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BCM - Baylor College of Medicine

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The Elkins Pancreas Center

Diagnosis and Staging of Pancreatic Cancer

Radiology

CT SCAN (Computed Tomography)

A CT scan is an X-ray technique that produces images of your body that visualize internal structures in cross section. The detailed images enable your doctor to determine the relationship of a tumor in the pancreas to important surrounding structures like blood vessels and to determine if there is any spread of the tumor to other locations such as the liver or lymph nodes. A high-quality CT scan is currently the best staging modality for pancreas tumors. The CT scan must be performed on a high quality machine using a technique specifically designed to accurately stage pancreatic cancer. For this reason, you may need to have a CT scan repeated at The Elkins Pancreas Center.

MRI (Magnetic Resonance Imaging)

Abdominal MRI is a noninvasive test that uses powerful magnets and radio waves to create pictures of the inside of the abdomen. It does not use radiation (x-rays). The images can sometimes be complementary to those obtained from CT scans. The MRI can provide excellent views of the bile duct and pancreatic duct and is sometimes used to clarify findings seen on CT imaging.

EUS (Endoscopic Ultrasound)

You may associate ultrasound images with a developing fetus. But ultrasound is used in many areas of medicine. Ultrasound examination, also called diagnostic medical sonography or sonography, is an imaging method that uses high-frequency sound waves to produce images of structures within your body.

Endoscopic ultrasound (EUS) for the evaluation of the pancreas involves passing a thin, flexible tube (endoscope) through a patient's mouth. A small ultrasound transducer at the tip of the endoscope produces sound waves that create a viewable image of surrounding tissue. Physicians can use EUS to examine the lining and walls of the upper gastrointestinal tract and nearby pancreas and blood vessels around the pancreas.

When combined with fine-needle aspiration, EUS is a minimally invasive, state-of-the-art alternative to exploratory surgery to remove tissue samples from the pancreas. Physicians can also use EUS to guide injections of therapeutic agents into pancreatic tumors.

ERCP (Endoscopic Retrograde Cholangiopancreatography)

ERCP is used primarily to diagnose and treat conditions of the bile ducts and pancreas. ERCP combines the use of x-rays and an endoscope, which is a long, flexible, lighted tube. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on x-rays.

The scope is guided through your esophagus, stomach, and duodenum until it reaches the spot where the ducts of the biliary tree and pancreas open into the duodenum. A small plastic tube is passed through the scope and used to inject a dye into the ducts to make them show up clearly on x-rays. X-rays are taken as soon as the dye is injected. At the Elkins Pancreas Center, gastroenterologists have special equipment and the ability to pass a tiny endoscope through the standard size endoscope. The tiny endoscope can be advanced into the bile duct or pancreatic duct to directly visualize a narrowing or blockage.

If the exam shows narrowing of the ducts, biopsies can be taken and a stent can be placed to temporarily relieve the obstruction.

Staging

When the physicians talk about staging, they are referring to determining the size of the tumor and if it has spread or not. This information is then used to determine the best treatment. In the case of pancreatic cancer, the size of the tumor and whether or not it involves important blood vessels determines if it can be surgically removed. Pancreatic cancer is staged on the TNM system (also called tumor - node - metastasis system). This describes the size of the tumor (T), if the lymph nodes are involved (N), and if it has spread to other areas of the body (M).

  • Tis: "In situ"
  • T1: Tumor confined to the pancreas, 2 cm or less
  • T2: Tumor confined to the pancreas, greater than 2 cm
  • T3: Tumor extending beyond the pancreas, but not involving the superior mesenteric artery or celiac axis
  • T4: Tumor involves the superior mesenteric artery or celiac axis
  • T4: Tumor involves the superior mesenteric artery or celiac axis
  • N0: No lymph node involvement
  • N1: Lymph nodes are positive for cancer
  • M0: No distant metastases
  • M1: Distant metastases are present.
Characteristics of Various Stages

Stage

Tumor

Node

Metastasis

Stage 0

Tis

N0

M0

Stage IA

T1

N0

M0

Stage IB

T2

N0

M0

Stage IIA

T3

N0

M0

Stage IIB

T1

N1

M0

Stage IIB

T2

N1

M0

Stage IIB

T3

N1

M0

Stage III

T4

Any N

M0

Stage IV

Any T

Any N

M1