**6. Diagnostic evaluation**

Mary Joseph's nodule) [37] and peritoneal seeding (Blumer's shelf) are also rarely found with pancreatic metastatic disease. Migratory thrombophlebitis (Trousseau's sign), which is evidence of intravascular thrombosis, may occur in patients with advanced pancreatic cancer as well as other advanced cancers resulting from a hypercoagulable state from malignant

The AJCC staging system, based on the TNM stage, is most often used staging system for pancreatic cancer. The tumor stage describes the size of the primary tumor, vascular structure involvement and any direct extension of the tumor outside of the pancreas. The nodal stage assesses the presence or absence of any regional lymph node involvement. The metastasis stage

T3 Tumor extends beyond the pancreas but without involvement of the celiac axis or superior mesenteric artery

T2 N1 M0 T3 N1 M0

T4 Tumor invades the celiac axis or the superior mesenteric artery (unresectable primary tumor)

Stage 0 Tis N0 M0 Stage IA T1 N0 M0 Stage IB T2 N0 M0 Stage IIA T3 N0 M0 Stage IIB T1 N1 M0

Stage III T4 Any N M0 Stage IV Any T Any N M1

describes the presence or absence of any distant disease (Table 1).

Tis Carcinoma in situ (includes lesions classified as PanInIII classification) T1 Tumor limited to the pancreas, 2 cm or less in greatest dimension T2 Tumor limited to the pancreas, more than 2 cm in greatest dimension

disease [38].

230 Updates on Cancer Treatment

**5. Staging**

**(a) Primary Tumor (T)**

Tx Primary tumor cannot be assessed T0 No evidence of primary tumor

**(b) Regional Lymph Nodes (N)**

Nx Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Regional lymph node metastasis **(c) Distant Metastasis (M)** M0 No distant metastasis M1 Distant metastasis

**(d) Anatomic Stage/Prognostic Groups**

**Table 1.** TNM staging system for pancreatic cancer

Routine laboratory analyses are rarely abnormal and if abnormal they lack specificity for a diagnosis of pancreatic cancer. Evidence of extrahepatic obstruction may be revealed by increased levels of serum alkaline phosphatase, bilirubin and gamma-glutamyl transferase with possible mild elevations in hepatic aminotransferases [31]. Hypoalbuminemia and anemia may be present in patients with advanced disease. Mild coagulopathy can be seen in patients with obstructive jaundice. Poor flow of bile acids in the small bowel in these patients decreases vitamin K absorption resulting in depletion of vitamin K dependent clotting factors over time. Elevated pancreatic enzymes (elevated amylase and lipase) associated with acute pancreatitis can rarely be the first manifestation of pancreatic cancer [41].

There are no accurate or reliable serum markers to aid in the diagnosis of pancreatic cancer. Low sensitivity and cross-reactivity with other tumors have prevented the clinical use of carcinoembryonic antigen (CEA), fetoprotein, and pancreatic oncofetal antigen in the diagno‐ sis of pancreatic cancer. Carbohydrate antigen 19-9 levels (normal <37 units/mL) has been the most useful commercially available test. However, the sensitivity of CA 19-9 ranges from 70% to 92% and the specificity is poor (68% to 92%) [42]. The accuracy of CA 19-9 in the diagnosis of pancreatic cancer is excellent when combined with ERCP, abdominal CT, or abdominal US [43]. High levels of CA 19-9 have been associated with poor prognosis and tumor unresecta‐ bility [43]. CA 19-9 is also useful in monitoring the response of therapeutic interventions. As the CA 19-9 requires the presence of Lewis blood group antigen (a glycosyl transferase enzyme) to be expressed, this serum marker is of no value in 10% of the population who is negative for this antigen [44, 45].
