Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer

Carlos Fernandez-del Castillo, MD
Section Editors
Kenneth K Tanabe, MD
Douglas A Howell, MD, FASGE, FACG
Deputy Editors
Diane MF Savarese, MD
Kristen M Robson, MD, MBA, FACG


Cancer of the exocrine pancreas is a highly lethal malignancy. It is the fourth leading cause of cancer-related death in the United States and second only to colorectal cancer as a cause of digestive cancer-related death. (See "Epidemiology and nonfamilial risk factors for exocrine pancreatic cancer", section on 'Epidemiology'.)

Surgical resection is the only potentially curative treatment. Unfortunately, because of the late presentation, only 15 to 20 percent of patients are candidates for pancreatectomy. Furthermore, prognosis is poor, even after a complete resection. Five-year survival after margin-negative (R0) pancreaticoduodenectomy is approximately 30 percent for node-negative and 10 percent for node-positive disease (figure 1) [1]. (See "Overview of surgery in the treatment of exocrine pancreatic cancer and prognosis".)

The clinical presentation, diagnostic evaluation, and staging workup for pancreatic exocrine cancer will be reviewed here. Epidemiology and risk factors, pathology, surgical management, adjuvant and neoadjuvant therapy, and treatment of advanced pancreatic exocrine cancer, including palliative local management, are discussed elsewhere.

(See "Epidemiology and nonfamilial risk factors for exocrine pancreatic cancer".)

(See "Pathology of exocrine pancreatic neoplasms".)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Mar 2017. | This topic last updated: Mar 21, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Allen PJ, Kuk D, Castillo CF, et al. Multi-institutional Validation Study of the American Joint Commission on Cancer (8th Edition) Changes for T and N Staging in Patients With Pancreatic Adenocarcinoma. Ann Surg 2017; 265:185.
  2. Porta M, Fabregat X, Malats N, et al. Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage. Clin Transl Oncol 2005; 7:189.
  3. Modolell I, Guarner L, Malagelada JR. Vagaries of clinical presentation of pancreatic and biliary tract cancer. Ann Oncol 1999; 10 Suppl 4:82.
  4. Kalser MH, Barkin J, MacIntyre JM. Pancreatic cancer. Assessment of prognosis by clinical presentation. Cancer 1985; 56:397.
  5. Bakkevold KE, Arnesjø B, Kambestad B. Carcinoma of the pancreas and papilla of Vater: presenting symptoms, signs, and diagnosis related to stage and tumour site. A prospective multicentre trial in 472 patients. Norwegian Pancreatic Cancer Trial. Scand J Gastroenterol 1992; 27:317.
  6. Furukawa H, Okada S, Saisho H, et al. Clinicopathologic features of small pancreatic adenocarcinoma. A collective study. Cancer 1996; 78:986.
  7. Tsuchiya R, Noda T, Harada N, et al. Collective review of small carcinomas of the pancreas. Ann Surg 1986; 203:77.
  8. Mujica VR, Barkin JS, Go VL. Acute pancreatitis secondary to pancreatic carcinoma. Study Group Participants. Pancreas 2000; 21:329.
  9. Manabe T, Miyashita T, Ohshio G, et al. Small carcinoma of the pancreas. Clinical and pathologic evaluation of 17 patients. Cancer 1988; 62:135.
  10. Holly EA, Chaliha I, Bracci PM, Gautam M. Signs and symptoms of pancreatic cancer: a population-based case-control study in the San Francisco Bay area. Clin Gastroenterol Hepatol 2004; 2:510.
  11. Chari ST, Leibson CL, Rabe KG, et al. Probability of pancreatic cancer following diabetes: a population-based study. Gastroenterology 2005; 129:504.
  12. Aggarwal G, Kamada P, Chari ST. Prevalence of diabetes mellitus in pancreatic cancer compared to common cancers. Pancreas 2013; 42:198.
  13. Khorana AA, Fine RL. Pancreatic cancer and thromboembolic disease. Lancet Oncol 2004; 5:655.
  14. Chen L, Li Y, Gebre W, Lin JH. Myocardial and cerebral infarction due to nonbacterial thrombotic endocarditis as an initial presentation of pancreatic adenocarcinoma. Arch Pathol Lab Med 2004; 128:1307.
