Diagnosis & Staging of Pancreatic Cancer

The diagnosis and The diagnosis and staging of Pancreatic staging of Pancreatic

CancerCancerVino J. Verghese, M.DVino J. Verghese, M.D

Gastroenterology Consultants of Gastroenterology Consultants of the Peninsulathe Peninsula

Pancreatic CancerPancreatic Cancer

Fourth leading cause of cancer related Fourth leading cause of cancer related deathdeath

Surgery offers the only chance of a cureSurgery offers the only chance of a cure Only 15-20% of patients are candidates Only 15-20% of patients are candidates

for surgeryfor surgery 5 year survival after a Whipple resection5 year survival after a Whipple resection

30% for node negative disease30% for node negative disease

10% for node positive disease10% for node positive disease


Recent data suggests that survival may Recent data suggests that survival may be improvingbe improving

One of the strongest predictors for One of the strongest predictors for increased survival on recent studies has increased survival on recent studies has been the use of adjuvant chemoradiation been the use of adjuvant chemoradiation therapytherapy

Three year survival was significantly Three year survival was significantly higher among those who received higher among those who received chemoradiation (45% vs. 30%) compared chemoradiation (45% vs. 30%) compared to those who did notto those who did not

Risk FactorsRisk Factors

Hereditary (5-10%) Hereditary (5-10%) SmokingSmoking DiabetesDiabetes Chronic pancreatitis, Hereditary Chronic pancreatitis, Hereditary

pancreatitispancreatitis ?Alcohol ?Coffee?Alcohol ?Coffee ?Obesity/High fat diet?Obesity/High fat diet -Aspirin-Aspirin

Surveillance for High Surveillance for High RiskRisk

Not yet proven to improve survivalNot yet proven to improve survival Screening begins 10 years before Screening begins 10 years before

the age at which the diagnosis was the age at which the diagnosis was made made

AGA recommends CT and EUSAGA recommends CT and EUS ?CA 19-9?CA 19-9 ?MRI?MRI ?ERCP?ERCP

Clinical FeaturesClinical Features

PainPain JaundiceJaundice Weight lossWeight loss SteatorrheaSteatorrhea New onset DiabetesNew onset Diabetes Acute pancreatitisAcute pancreatitis ThrombophlebitisThrombophlebitis

Physical FindingsPhysical Findings

Abdominal massAbdominal mass Enlarged nontender gallbladderEnlarged nontender gallbladder Virchows nodeVirchows node AscitesAscites Hypercoaguable stateHypercoaguable state

Lab FindingsLab Findings

Abnormal LFTsAbnormal LFTs Tumor markers (CEA)Tumor markers (CEA) Sensitivity and Specificity of 80%Sensitivity and Specificity of 80% Sensitivity is limited in small potentially Sensitivity is limited in small potentially

resectable tumorsresectable tumors Not recommended for screeningNot recommended for screening Values >37U/ml useful for Values >37U/ml useful for

discriminating benign from malignant discriminating benign from malignant causescauses

Lab Findings (CEA)Lab Findings (CEA)

Not recommended as an indicator of Not recommended as an indicator of OperabilityOperability

Serial monitoring at 3 month Serial monitoring at 3 month intervals is recommended in post-op intervals is recommended in post-op patients and in those with patients and in those with unresectable disease receiving unresectable disease receiving chemo-radiation therapychemo-radiation therapy

Differential DiagnosisDifferential Diagnosis

Chronic pancreatitisChronic pancreatitis Neuro-endocrine tumorsNeuro-endocrine tumors Auto-immune pancreatitisAuto-immune pancreatitis LymphomaLymphoma

DiagnosisDiagnosis

Transabdominal ultrasound, CT scan, Transabdominal ultrasound, CT scan, MRI, ERCP and EUS are the modalities MRI, ERCP and EUS are the modalities most commonly usedmost commonly used

Contrast enhanced helical CT is the Contrast enhanced helical CT is the preferred method to diagnose and stage preferred method to diagnose and stage Pancreatic CancerPancreatic Cancer

CT is useful for detecting metastasis CT is useful for detecting metastasis and for determining resectabilityand for determining resectability

EUS is most useful for T staging as well EUS is most useful for T staging as well as for determining vascular involvementas for determining vascular involvement

Diagnosis (cont.)Diagnosis (cont.)

