## Investigation of Choice for Pancreatic Cancer Diagnosis and Staging **Key Point:** Contrast-enhanced CT (CECT) with pancreatic protocol is the gold standard imaging modality for diagnosis, staging, and assessment of resectability in suspected pancreatic cancer. ### Why CECT Pancreatic Protocol? 1. **Diagnostic accuracy**: Detects lesions as small as 2–3 cm with high sensitivity (85–90%) and specificity for pancreatic adenocarcinoma. 2. **Resectability assessment**: Evaluates vascular involvement (superior mesenteric artery, portal vein, celiac axis) — critical for surgical planning. 3. **Staging**: Identifies metastases (liver, peritoneum, distant nodes) in a single study. 4. **Technique-specific**: Multiphasic imaging (arterial, pancreatic, portal venous phases) optimizes visualization of the hypodense tumor. ### Comparison of Investigations | Investigation | Role | Limitation | |---|---|---| | **CECT pancreatic protocol** | Diagnosis, staging, resectability | Gold standard | | ERCP | Therapeutic (biliary stent) + biopsy | Invasive; not for initial staging | | MRCP | Biliary tree visualization | Lower sensitivity for small tumors; no vascular assessment | | PET-CT | Metastatic disease detection | Low sensitivity for primary tumor; not for diagnosis | **Clinical Pearl:** In this patient with obstructive jaundice and imaging evidence of a pancreatic head lesion, CECT must be performed BEFORE ERCP to avoid pancreatitis and to complete staging. ERCP is reserved for therapeutic drainage if the patient is unresectable or for preoperative biliary decompression. **High-Yield:** CECT is the single most important investigation — it answers three questions: (1) Is it cancer? (2) Can it be resected? (3) Has it spread? All other investigations are adjunctive. [cite:Harrison 21e Ch 297]
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