  15. Pinzon R, Drewinko B, Trujillo JM, et al. Pancreatic carcinoma and Trousseau's syndrome: experience at a large cancer center. J Clin Oncol 1986; 4:509.
  16. Ostlere LS, Branfoot AC, Staughton RC. Cicatricial pemphigoid and carcinoma of the pancreas. Clin Exp Dermatol 1992; 17:67.
  17. Galvañ VG. Sister Mary Joseph's nodule. Ann Intern Med 1998; 128:410.
  18. Goodman M, Willmann JK, Jeffrey RB. Incidentally discovered solid pancreatic masses: imaging and clinical observations. Abdom Imaging 2012; 37:91.
  19. Stapley S, Peters TJ, Neal RD, et al. The risk of pancreatic cancer in symptomatic patients in primary care: a large case-control study using electronic records. Br J Cancer 2012; 106:1940.
  20. Rose JF, Jie T, Usera P, Ong ES. Pancreaticoduodenectomy for primary pancreatic lymphoma. Gastrointest Cancer Res 2012; 5:32.
  21. Rock J, Bloomston M, Lozanski G, Frankel WL. The spectrum of hematologic malignancies involving the pancreas: potential clinical mimics of pancreatic adenocarcinoma. Am J Clin Pathol 2012; 137:414.
  22. DiMagno EP, Malagelada JR, Taylor WF, Go VL. A prospective comparison of current diagnostic tests for pancreatic cancer. N Engl J Med 1977; 297:737.
  23. Brambs HJ, Claussen CD. Pancreatic and ampullary carcinoma. Ultrasound, computed tomography, magnetic resonance imaging and angiography. Endoscopy 1993; 25:58.
  24. Tanaka S, Kitamra T, Yamamoto K, et al. Evaluation of routine sonography for early detection of pancreatic cancer. Jpn J Clin Oncol 1996; 26:422.
  25. Pasanen PA, Eskelinen M, Partanen K, et al. A prospective study of the value of imaging, serum markers and their combination in the diagnosis of pancreatic carcinoma in symptomatic patients. Anticancer Res 1992; 12:2309.
  26. Pasanen PA, Partanen KP, Pikkarainen PH, et al. A comparison of ultrasound, computed tomography and endoscopic retrograde cholangiopancreatography in the differential diagnosis of benign and malignant jaundice and cholestasis. Eur J Surg 1993; 159:23.
  27. Hessel SJ, Siegelman SS, McNeil BJ, et al. A prospective evaluation of computed tomography and ultrasound of the pancreas. Radiology 1982; 143:129.
  28. Bluemke DA, Cameron JL, Hruban RH, et al. Potentially resectable pancreatic adenocarcinoma: spiral CT assessment with surgical and pathologic correlation. Radiology 1995; 197:381.
  29. Brand R. The diagnosis of pancreatic cancer. Cancer J 2001; 7:287.
  30. Wang W, Shpaner A, Krishna SG, et al. Use of EUS-FNA in diagnosing pancreatic neoplasm without a definitive mass on CT. Gastrointest Endosc 2013; 78:73.
  31. Karlson BM, Ekbom A, Lindgren PG, et al. Abdominal US for diagnosis of pancreatic tumor: prospective cohort analysis. Radiology 1999; 213:107.
  32. Maringhini A, Ciambra M, Raimondo M, et al. Clinical presentation and ultrasonography in the diagnosis of pancreatic cancer. Pancreas 1993; 8:146.
  33. Freeny PC, Marks WM, Ryan JA, Traverso LW. Pancreatic ductal adenocarcinoma: diagnosis and staging with dynamic CT. Radiology 1988; 166:125.
  34. Valls C, Andía E, Sanchez A, et al. Dual-phase helical CT of pancreatic adenocarcinoma: assessment of resectability before surgery. AJR Am J Roentgenol 2002; 178:821.
  35. Bronstein YL, Loyer EM, Kaur H, et al. Detection of small pancreatic tumors with multiphasic helical CT. AJR Am J Roentgenol 2004; 182:619.
  36. Yoon SH, Lee JM, Cho JY, et al. Small (≤ 20 mm) pancreatic adenocarcinomas: analysis of enhancement patterns and secondary signs with multiphasic multidetector CT. Radiology 2011; 259:442.
  37. Nino-Murcia M, Jeffrey RB Jr, Beaulieu CF, et al. Multidetector CT of the pancreas and bile duct system: value of curved planar reformations. AJR Am J Roentgenol 2001; 176:689.
