Diagnosing Pancreatic Cancer

Doctors at NYU Langone’s Perlmutter Cancer Center provide expert care for people with pancreatic cancer, which develops in the cells of the pancreas, a flat, oblong gland located behind the stomach. The pancreas has two major functions: It produces enzymes that help you digest food, and it makes important hormones such as insulin, which regulates blood sugar. 

Most pancreatic cancers arise in the cells that create digestive enzymes, or the exocrine cells. These tumors are known as pancreatic adenocarcinomas. Rarely, tumors form in the cells that produce hormones, or the endocrine cells. These tumors are called pancreatic neuroendocrine neoplasms.

Symptoms

People with early pancreatic cancer usually experience no obvious symptoms. As a result, the condition is often diagnosed when it’s advanced. The symptoms that eventually develop often depend on the location of the cancer. 

The organ can be divided into three sections: the head, the body, and the tail. Many pancreatic cancers develop in the head, or the rounded top portion of the organ. That’s where a tube-like structure called the common bile duct passes through the pancreas. This duct carries bile from the liver to the small intestine, where it aids in the breakdown and absorption of food.

The pancreatic duct, which carries digestive enzymes produced by the exocrine cells in the pancreas, joins the common bile duct as it enters the small intestine, at an opening called the ampulla of Vater. 

Tumors in the head of the pancreas can grow large enough to block the common bile duct. When this occurs, bile backs up in the liver and enters the bloodstream. Eventually, this results in jaundice, which leads to symptoms such as yellowing of the skin and eyes, dark urine, light colored stools, and itching. You may also experience nausea and vomiting. 

Tumors in the body, or middle portion, and tail of the pancreas may cause abdominal pain that radiates to the back and worsens after eating.

Sometimes, pancreatic cancer can cause the organ to become inflamed, a condition called pancreatitis. If a tumor has damaged most of the pancreas, it may not be able to produce insulin, which can lead to diabetes. 

Risk Factors

There are a number of risk factors for developing pancreatic cancer. Obesity or being overweight as well as having a diet high in fat content are important factors. NYU Langone’s Weight Management Program can help you to achieve your weight goals.

A history of pancreatitis can also increase your risk. This condition can be caused by gallstones, alcohol abuse, and, sometimes, the use of certain medications. There are also genetic causes for pancreatitis.

Smoking cigarettes and using other forms of tobacco also increase the risk of pancreatic cancer. Doctors at NYU Langone urge people to quit smoking. Our doctors know how difficult this can be. The specialists at NYU Langone’s Tobacco Cessation Programs can help you every step of the way. 

Other risk factors for pancreatic cancer include being older than age 60, being African American, having a close relative who’s had pancreatic cancer, being male, and having certain genetic syndromes. 

Genetic syndromes that increase the risk of pancreatic cancer include hereditary breast and ovarian cancer, familial melanoma, and hereditary nonpolyposis colorectal cancer, which is also known as Lynch syndrome. Peutz–Jeghers syndrome and von Hippel–Lindau syndrome also increase a person’s chance of developing pancreatic cancer.

Pancreatic neuroendocrine tumors can also be caused by genetic syndromes, such as neurofibromatosis type 1 and multiple endocrine neoplasia type 1. NYU Langone specialists carefully monitor people with these genetic conditions for the development of pancreatic tumors.

Our doctors also monitor people with pancreatic cysts, which are fluid-filled structures or sacs that develop in this organ. These cysts may be identified on imaging studies performed for other reasons. Although most cysts are benign and never turn into cancer, some can become malignant. At NYU Langone, our doctors create individualized monitoring plans for people with these cysts.

To diagnose pancreatic cancer, an NYU Langone doctor may ask about your symptoms, take a medical history, and perform several tests.

CT Scans

A CT scan uses X-rays to create cross-sectional, three-dimensional images of the body. NYU Langone radiologists use a special CT scan protocol to view the pancreas and to detect cancer.

Before the exam, you are given a contrast agent, which is taken by mouth, to highlight and distinguish the intestines from the pancreas and to see if cancer has spread there. In addition, a contrast dye is given through a vein. As it travels through the pancreas, the doctor takes pictures at three different times. 

