Pancreatic Cancer Diagnosis and Staging

November 22, 2024

This page was reviewed under our medical and editorial policy by Laleh Melstrom, M.D., M.S., associate professor of surgery and immuno-oncology, Division of Surgical Oncology, Department of Surgery, City of Hope^® Cancer Center Duarte

The pancreas is located deep within the body, making it difficult to detect early tumors during a routine physical exam. Additionally, there are no reliable screening options for pancreatic cancer, so it tends to be diagnosed at later stages when the cancer has grown and spread.

Tests to Diagnose Pancreatic Cancer

Various tests are used to diagnose and stage pancreatic cancer. If a doctor suspects that pancreatic cancer may be present, one or more of these tests may be used.

Imaging Tests

The following imaging tests may be used to diagnose and stage cancer, and also to look for cancer recurrence and measure how the cancer is responding to treatment.

Ultrasound: Using high-energy sound waves, an ultrasound allows doctors to obtain images of internal areas of the body.

• An abdominal ultrasound is often the first test performed if pancreatic cancer is suspected. A technician presses a device called a transducer against the abdomen, which produces sound waves. This creates an image of the abdominal area.
• An endoscopic ultrasound is used for both diagnosing and staging pancreatic cancer. Patients are given light sedation before the procedure so they do not feel discomfort. A long, thin, flexible device called an endoscope is inserted into the rectum or mouth. The endoscope has a probe that bounces sound waves off internal organs to create an image.

Computed tomography (CT) scan: This procedure uses X-rays and computers to obtain detailed, cross-sectional images of the body. CT scans aid with diagnosis and staging and help doctors see if cancer has spread to other areas of the body.

• In some instances, a contrast dye may be injected or swallowed prior to the CT scan, as this results in more detailed images.
• A CT scan may also be performed at the same time as a positron emission tomography (PET) scan. In a PET scan, a small amount of radioactive glucose is injected into a vein. Because cancer cells consume more glucose than normal cells, this allows cancer cells to show up more clearly on an imaging scan.

Magnetic resonance imaging (MRI): Radio waves and strong magnets are used to take images of the body. MRI tests are not as commonly used for pancreatic cancer; however, an MRI may be used to see if the cancer has spread.

Cholangiopancreatography: This procedure helps doctors look at the pancreatic bile ducts to determine if a tumor is blocking a duct. This helps doctors develop an optimal treatment plan.

There are several types of cholangiopancreatographies:

Endoscopic retrograde cholangiopancreatography (ERCP): This procedure uses both an upper gastrointestinal endoscopy and X-rays to examine the pancreatic ducts and bile. It may be performed when the ducts are blocked or leaking and doctors want to determine if this is due to cancer or another cause. During the procedure, a biopsy may be taken or a stent put in place to help keep a duct open.

Percutaneous transhepatic cholangiography (PTC): This is less commonly used for pancreatic cancer. During a PTC, a thin, hollow needle is inserted through the skin of the abdomen and into the bile duct. Contrast dye, inserted through the needle, allows doctors to obtain clear X-ray images. During the procedure, a biopsy may be taken or a stent put into place. 

Magnetic resonance cholangiopancreatography (MRCP): This is a noninvasive procedure that allows doctors to obtain images of the pancreas.

Blood Tests for Pancreatic Cancer

Blood tests may be used to assist with diagnosis and to check a patient’s health, which is useful in determining which treatment options are most suitable.

Blood tests used for pancreatic cancer may include the following.

Tumor marker testing: This type of blood test measures small amounts of genetic material, known as microRNA, released by cancer tumors. Most often, this test looks for a type of protein called CA 19-9 and, less frequently, another protein type called carcinoembryonic antigen (CEA).

While these tests assist with early-stage pancreatic cancer diagnosis, elevated levels of CA 19-9 and CEA may also be present without cancer.

Liver functionality testing: Measuring the liver’s functions helps doctors look for jaundice, an early sign of pancreatic cancer. Blood tests measure levels of bilirubin, a chemical produced by the liver, which helps doctors identify the cause.