  38. Fulcher AS, Turner MA. MR pancreatography: a useful tool for evaluating pancreatic disorders. Radiographics 1999; 19:5.
  39. Kim JH, Kim MJ, Chung JJ, et al. Differential diagnosis of periampullary carcinomas at MR imaging. Radiographics 2002; 22:1335.
  40. Chen CT, Chiang CL, Huang HH. IgG4-related double duct sign mimicking pancreatic head cancer. QJM 2016; 109:207.
  41. Niederau C, Grendell JH. Diagnosis of pancreatic carcinoma. Imaging techniques and tumor markers. Pancreas 1992; 7:66.
  42. Varghese JC, Farrell MA, Courtney G, et al. Role of MR cholangiopancreatography in patients with failed or inadequate ERCP. AJR Am J Roentgenol 1999; 173:1527.
  43. Adamek HE, Albert J, Breer H, et al. Pancreatic cancer detection with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography: a prospective controlled study. Lancet 2000; 356:190.
  44. Lopez Hänninen E, Amthauer H, Hosten N, et al. Prospective evaluation of pancreatic tumors: accuracy of MR imaging with MR cholangiopancreatography and MR angiography. Radiology 2002; 224:34.
  45. Pleskow DK, Berger HJ, Gyves J, et al. Evaluation of a serologic marker, CA19-9, in the diagnosis of pancreatic cancer. Ann Intern Med 1989; 110:704.
  46. Cwik G, Wallner G, Skoczylas T, et al. Cancer antigens 19-9 and 125 in the differential diagnosis of pancreatic mass lesions. Arch Surg 2006; 141:968.
  47. van den Bosch RP, van Eijck CH, Mulder PG, Jeekel J. Serum CA19-9 determination in the management of pancreatic cancer. Hepatogastroenterology 1996; 43:710.
  48. Paganuzzi M, Onetto M, Marroni P, et al. CA 19-9 and CA 50 in benign and malignant pancreatic and biliary diseases. Cancer 1988; 61:2100.
  49. Malesci A, Tommasini MA, Bonato C, et al. Determination of CA 19-9 antigen in serum and pancreatic juice for differential diagnosis of pancreatic adenocarcinoma from chronic pancreatitis. Gastroenterology 1987; 92:60.
  50. DiMagno EP, Reber HA, Tempero MA. AGA technical review on the epidemiology, diagnosis, and treatment of pancreatic ductal adenocarcinoma. American Gastroenterological Association. Gastroenterology 1999; 117:1464.
  51. Steinberg W. The clinical utility of the CA 19-9 tumor-associated antigen. Am J Gastroenterol 1990; 85:350.
  52. Lamerz R. Role of tumour markers, cytogenetics. Ann Oncol 1999; 10 Suppl 4:145.
  53. Goggins M. Molecular markers of early pancreatic cancer. J Clin Oncol 2005; 23:4524.
  54. Tempero MA, Uchida E, Takasaki H, et al. Relationship of carbohydrate antigen 19-9 and Lewis antigens in pancreatic cancer. Cancer Res 1987; 47:5501.
  55. Kim HJ, Kim MH, Myung SJ, et al. A new strategy for the application of CA19-9 in the differentiation of pancreaticobiliary cancer: analysis using a receiver operating characteristic curve. Am J Gastroenterol 1999; 94:1941.
  56. Molina V, Visa L, Conill C, et al. CA 19-9 in pancreatic cancer: retrospective evaluation of patients with suspicion of pancreatic cancer. Tumour Biol 2012; 33:799.
  57. Kim JE, Lee KT, Lee JK, et al. Clinical usefulness of carbohydrate antigen 19-9 as a screening test for pancreatic cancer in an asymptomatic population. J Gastroenterol Hepatol 2004; 19:182.
  58. Locker GY, Hamilton S, Harris J, et al. ASCO 2006 update of recommendations for the use of tumor markers in gastrointestinal cancer. J Clin Oncol 2006; 24:5313.
  59. Goonetilleke KS, Siriwardena AK. Systematic review of carbohydrate antigen (CA 19-9) as a biochemical marker in the diagnosis of pancreatic cancer. Eur J Surg Oncol 2007; 33:266.
  60. Marcouizos G, Ignatiadou E, Papanikolaou GE, et al. Highly elevated serum levels of CA 19-9 in choledocholithiasis: a case report. Cases J 2009; 2:6662.