A pancreatic protocol CT scan produces images of thin cross sections, or “slices,” of the organ, enabling doctors to detect pancreatic cancer. The test also helps determine if cancer has spread to nearby blood vessels and organs, such as the stomach and spleen. Pancreatic cancer may also spread to the lymph nodes, which are immune system glands that trap viruses and bacteria, helping to fight infection.

If pancreatic cancer is present, this test helps our team to determine whether surgery is an option. Surgery may not be possible if the tumor has invaded the portal vein or the hepatic artery, both of which carry blood to the liver, and the mesenteric blood vessels, which carry blood to and from the intestines. The extent of tumor involvement with these vessels determines whether our surgeons can remove parts of these blood vessels and reconstruct them. 

MRI Scans

If a pancreatic protocol CT scan does not provide enough detail of the pancreas and surrounding organs, your doctor may order an MRI scan. This test uses a magnetic field and radio waves to create computerized, three-dimensional images of the organs. A contrast agent is usually injected into a vein to enhance the images. 

MRI scans can sometimes highlight tumors that CT scans cannot. For this reason, both tests may be used to offer the complementary information needed to diagnose and treat people with pancreatic cancer. 

Endoscopic Ultrasound with Biopsy

Endoscopic ultrasound may be used to detect pancreatic cancer or to obtain a biopsy of a tumor. This test uses sound waves to create images that are viewed on a computer monitor. It’s performed with a flexible endoscope, a thin tube with an ultrasound probe on the end of it, called an echoendoscope. 

The echoendoscope is placed in a person’s mouth after he or she has been sedated. The doctor moves the endoscope into the stomach and the first part of the small intestine, called the duodenum. This allows the doctor to see the pancreas and deep layers of the upper gastrointestinal tract.

An endoscopic ultrasound enables a doctor to detect small tumors that other imaging methods may miss. If the doctor finds a tumor, he or she can place a small needle through the endoscope to conduct a biopsy, in which a collection of cells is removed and analyzed under a microscope for signs of cancer. 

Endoscopic Retrograde Cholangiopancreatography 

If a person has jaundice and the doctor suspects a tumor may be blocking the bile duct, he or she may perform an endoscopic retrograde cholangiopancreatography.

This procedure creates a picture of the bile duct and the pancreatic duct with the assistance of fluoroscopy, a special X-ray. During the procedure, physicians place an endoscope into the mouth and pass it into the small intestine to identify the ampulla of Vater, the place where the common bile duct and pancreatic duct join and empty into the small intestine. 

A doctor places a small tube called a catheter into the ampulla of Vater and injects a contrast agent. It enhances X-ray images of the pancreatic and bile ducts and helps the doctor determine whether a tumor may be blocking them. If a tumor is identified, a doctor uses a small brush to collect cell samples from the ducts to examine under a microscope for signs of cancer. 

If necessary, a doctor may place a plastic or metal device called a stent into a duct that’s blocked by a tumor. The stent opens the duct and allows bile to flow into the intestine, relieving the symptoms of jaundice. 

Magnetic Resonance Cholangiopancreatography

If a person has jaundice, a doctor may recommend a magnetic resonance cholangiopancreatography. This test uses an MRI scan to determine whether a tumor is blocking the bile duct. It may be conducted at the same time as a standard MRI.

The test produces detailed images of the complex structure of the bile ducts that other imaging tests may not provide. It does not require a contrast agent or the insertion of an endoscope, and does not allow a doctor to place stents or collect cell samples. 

Blood Tests

An NYU Langone doctor may conduct blood tests to measure tumor markers, substances that are associated with pancreatic cancer. For example, elevated levels of CA 19-9, a protein produced by pancreatic cancer cells, may indicate the presence of a tumor.

However, not everyone with pancreatic cancer has elevated CA 19-9 levels. An elevated level may indicate a noncancerous condition, such as pancreatitis. 

CA 19-9 levels often drop after treatment for pancreatic cancer. For this reason, measurements may be used to assess the effect of therapy immediately after treatment and during follow-up care.

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