Challenges in diagnosis of pancreatic cancer

Abstract

Pancreatic cancer is a growing source of cancer related death, yet has poor survival rates which have not improved in the last few decades. Its high mortality rate is attributed to pancreatic cancer biology, difficulty in early diagnosis and the lack of standardised international guidelines in assessing suspicious pancreatic masses. This review aims to provide an update in the current state of play in pancreatic cancer diagnosis and to evaluate the benefits and limitations of available diagnostic technology. The main modalities discussed are imaging with computed tomography, magnetic resonance imaging, endoscopic ultrasound and positron emission tomography and tissue acquisition with fine needle aspiration. We also review the improvements in the techniques used for tissue acquisition and the opportunity for personalised cancer medicine. Screening of high risk individuals, promising biomarkers and common mimickers of pancreatic cancer are also explored, as well as suggestions for future research directions to allow for earlier detection of pancreatic cancer. Timely and accurate diagnosis of pancreatic cancer can lead to improvements in the current poor outcome of this disease.

Keywords: Biomarkers; Challenges; Diagnosis; Endoscopic ultrasound; Imaging; Pancreatic cancer; Pitfalls; Screening.

Figure 1

Algorithm for the evaluation of a patient that has clinical suspicion of pancreatic cancer. ¹Multi-disciplinary review should involve a panel including gastroenterologist, surgeon, medical and or radiation oncologist, diagnostic imaging and pathologist. CT: Computed tomography; MDCT: Multi-detector computed tomography; MRI: Magnetic resonance imaging; EUS: Endoscopic ultrasound; FNA: Fine needle aspiration.

Figure 2

Axial and coronal plane view on computed tomography of a patient with a 2 cm mass in the body of pancreas (blue arrow), abutting splenic artery (red arrow).

Figure 3

Multimodal imaging techniques utilised for a patient with 2.8 cm head of pancreas cancer (blue arrow) with portal vein and superior mesenteric vein invasion. A: Hypodense mass on coronal view on CT; B: T1-weighted coronal view on MRI; C: T1-weighted axial view on MRI; D: MRCP view with dilated CBD and PD (double duct sign); E: Axial view on PET CT imaging showing marked FDG avidity. CT: Computed tomography; MDCT: Multi-detector computed tomography; MRI: Magnetic resonance imaging; PET: Positron emission tomography; MRCP: Magnetic resonance cholangiopancreatography; FDG: Fluorodeoxyglucose.

Figure 4

Endoscopic ultrasound images of (A) a small pancreatic adenocarcinoma in the head of the pancreas (1.8 cm) not seen on other modalities; and (B) a 3.1 cm pancreatic adenocarcinoma in the tail of the pancreas.

Figure 5

Multimodal imaging techniques demonstrating autoimmune pancreatitis in a patient. A: Diffuse enlargement “sausage shape” of the tail axial view on CT; B: Head of the pancreas axial view in arterial phase on MRI; C: Tail of the pancreas T1-weighted axial view on MRI; D: Homogenous restricted diffusion on DWI axial view MRI. CT: Computed tomography; MRI: Magnetic resonance imaging; DWI: Diffusion-weighted imaging.