  61. Maisey NR, Norman AR, Hill A, et al. CA19-9 as a prognostic factor in inoperable pancreatic cancer: the implication for clinical trials. Br J Cancer 2005; 93:740.
  62. Berger AC, Garcia M Jr, Hoffman JP, et al. Postresection CA 19-9 predicts overall survival in patients with pancreatic cancer treated with adjuvant chemoradiation: a prospective validation by RTOG 9704. J Clin Oncol 2008; 26:5918.
  63. Koom WS, Seong J, Kim YB, et al. CA 19-9 as a predictor for response and survival in advanced pancreatic cancer patients treated with chemoradiotherapy. Int J Radiat Oncol Biol Phys 2009; 73:1148.
  64. Kondo N, Murakami Y, Uemura K, et al. Prognostic impact of perioperative serum CA 19-9 levels in patients with resectable pancreatic cancer. Ann Surg Oncol 2010; 17:2321.
  65. Abdel-Misih SR, Hatzaras I, Schmidt C, et al. Failure of normalization of CA19-9 following resection for pancreatic cancer is tantamount to metastatic disease. Ann Surg Oncol 2011; 18:1116.
  66. Humphris JL, Chang DK, Johns AL, et al. The prognostic and predictive value of serum CA19.9 in pancreatic cancer. Ann Oncol 2012; 23:1713.
  67. Maithel SK, Maloney S, Winston C, et al. Preoperative CA 19-9 and the yield of staging laparoscopy in patients with radiographically resectable pancreatic adenocarcinoma. Ann Surg Oncol 2008; 15:3512.
  68. Karachristos A, Scarmeas N, Hoffman JP. CA 19-9 levels predict results of staging laparoscopy in pancreatic cancer. J Gastrointest Surg 2005; 9:1286.
  69. Fujioka S, Misawa T, Okamoto T, et al. Preoperative serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels for the evaluation of curability and resectability in patients with pancreatic adenocarcinoma. J Hepatobiliary Pancreat Surg 2007; 14:539.
  70. Kiliç M, Göçmen E, Tez M, et al. Value of preoperative serum CA 19-9 levels in predicting resectability for pancreatic cancer. Can J Surg 2006; 49:241.
  71. Bergquist JR, Puig CA, Shubert CR, et al. Carbohydrate Antigen 19-9 Elevation in Anatomically Resectable, Early Stage Pancreatic Cancer Is Independently Associated with Decreased Overall Survival and an Indication for Neoadjuvant Therapy: A National Cancer Database Study. J Am Coll Surg 2016; 223:52.
  72. Hartwig W, Strobel O, Hinz U, et al. CA19-9 in potentially resectable pancreatic cancer: perspective to adjust surgical and perioperative therapy. Ann Surg Oncol 2013; 20:2188.
  73. Khorana AA, Mangu PB, Berlin J, et al. Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 2016; 34:2541.
  74. Koopmann J, Rosenzweig CN, Zhang Z, et al. Serum markers in patients with resectable pancreatic adenocarcinoma: macrophage inhibitory cytokine 1 versus CA19-9. Clin Cancer Res 2006; 12:442.
  75. Kaur S, Smith LM, Patel A, et al. A Combination of MUC5AC and CA19-9 Improves the Diagnosis of Pancreatic Cancer: A Multicenter Study. Am J Gastroenterol 2017; 112:172.
  76. DelMaschio A, Vanzulli A, Sironi S, et al. Pancreatic cancer versus chronic pancreatitis: diagnosis with CA 19-9 assessment, US, CT, and CT-guided fine-needle biopsy. Radiology 1991; 178:95.
  77. Johnson DE, Pendurthi TK, Balshem AM, et al. Implications of fine-needle aspiration in patients with resectable pancreatic cancer. Am Surg 1997; 63:675.
  78. Micames C, Jowell PS, White R, et al. Lower frequency of peritoneal carcinomatosis in patients with pancreatic cancer diagnosed by EUS-guided FNA vs. percutaneous FNA. Gastrointest Endosc 2003; 58:690.
  79. Chong A, Venugopal K, Segarajasingam D, Lisewski D. Tumor seeding after EUS-guided FNA of pancreatic tail neoplasia. Gastrointest Endosc 2011; 74:933.
