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Pancreatic Cancer:
Diagnostic & Maintenance Tools
Felice Schnoll-Sussman, MD
Jay Monahan Center for Gastrointestinal Health
New York Hospital/ Weill Cornell Medical College
Normal Hepatobiliary Anatomy
An abnormality of the
hepatobiliary system is
suspected...
WHAT IS THE NEXT STEP???
ULTRASOUND
CT SCAN
MRCP
???
MRI
EUS
CA19-9
Ultrasound
Least invasive radiologic technique
 Portable, quick and can guide interventional
procedures
 No ionizing radiation
 High sensitivity for detected dilated bile
ducts and biliary tract obstruction
(obstructive jaundice)
 Very sensitive for differentiating cystic from
solid lesions
 Overlying gas may obscure visualization

Ultrasound (Sonogram)
Patient Preparation
Clear liquid diet for 24 hours prior to exam
 Liquids include clear juices such as apple,
cranberry & grape, clear soups, jello, coffee
or tea. No milk products or carbonated
bevarages

CT SCAN
(Computed Tomography)
Primary imaging study for patients
suspected of having pancreatic lesion
 Thin section dual-phase spiral CT scan
 Obtained during optimal pancreatic arterial
and portal venous enhancement and hepatic
phase

CT (CAT SCAN)
Patient Preparation
Clear liquid diet for 24 hours prior to exam
 Patients with prior reactions to iodinated
contrast or allergic history require
pretreatment medication
 Diabetics: Alert doctor if your are taking
glucophage

ERCP
(Endoscopic Retrograde
Cholangiopancreatography)
Patient Preparation
Nothing by mouth after midnight the
evening before procedure
 No aspirin or nonsteroidal medications one
week before procedure

Pancreatic Cancer
ERCP Tools
Sphincterotome
ERCP Tools
Balloon
ERCP Tools
Stents
ERCP Tools
Wallstent
Normal ERCP
Cystic Duct
Bile Duct
GB
Pancreatic Duct
Pancreatic Cancer
stricture
Balloon Dilatation of Stricture
Diagnostic ERCP
Double duct sign
CBD Stricture
Main PD stricture
Stent
Combined Procedure
PTC
ERCP
Wall Street Journal
October 28, 1981
MRI has arrived ...
What is MRCP?
Magnetic Resonance
Cholangiopancreatography
Well established tool for evaluating the
biliary tree, pancreatic ducts and gallbladder
 Well tolerated
 Role:

– To DIAGNOSE (not treat) diseases of the
biliary and pancreatic ducts
– To avoid invasive procedure risks
– Reduce morbidity
MRCP: Background




MRI of the bile ducts and pancreatic ducts
Relies on radiofrequency, pulse-induced excitation
of protons within a magnetic field to generate an
image
Fluid in the biliary and pancreatic ducts serves as
an intrinsic contrast medium
The ductal systems appear white against the black
background, providing images similar to those of
ERCP
MRI Patient preparation
Inform doctor if you have any of the following:
 Surgical vascular clips
 Neurostimulators
 Cochlear Implants
 Breast Tissue Expander
 History of claustrophobia
 IVC Filter
 Penile Implants
 Pacemaker
 Silver backed dermal patches
MRI Patient Preparation
Do not wear make-up
 Music is available during the examination.
Most centers will allow you to bring your
own tape or CD

Pancreatic cancer - ERCP vs. MRCP
EUS
ENDOSCOPIC ULTRASOUND
EUS TOOLS
EUS TOOLS
EUS TOOLS
Doppler Vessel Identification
EUS
(Endoscopic Ultrasound)
Patient Preparation
Nothing by mouth after midnight the
evening before procedure
 No aspirin or nonsteroidal medications one
week before procedure

Pancreatic Cancer Staging
Primary Tumor (T)
TX Primary Tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor limited to pancreas, 2 cm or less
T2 Tumor limited to pancreas, greater than 2 cm
T3 Tumor extends beyond pancreas, no celiac or SMA involvement
T4 Tumor involves celiac axis or SMA (unresectable primary)
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph nodes
N1 Regional lymph node metastasis
Distant Metastasis (M)
MX Presence of distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
CA 19-9
Tumor marker
 Amongst markers found to have the greatest
sensitivity (70%) and tumor specificity (87%)
 Cutoff value of 70 U/ml
 Can be elevated with biliary tract obstruction
by a noncancerous lesion

The diagnosis is made...
Can you do anything for the pain?
Therapeutic EUS
Celiac Plexus Block
Conclusions
Myriad of well established tools to help
guide diagnosis and management
 Studies are complementary and should be
used together
 Future holds great promise for additional
innovations
