Background: A large number of diagnostic procedures (e.g., ultrasound, computed tomography [CT] scan, fine-needle aspiration [FNA], angiography, endoscopic retrograde cholangiopancreatography [ERCP], and laparoscopy), are available to the clinician as he/she pursues the workup of patients who are thought to have a pancreatic (periampullary) malignancy. Not all of these procedures should be used in every patient and some have been overused.
Methods: Based on a current literature review and their own experience, the authors describe the rationale of the diagnostic workup in patients with suspected pancreatic carcinoma in a single institution (a university medical center).
Results: Helical CT scan provides the best overall assessment of patients with periampullary malignancies, and it is often the only test required. If the patient's history and blood test abnormalities suggest pancreatic carcinoma and the helical CT scan shows a mass in the head of the pancreas that appears to be resectable, the patient should be prepared for surgery. If no mass is apparent on the helical CT scan, a diagnostic ERCP is indicated. If microscopic proof of the diagnosis will avoid surgery, then an FNA for cytology should be performed. When unresectability appears likely and cannot be confirmed in less invasive ways, laparoscopy is indicated.
Conclusions: In patients with periampullary malignancies, helical CT scan provides the best overall assessment. Guidelines are presented for the selective use of ultrasound, FNA, ERCP, and laparoscopy, which are important for the most cost-effective workup of these patients.