  80. Paquin SC, Gariépy G, Lepanto L, et al. A first report of tumor seeding because of EUS-guided FNA of a pancreatic adenocarcinoma. Gastrointest Endosc 2005; 61:610.
  81. AJCC (American Joint Committee on Cancer) Cancer Staging Manual, 7th ed, Edge SB, Byrd DR, Compton CC, et al (Eds), Springer, New York Vol 2010, p.241.
  82. Kakar S, Pawlik TM, Allen PJ, Vauthey J-N.. Exocrine pancreas. In: AJCC Cancer Staging Manual, 8th, Amin MB. (Ed), AJCC, Chicago 2017. p.337.
  83. Horton KM, Fishman EK. Multidetector row CT with dual-phase CT angiography in the preoperative evaluation of pancreatic cancer. Crit Rev Comput Tomogr 2002; 43:323.
  84. DeWitt J, Devereaux B, Chriswell M, et al. Comparison of endoscopic ultrasonography and multidetector computed tomography for detecting and staging pancreatic cancer. Ann Intern Med 2004; 141:753.
  85. Smith SL, Rajan PS. Imaging of pancreatic adenocarcinoma with emphasis on multidetector CT. Clin Radiol 2004; 59:26.
  86. Wong JC, Raman S. Surgical resectability of pancreatic adenocarcinoma: CTA. Abdom Imaging 2010; 35:471.
  87. Lu DS, Vedantham S, Krasny RM, et al. Two-phase helical CT for pancreatic tumors: pancreatic versus hepatic phase enhancement of tumor, pancreas, and vascular structures. Radiology 1996; 199:697.
  88. Fletcher JG, Wiersema MJ, Farrell MA, et al. Pancreatic malignancy: value of arterial, pancreatic, and hepatic phase imaging with multi-detector row CT. Radiology 2003; 229:81.
  89. Francis IR, Cohan RH, McNulty NJ, et al. Multidetector CT of the liver and hepatic neoplasms: effect of multiphasic imaging on tumor conspicuity and vascular enhancement. AJR Am J Roentgenol 2003; 180:1217.
  90. Ryan DP, Hong TS, Bardeesy N. Pancreatic adenocarcinoma. N Engl J Med 2014; 371:1039.
  91. Al-Hawary MM, Francis IR, Chari ST, et al. Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association. Radiology 2014; 270:248.
  92. Katz MH, Pisters PW, Evans DB, et al. Borderline resectable pancreatic cancer: the importance of this emerging stage of disease. J Am Coll Surg 2008; 206:833.
  93. National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on February 27, 2016).
  94. Callery MP, Chang KJ, Fishman EK, et al. Pretreatment assessment of resectable and borderline resectable pancreatic cancer: expert consensus statement. Ann Surg Oncol 2009; 16:1727.
  95. Bold RJ, Charnsangavej C, Cleary KR, et al. Major vascular resection as part of pancreaticoduodenectomy for cancer: radiologic, intraoperative, and pathologic analysis. J Gastrointest Surg 1999; 3:233.
  96. Strobel O, Berens V, Hinz U, et al. Resection after neoadjuvant therapy for locally advanced, "unresectable" pancreatic cancer. Surgery 2012; 152:S33.
  97. Satoi S, Yamamoto H, Takai S, et al. Clinical impact of multidetector row computed tomography on patients with pancreatic cancer. Pancreas 2007; 34:175.
  98. Holzapfel K, Reiser-Erkan C, Fingerle AA, et al. Comparison of diffusion-weighted MR imaging and multidetector-row CT in the detection of liver metastases in patients operated for pancreatic cancer. Abdom Imaging 2011; 36:179.
  99. Motosugi U, Ichikawa T, Morisaka H, et al. Detection of pancreatic carcinoma and liver metastases with gadoxetic acid-enhanced MR imaging: comparison with contrast-enhanced multi-detector row CT. Radiology 2011; 260:446.
  100. John TG, Greig JD, Carter DC, Garden OJ. Carcinoma of the pancreatic head and periampullary region. Tumor staging with laparoscopy and laparoscopic ultrasonography. Ann Surg 1995; 221:156.
  101. Gullà N, Patriti A, Cirocchi R, et al. [The role of laparoscopy in the identification of peritoneal carcinosis from abdominal neoplasms. Analysis of our initial experience]. Minerva Chir 2000; 55:737.
