MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed by the body and then released in a pattern formed by the type of body tissue and by certain diseases. A computer translates the pattern into a detailed image of parts of the body. A contrast material might be injected just as with CT scans, but this is used less often.
Most doctors prefer to look at the pancreas with CT scans, but an MRI can also be done.
Special types of MRI scans can also be used in people who might have pancreatic cancer:
MR cholangiopancreatography (MRCP), which can be used to look at the pancreatic and bile ducts, is described below in the section on cholangiopancreatography.
• MR angiography (MRA), which looks at blood vessels, is mentioned below in the section on angiography.
MRI scans take longer than CT scans – often up to an hour – and are a little more uncomfortable. You may have to lie inside a narrow tube, which is confining and can be distressing to some people. Newer, more open MRI machines may be another option. The MRI machine makes loud buzzing and clicking noises that you might find disturbing. Some places give you headphones or earplugs to help block this noise out.
Ultrasound tests use sound waves to create images of organs such as the pancreas.
Abdominal ultrasound: For this test, a wand-shaped probe called a transducer is moved over the skin of the abdomen. It gives off sound waves and detects the echoes as they bounce off organs. The pattern of echoes is processed by a computer to produce an image on a screen. The echoes made by most pancreatic tumors differ from those of normal pancreas tissue. Different echo patterns can help doctors tell some types of pancreatic tumors from one another.
If it’s not clear what might be causing a person’s abdominal symptoms, an ultrasound might be the first test done because it is easy to do and it doesn’t expose a person to radiation. But if signs and symptoms are more likely to be caused by pancreatic cancer, a CT scan is often more useful for looking at the pancreas than an ultrasound.
Ultrasound is also commonly used to look at the liver, and may be used if someone has symptoms (like jaundice) that point to a liver problem.
Endoscopic ultrasound (EUS): This test is more accurate than abdominal ultrasound and can be very helpful in diagnosing pancreatic cancer. This test is done with a small ultrasound probe on the tip of an endoscope — a thin, flexible tube that doctors use to look at the inside of the digestive tract.
For this test, you will first be sedated (given medicine to make you sleepy). The probe is then passed through your mouth or nose, down through the esophagus and stomach, and into the first part of the small intestine. It is then pointed toward the pancreas, which is next to the small intestine. The probe on the tip of the endoscope can get very close to the pancreas, so this is a very good way to look at the pancreas. It is better than CT scans for spotting small tumors. If a tumor is seen, a small, hollow needle can be passed down the endoscope to get biopsy samples of it during this procedure.
A cholangiopancreatogram is an imaging test that looks at the pancreatic and bile ducts to see if they are blocked, narrowed, or dilated. These tests can help show if someone might have a pancreatic tumor that is blocking a duct. They can also be used to help plan surgery. The test can be done in different ways, each of which has pros and cons.
Endoscopic retrograde cholangiopancreatography (ERCP): For this test, an endoscope (a thin, flexible tube with a tiny video camera on the end) is passed down the throat, through the esophagus and stomach, and into the first part of the small intestine. This is usually done while you are sedated (given medicine to make you sleepy).
The doctor can see through the endoscope to find the ampulla of Vater (where the common bile duct empties into the small intestine). The doctor guides a catheter (a very small tube) through the tip of the endoscope and into the common bile duct. A small amount of dye (contrast material) is then injected into the common bile duct, and x-rays are taken. This dye outlines the bile and pancreatic ducts. The x-ray images can show narrowing or blockage in these ducts that might be due to pancreatic cancer.
The doctor doing this test can also put a small brush through the tube to remove cells for a biopsy (to view under a microscope to see whether or not they look like cancer). ERCP can also be used to place a stent (small tube) into a bile or pancreatic duct to keep it open if a nearby tumor is pressing on it. This is described in more detail in the section on palliative surgery in the “Surgery for pancreatic cancer” section.
Magnetic resonance cholangiopancreatography (MRCP): This is a non-invasive way to look at the pancreatic and bile ducts using the same type of machine used for standard MRI scans. It does not require an infusion of a contrast agent and is not invasive, unlike ERCP. Because it is non-invasive, doctors often use MRCP if the purpose of the test is just to look at the pancreatic and bile ducts. But this test can’t be used to get biopsy samples of tumors or to place stents in ducts.