Complete blood count (CBC): This may be used to gauge a patient’s general health before deciding on treatment options.

Pancreas Biopsy

During a biopsy, a tissue sample is removed from the body and examined under a microscope to look for cancer cells. This is the only definitive way to diagnose pancreatic cancer.

A biopsy may be performed in several different ways.

Fine needle aspiration: A small, hollow needle is inserted through the skin, guided by the results of imaging tests, and a small sample of tissue is removed.

Endoscopic: Doctors pass a thin tube with a camera at the end down the throat and remove a tissue sample.

Surgery: During a laparoscopy, a surgery used to look for disease within the organs, a tissue sample may be removed. Surgical biopsies are not common, but may be used in tumors that have spread beyond the pancreas.

Genetic Testing

For patients already diagnosed, genetic testing may help doctors understand the tumor’s makeup. This information helps to guide an optimal treatment plan.

In patients with a family history of pancreatic cancer, genetic testing may be used to look for certain hereditary conditions that may increase a person’s risk for the disease. These include hereditary breast and ovarian cancers and other inherited syndromes.

Pancreatic Cancer Screening

Screening all adults for pancreatic cancer is not recommended, as this cancer is difficult to detect early and screening has not been shown to impact survival rates.

However, for patients who have an increased risk due to family history or inherited genetic conditions, more frequent testing may be recommended. This may include regular imaging tests, including MRIs and ultrasounds.

If patients are concerned about their risk of developing pancreatic cancer, they should talk with their doctor to learn more.

Pancreatic Cancer Stages

Staging is a measure of a cancer’s size, location in the body and whether it has spread to other areas. Understanding a cancer’s stage also helps doctors in determining an optimal treatment plan for each patient.

Pancreatic cancer is staged using the American Joint Committee on Cancer (AJCC) TNM system. TNM stands for the following.

Tumor (T): This considers the size of the tumor and whether it has spread beyond the pancreas.

Lymph nodes (N): This considers whether the cancer has spread into the lymph nodes and, if so, how many lymph nodes are affected.

Metastasized (M): This considers whether the cancer has spread into distant areas of the body, which may include the lungs, bones and liver.

Stage 0

Also called carcinoma in situ, abnormal cells are present in the pancreas. These cells are considered precancerous because they may develop into cancer later on. Stage 0 pancreatic cancer is only found in the pancreas.

Stage 1

Stage 1 pancreatic cancer has two subtypes, depending on the tumor’s size. In both subtypes, Stage 1 cancer is confined to the pancreas and has not spread to other areas of the body.

1a: The tumor is less than 2 centimeters (cm) in size.

1b: The tumor is between 2 and 4 cm in size.

Stage 2

Stage 2 pancreatic cancer has two subtypes.

2a: The tumor is larger than 4 cm, but has not spread beyond the pancreas.

2b: The tumor may be any size and has spread into one to three nearby lymph nodes. The cancer is otherwise still within the pancreas.

Stage 3

The tumor is larger than 4 cm and has spread to at least four nearby lymph nodes. Or, it is growing into major blood vessels near the pancreas and possibly to nearby lymph nodes.

Stage 4

In Stage 4 pancreatic cancer, the cancer cells have spread to distant areas of the body, such as the liver, lungs, bones or the abdominal cavity lining. The cancer may be any size and may or may not have spread into nearby lymph nodes.

Unresectable Versus Resectable

Doctors may use the terms resectable and unresectable to describe a patient’s pancreatic cancer.

Resectable describes a tumor that is contained within the pancreas and has not spread into the vascular system or blood vessels. A resectable tumor is usually able to be surgically removed.

A borderline resectable tumor may be able to be removed with surgery, but not always. It may have spread into nearby areas of the body, and the surgery is likely to be more complex. It may also require chemotherapy or radiation therapy prior to surgery, which may help reduce the tumor’s size and make it easier to remove.

If a pancreatic tumor is unresectable, this means the cancer is unable to be completely removed by surgery due to its size and/or location. This could be because it is locally advanced, having spread into nearby blood vessels, or it could have metastasized and spread into distant areas of the body.