  102. Reddy KR, Levi J, Livingstone A, et al. Experience with staging laparoscopy in pancreatic malignancy. Gastrointest Endosc 1999; 49:498.
  103. Roche CJ, Hughes ML, Garvey CJ, et al. CT and pathologic assessment of prospective nodal staging in patients with ductal adenocarcinoma of the head of the pancreas. AJR Am J Roentgenol 2003; 180:475.
  104. Li H, Zeng MS, Zhou KR, et al. Pancreatic adenocarcinoma: the different CT criteria for peripancreatic major arterial and venous invasion. J Comput Assist Tomogr 2005; 29:170.
  105. Lu DS, Reber HA, Krasny RM, et al. Local staging of pancreatic cancer: criteria for unresectability of major vessels as revealed by pancreatic-phase, thin-section helical CT. AJR Am J Roentgenol 1997; 168:1439.
  106. O'Malley ME, Boland GW, Wood BJ, et al. Adenocarcinoma of the head of the pancreas: determination of surgical unresectability with thin-section pancreatic-phase helical CT. AJR Am J Roentgenol 1999; 173:1513.
  107. Loyer EM, David CL, Dubrow RA, et al. Vascular involvement in pancreatic adenocarcinoma: reassessment by thin-section CT. Abdom Imaging 1996; 21:202.
  108. Nakayama Y, Yamashita Y, Kadota M, et al. Vascular encasement by pancreatic cancer: correlation of CT findings with surgical and pathologic results. J Comput Assist Tomogr 2001; 25:337.
  109. Saldinger PF, Reilly M, Reynolds K, et al. Is CT angiography sufficient for prediction of resectability of periampullary neoplasms? J Gastrointest Surg 2000; 4:233.
  110. Coley SC, Strickland NH, Walker JD, Williamson RC. Spiral CT and the pre-operative assessment of pancreatic adenocarcinoma. Clin Radiol 1997; 52:24.
  111. Kaneko OF, Lee DM, Wong J, et al. Performance of multidetector computed tomographic angiography in determining surgical resectability of pancreatic head adenocarcinoma. J Comput Assist Tomogr 2010; 34:732.
  112. Vedantham S, Lu DS, Reber HA, Kadell B. Small peripancreatic veins: improved assessment in pancreatic cancer patients using thin-section pancreatic phase helical CT. AJR Am J Roentgenol 1998; 170:377.
  113. Zhao WY, Luo M, Sun YW, et al. Computed tomography in diagnosing vascular invasion in pancreatic and periampullary cancers: a systematic review and meta-analysis. Hepatobiliary Pancreat Dis Int 2009; 8:457.
  114. Tamburrino D, Riviere D, Yaghoobi M, et al. Diagnostic accuracy of different imaging modalities following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer. Cochrane Database Syst Rev 2016; 9:CD011515.
  115. Yoon WJ, Daglilar ES, Fernández-del Castillo C, et al. Peritoneal seeding in intraductal papillary mucinous neoplasm of the pancreas patients who underwent endoscopic ultrasound-guided fine-needle aspiration: the PIPE Study. Endoscopy 2014; 46:382.
  116. Li KC, Hopkins KL, Dalman RL, Song CK. Simultaneous measurement of flow in the superior mesenteric vein and artery with cine phase-contrast MR imaging: value in diagnosis of chronic mesenteric ischemia. Work in progress. Radiology 1995; 194:327.
  117. Megibow AJ, Zhou XH, Rotterdam H, et al. Pancreatic adenocarcinoma: CT versus MR imaging in the evaluation of resectability--report of the Radiology Diagnostic Oncology Group. Radiology 1995; 195:327.
  118. Irie H, Honda H, Kaneko K, et al. Comparison of helical CT and MR imaging in detecting and staging small pancreatic adenocarcinoma. Abdom Imaging 1997; 22:429.
  119. Sheridan MB, Ward J, Guthrie JA, et al. Dynamic contrast-enhanced MR imaging and dual-phase helical CT in the preoperative assessment of suspected pancreatic cancer: a comparative study with receiver operating characteristic analysis. AJR Am J Roentgenol 1999; 173:583.
  120. Buchs NC, Chilcott M, Poletti PA, et al. Vascular invasion in pancreatic cancer: Imaging modalities, preoperative diagnosis and surgical management. World J Gastroenterol 2010; 16:818.
