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There may be mild anemia Glycosuria, hyperglycemia, and impaired glucose tolerance or true diabetes mellitus are found in 10 20% of cases The serum amylase or lipase level is occasionally elevated Liver biochemical tests may suggest obstructive jaundice Steatorrhea in the absence of jaundice is uncommon Occult blood in the stool is suggestive of carcinoma of the ampulla of Vater (the combination of biliary obstruction and bleeding may give the stools a distinctive silver appearance) CA 19-9, with a sensitivity of 70% and a specificity of 87%, has not proved sensitive enough for early detection of pancreatic cancer; increased values are also found in acute and chronic pancreatitis and cholangitis Point mutations in codon 12 of the K-ras oncogene are found in 70 100%, and inactivation of the tumor suppressor genes P16 on chromosome 9, TP53 on chromosome 17, and MADH4 on chromosome 18 is found in 95%, 75%, and 55% of pancreatic cancers, respectively
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Ultrasound is not reliable because of interference by intestinal gas Multiphase thin-cut helical CT scanning is generally the initial diagnostic procedure and detects a mass in over 80% of cases CT scanning identifies metastases, delineates the extent of the tumor, and allows for percutaneous FNA for cytologic studies and tumor markers MRI is an alternative to CT scanning Preliminary experience suggests that PET is a sensitive technique for detecting pancreatic cancer and metastases Selective celiac and superior mesenteric arteriography may demonstrate vessel invasion by tumor, a finding that would interdict attempts at surgical resection, but it is less widely used since the advent of multiphase helical CT Endoscopic ultrasonography is more sensitive than CT scanning for detecting pancreatic cancer and equivalent to CT scanning for determining nodal involvement and resectability A normal endoscopic ultrasound excludes pancreatic cancer Endoscopic ultrasonography may also be used to guide FNA for tissue diagnosis and tumor markers Endoscopic retrograde cholangiopancreatography (ERCP) may clarify an ambiguous CT scan or MRI study by delineating the pancreatic duct system or confirming an ampullary or biliary neoplasm In patients with bile duct obstruction, preoperative endoscopic placement of a biliary stent does not appear to reduce operative mortality or morbidity Magnetic resonance cholangiopancreatography (MRCP) appears to be at least as sensitive as ERCP in diagnosing pancreatic cancer In some centers, pancreatoscopy or intraductal ultrasonography can be used to evaluate filling defects in the pancreatic duct and assess resectability of intraductal papillary mucinous tumors With obstruction of the splenic vein, splenomegaly or gastric varices are present, the latter delineated by endoscopy, endoscopic ultrasonography, or angiography Cystic neoplasms can be distinguished by their appearance on CT, endoscopic ultrasonography, and ERCP and features of the cyst fluid on gross and cytologic analysis For example, serious cystadenomas may have a central scar or honeycomb appearance; mucinous cystadenomas are unilocular or multilocular and contain mucin-rich fluid with high carcinoembryonic antigen levels; and intraductal papillary mucinous neoplasms are associated with a dilated pancreatic duct and extrusion of gelatinous material from the ampulla Staging of pancreatic cancer by the TNM classification includes the following definitions: Tis: carcinoma in situ; T1: tumor limited to the pancreas, 2 cm or less in greatest dimension; T2: tumor limited to the pancreas, more than 2 cm in greatest dimension; T3: tumor extends beyond the pancreas but without involvement of the celiac axis or the superior mesenteric artery; T4, tumor involves the celiac axis or the superior mesenteric artery (unresectable primary tumor)
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Abdominal exploration is usually necessary when cytologic diagnosis cannot be made or if resection is to be attempted, which includes about 30% of patients In a patient with a localized mass in the head of the pancreas and without jaundice, laparoscopy may detect tiny peritoneal or liver metastases and thereby avoid resection in 4 13% of patients Radical pancreaticoduodenal (Whipple) resection is indi-
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