PET scanning is useful for detecting PET scanning is useful for detecting occult metastatic diseaseoccult metastatic disease

US, ERCP, MRI and MRCP are also US, ERCP, MRI and MRCP are also useful in the diagnosisuseful in the diagnosis

Criteria of Criteria of UnresectabilityUnresectability

Distant MetastasisDistant Metastasis Extrapancreatic involvementExtrapancreatic involvement Vascular involvementVascular involvement Encasement of SMV Encasement of SMV Involvment of SMA, Aorta, Celiac Involvment of SMA, Aorta, Celiac

Axis, Hepatic arteryAxis, Hepatic artery Borderline ResectabilityBorderline Resectability

Staging of Pancreatic Staging of Pancreatic CancerCancer

T1: Tumor limited to pancreas <2cmT1: Tumor limited to pancreas <2cm T2: Tumor limited to pancreas >2cmT2: Tumor limited to pancreas >2cm T3: Tumor extends beyond pancreas T3: Tumor extends beyond pancreas

without involvment of CA or SMAwithout involvment of CA or SMA T4: Tumor involves CA or SMAT4: Tumor involves CA or SMA N1: Regional lymph node metastasisN1: Regional lymph node metastasis M1: Distant metastasisM1: Distant metastasis

Helical CT for StagingHelical CT for Staging

Arterial and Portal venous phaseArterial and Portal venous phase Diagnostic test of choice for Pre-Diagnostic test of choice for Pre-

operative Stagingoperative Staging High Predictive value for High Predictive value for

unresectability (90%)unresectability (90%) 65-90% Predictive value for 65-90% Predictive value for

resectabilityresectability

Endoscopic UltrasoundEndoscopic Ultrasound

Pancreatic CystPancreatic Cyst

Pancreatic cystPancreatic cyst

EUS for stagingEUS for staging

T stage accuracy as high as 80-95% T stage accuracy as high as 80-95% N stage accuracy as high as 80% N stage accuracy as high as 80% Diagnostic accuracy of EUS is further Diagnostic accuracy of EUS is further

enhanced by the ability to perform enhanced by the ability to perform needle biopsies of pancreatic lesions needle biopsies of pancreatic lesions with a sensitivity >90%with a sensitivity >90%

Accuracy of staging is operator Accuracy of staging is operator dependent (increases with staging dependent (increases with staging >100 tumors)>100 tumors)

StagingStaging

Dual phase helical CT is routinely Dual phase helical CT is routinely performed as the first step performed as the first step

EUS is most useful in patients with EUS is most useful in patients with equivocal findings on CT scan and those equivocal findings on CT scan and those with potentially resectable disease with potentially resectable disease

EUS can be used to assess for the EUS can be used to assess for the presence of metastatic lymph nodes as presence of metastatic lymph nodes as well as to obtain a tissue diagnosis when well as to obtain a tissue diagnosis when needed needed

EUS Guided BiopsyEUS Guided Biopsy

Fine needle aspiration with a 22 guage Fine needle aspiration with a 22 guage needle is most commonly employedneedle is most commonly employed

EUS guided Trucut biopsy is also EUS guided Trucut biopsy is also availableavailable

Biopsy helps to differentiate between Biopsy helps to differentiate between adenocarcinomas, lymphomas and adenocarcinomas, lymphomas and neuroendocrine tumors neuroendocrine tumors

Most patients want to know the diagnosis Most patients want to know the diagnosis before undergoing surgical resection before undergoing surgical resection

Neuroendocrine tumorNeuroendocrine tumor

Peripancreatic nodePeripancreatic node

Celiac nodesCeliac nodes

Celiac BlockCeliac Block

ConclusionsConclusions Although surgery offers the only chance of Although surgery offers the only chance of

a cure in Pancreatic cancer, survival may a cure in Pancreatic cancer, survival may be improved with use of adjuvant be improved with use of adjuvant chemoradiationchemoradiation

CT is useful for detecting metastasis and CT is useful for detecting metastasis and for determining resectabilityfor determining resectability

EUS is most useful for T staging as well as EUS is most useful for T staging as well as for determining vascular involvementfor determining vascular involvement

EUS can be used to assess for the presence EUS can be used to assess for the presence of metastatic lymph nodes as well as to of metastatic lymph nodes as well as to obtain a tissue diagnosis when neededobtain a tissue diagnosis when needed

Diagnosis & Staging of Pancreatic Cancer

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