  121. Trede M, Rumstadt B, Wendl K, et al. Ultrafast magnetic resonance imaging improves the staging of pancreatic tumors. Ann Surg 1997; 226:393.
  122. Balci NC, Semelka RC. Radiologic diagnosis and staging of pancreatic ductal adenocarcinoma. Eur J Radiol 2001; 38:105.
  123. Nordback I, Saaristo R, Piironen A, Sand J. Chest computed tomography in the staging of pancreatic and periampullary carcinoma. Scand J Gastroenterol 2004; 39:81.
  124. Singer E, Gschwantler M, Plattner D, et al. Differential diagnosis of benign and malign pancreatic masses with 18F-fluordeoxyglucose-positron emission tomography recorded with a dual-head coincidence gamma camera. Eur J Gastroenterol Hepatol 2007; 19:471.
  125. Izuishi K, Yamamoto Y, Sano T, et al. Impact of 18-fluorodeoxyglucose positron emission tomography on the management of pancreatic cancer. J Gastrointest Surg 2010; 14:1151.
  126. Heinrich S, Goerres GW, Schäfer M, et al. Positron emission tomography/computed tomography influences on the management of resectable pancreatic cancer and its cost-effectiveness. Ann Surg 2005; 242:235.
  127. Farma JM, Santillan AA, Melis M, et al. PET/CT fusion scan enhances CT staging in patients with pancreatic neoplasms. Ann Surg Oncol 2008; 15:2465.
  128. Schick V, Franzius C, Beyna T, et al. Diagnostic impact of 18F-FDG PET-CT evaluating solid pancreatic lesions versus endosonography, endoscopic retrograde cholangio-pancreatography with intraductal ultrasonography and abdominal ultrasound. Eur J Nucl Med Mol Imaging 2008; 35:1775.
  129. Kauhanen SP, Komar G, Seppänen MP, et al. A prospective diagnostic accuracy study of 18F-fluorodeoxyglucose positron emission tomography/computed tomography, multidetector row computed tomography, and magnetic resonance imaging in primary diagnosis and staging of pancreatic cancer. Ann Surg 2009; 250:957.
  130. Lytras D, Connor S, Bosonnet L, et al. Positron emission tomography does not add to computed tomography for the diagnosis and staging of pancreatic cancer. Dig Surg 2005; 22:55.
  131. Rijkers AP, Valkema R, Duivenvoorden HJ, van Eijck CH. Usefulness of F-18-fluorodeoxyglucose positron emission tomography to confirm suspected pancreatic cancer: a meta-analysis. Eur J Surg Oncol 2014; 40:794.
  132. Wu LM, Hu JN, Hua J, et al. Diagnostic value of diffusion-weighted magnetic resonance imaging compared with fluorodeoxyglucose positron emission tomography/computed tomography for pancreatic malignancy: a meta-analysis using a hierarchical regression model. J Gastroenterol Hepatol 2012; 27:1027.
  133. Tang S, Huang G, Liu J, et al. Usefulness of 18F-FDG PET, combined FDG-PET/CT and EUS in diagnosing primary pancreatic carcinoma: a meta-analysis. Eur J Radiol 2011; 78:142.
  134. Mertz HR, Sechopoulos P, Delbeke D, Leach SD. EUS, PET, and CT scanning for evaluation of pancreatic adenocarcinoma. Gastrointest Endosc 2000; 52:367.
  135. Nishiyama Y, Yamamoto Y, Yokoe K, et al. Contribution of whole body FDG-PET to the detection of distant metastasis in pancreatic cancer. Ann Nucl Med 2005; 19:491.
  136. Zafra M, Ayala F, Gonzalez-Billalabeitia E, et al. Impact of whole-body 18F-FDG PET on diagnostic and therapeutic management of Medical Oncology patients. Eur J Cancer 2008; 44:1678.
  137. Diederichs CG, Staib L, Vogel J, et al. Values and limitations of 18F-fluorodeoxyglucose-positron-emission tomography with preoperative evaluation of patients with pancreatic masses. Pancreas 2000; 20:109.
  138. Ghaneh P, Song WL, Titman A, et al. PET-PANC: Multicentre prospective diagnbstic accuracy and clinical value trial of FDG PET/CT in the diagnosis and management of suspected pancreatic cancer (abstract). J Clin Oncol 34, 2016 (suppl; abstr 4008). Abstract available online at http://meetinglibrary.asco.org/content/163707-176 (Accessed on June 13, 2016).
