicates an obstruction of the bile duct
• Ultrasound-guided percutaneous needle biopsy of a liver metastases shows adenocarcinoma histology
• The patient undergoes biliary stent placement based on endoscopic retrograde cholangiopancreatogram (ERCP) findings
• Diagnosis: stage IV pancreatic cancer with liver metastasis
• The patient was started with treatment on gemcitabine andnab-paclitaxel
• CT with contrast after two treatment cycles showed marked shrinkage of the pancreatic lesion and liver nodules.
• CT after 6 cycles showed stable disease

November 2016

• The patient reports symptoms of rapid weight loss, abdominal pain, dark urine, and jaundice; he has declining functional status and is often bedridden
• Systemic therapy is under consideration