Percutaneous transhepatic cholangiography (PTC): In this procedure, the doctor places a thin, hollow needle through the skin of the belly and into a bile duct within the liver. A contrast dye is then injected through the needle, and x-rays are taken as it passes through the bile and pancreatic ducts. As with ERCP, this approach can also be used to take fluid or tissue samples or to place a stent into a duct to help keep it open. Because it is more invasive (and might cause more pain), PTC is not usually used unless ERCP has already been tried or can’t be done for some reason.
For a PET scan, a form of radioactive sugar (known as fluorodeoxyglucose or FDG) is injected into the blood. The amount of radioactivity used is very low and will pass out of the body over the next day or so. Because cancer cells in the body grow quickly, they absorb large amounts of the radioactive sugar. After about an hour, you will be moved onto a table in the PET scanner. You lie on the table for about 30 minutes while a special camera creates a picture of areas of radioactivity in the body.
The picture is not finely detailed like a CT or MRI scan, but it can provide helpful information about your whole body. This test is sometimes used to look for spread from exocrine pancreatic cancers, but because NETs grow slowly, they do not show up well on PET scans.
Special machines can do both a PET and CT scan at the same time (known as a PET/CT scan). This lets the doctor compare areas of higher radioactivity on the PET scan with the more detailed appearance of that area on the CT scan. This test can help determine the stage (extent) of the cancer. It might be especially useful for spotting exocrine cancer that has spread beyond the pancreas and wouldn’t be treatable by surgery.
Several types of blood tests can be used to help diagnose pancreatic cancer or to help determine treatment options if it is found.
Liver function tests: Jaundice (yellowing of the skin and eyes) is often one of the first signs of pancreatic cancer, but it can have many causes other than cancer.Doctors often get blood tests to assess liver function in people with jaundice to help determine its cause.
For example, blood tests that look at levels of different kinds of bilirubin (a chemical made by the liver) can help tell whether a patient’s jaundice is caused by disease in the liver itself or by a blockage of bile flow (from a gallstone, a tumor, or other disease).
Tumor markers:Tumor markers are substances that can sometimes be found in the blood when cancer is present. Two tumor markers may be helpful in pancreatic cancer:
CA 19-9 is a substance often released into the blood by exocrine pancreatic cancer cells, although it often can’t be detected until the cancer is already advanced.
Carcinoembryonic antigen (CEA) is another tumor marker that might help find advanced pancreatic cancer in some people, but it is not used as often as CA 19-9.
Other blood tests: Other tests can help evaluate a person’s general health (such as kidney and bone marrow function). These tests can help determine if they’ll be able to withstand the stress of a major operation.
A person’s medical history, physical exam, and imaging test results may strongly suggest pancreatic cancer, but usually the only way to be sure is to remove a small sample of tumor and look at it under the microscope. This procedure is called a biopsy. Biopsies can be done in different ways.
Percutaneous (through the skin) biopsy: For this test, a doctor inserts a thin, hollow needle through the skin over the abdomen and into the pancreas to remove a small piece of a tumor. This is known as a fine needle aspiration (FNA). The doctor guides the needle into place using images from ultrasound or CT scans.
Endoscopic biopsy: Doctors can also biopsy a tumor during an endoscopy. The doctor passes an endoscope (a thin, flexible, tube with a small video camera on the end) down the throat and into the small intestine near the pancreas. At this point, the doctor can either use endoscopic ultrasound (EUS) to pass a needle into the tumor or endoscopic retrograde cholangiopancreatography (ERCP) to remove cells from the bile or pancreatic ducts. These tests are described in more detail above. You will be sedated (made sleepy) for these tests, but general anesthesia (being put into a deep sleep) is not usually needed. Major side effects from these types of biopsies are rare.
Surgical biopsy: Surgical biopsies are now done less often than in the past. They can be useful if the surgeon is concerned the cancer has spread beyond the pancreas and wants to look at (and possibly biopsy) other organs in the abdomen.
The most common way to do a surgical biopsy is to use laparoscopy (sometimes called keyhole surgery). You will be sedated or asleep for this procedure. The surgeon makes several small incisions (cuts) in the abdomen and inserts small telescope-like instruments. One of these has a small video camera on the end to let the surgeon see inside the abdomen. The surgeon can look at the pancreas and other organs for tumors and take biopsy samples of abnormal areas.
In the past, surgeons often used a laparotomy (a large incision through the skin into the wall of the abdomen) to examine internal organs and take biopsies. But this type of surgery requires a longer recovery and is now rarely used.
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