  139. Seufferlein T, Bachet JB, Van Cutsem E, et al. Pancreatic adenocarcinoma: ESMO-ESDO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012; 23 Suppl 7:vii33.
  140. Liu RC, Traverso LW. Diagnostic laparoscopy improves staging of pancreatic cancer deemed locally unresectable by computed tomography. Surg Endosc 2005; 19:638.
  141. Thomson BN, Parks RW, Redhead DN, et al. Refining the role of laparoscopy and laparoscopic ultrasound in the staging of presumed pancreatic head and ampullary tumours. Br J Cancer 2006; 94:213.
  142. Mayo SC, Austin DF, Sheppard BC, et al. Evolving preoperative evaluation of patients with pancreatic cancer: does laparoscopy have a role in the current era? J Am Coll Surg 2009; 208:87.
  143. Allen VB, Gurusamy KS, Takwoingi Y, et al. Diagnostic accuracy of laparoscopy following computed tomography (CT) scanning for assessing the resectability with curative intent in pancreatic and periampullary cancer. Cochrane Database Syst Rev 2016; 7:CD009323.
  144. Zamboni GA, Kruskal JB, Vollmer CM, et al. Pancreatic adenocarcinoma: value of multidetector CT angiography in preoperative evaluation. Radiology 2007; 245:770.
  145. Pisters PW, Lee JE, Vauthey JN, et al. Laparoscopy in the staging of pancreatic cancer. Br J Surg 2001; 88:325.
  146. Fernández-del Castillo C, Warshaw AL. Laparoscopy for staging in pancreatic carcinoma. Surg Oncol 1993; 2 Suppl 1:25.
  147. del Castillo CF, Warshaw L. Peritoneal metastases in pancreatic carcinoma. Hepatogastroenterology 1993; 40:430.
  148. Meszoely IM, Lee JS, Watson JC, et al. Peritoneal cytology in patients with potentially resectable adenocarcinoma of the pancreas. Am Surg 2004; 70:208.
  149. Yachida S, Fukushima N, Sakamoto M, et al. Implications of peritoneal washing cytology in patients with potentially resectable pancreatic cancer. Br J Surg 2002; 89:573.
  150. Yamada S, Fujii T, Kanda M, et al. Value of peritoneal cytology in potentially resectable pancreatic cancer. Br J Surg 2013; 100:1791.
  151. Warshaw AL. Implications of peritoneal cytology for staging of early pancreatic cancer. Am J Surg 1991; 161:26.
  152. Merchant NB, Conlon KC, Saigo P, et al. Positive peritoneal cytology predicts unresectability of pancreatic adenocarcinoma. J Am Coll Surg 1999; 188:421.
  153. Steen W, Blom R, Busch O, et al. Prognostic value of occult tumor cells obtained by peritoneal lavage in patients with resectable pancreatic cancer and no ascites: A systematic review. J Surg Oncol 2016; 114:743.
  154. Hartwig W, Schneider L, Diener MK, et al. Preoperative tissue diagnosis for tumours of the pancreas. Br J Surg 2009; 96:5.
  155. van Heerde MJ, Biermann K, Zondervan PE, et al. Prevalence of autoimmune pancreatitis and other benign disorders in pancreatoduodenectomy for presumed malignancy of the pancreatic head. Dig Dis Sci 2012; 57:2458.
  156. Abraham SC, Wilentz RE, Yeo CJ, et al. Pancreaticoduodenectomy (Whipple resections) in patients without malignancy: are they all 'chronic pancreatitis'? Am J Surg Pathol 2003; 27:110.
  157. Smith CD, Behrns KE, van Heerden JA, Sarr MG. Radical pancreatoduodenectomy for misdiagnosed pancreatic mass. Br J Surg 1994; 81:585.
  158. de la Fuente SG, Ceppa EP, Reddy SK, et al. Incidence of benign disease in patients that underwent resection for presumed pancreatic cancer diagnosed by endoscopic ultrasonography (EUS) and fine-needle aspiration (FNA). J Gastrointest Surg 2010; 14:1139.
  159. Gerritsen A, Molenaar IQ, Bollen TL, et al. Preoperative characteristics of patients with presumed pancreatic cancer but ultimately benign disease: a multicenter series of 344 pancreatoduodenectomies. Ann Surg Oncol 2014; 21:3999.
Topic Outline