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NCCN Guidelines for Patients



Pancreatic Cancer, Version 1.2017


Treatment planning

Cancer staging

FNA biopsy

An FNA biopsy is the type of biopsy used most often

to confirm pancreatic cancer. This type of biopsy

uses a very thin needle to remove the tissue sample.

There are two main ways to perform an FNA biopsy.


An FNA biopsy can be done during EUS with a thin

needle attached to the end of the endoscope. This is

called an EUS-guided FNA biopsy or EUS-FNA. For

this type of biopsy, the endoscope is passed through

the mouth and throat down into your stomach.

An ultrasound probe at the end of the endoscope

bounces sound waves off organs and tissues to

make a picture of the inside of your body. Your doctor

uses these pictures to guide the endoscope and

needle to the right spot. Then the needle is inserted

through your stomach or duodenum and into the

tumor in your pancreas.

CT or ultrasound-guided FNA

A second way to perform an FNA biopsy is to insert

a thin needle through the skin and into the tumor

using a CT scan or ultrasound for guidance. This is

called a CT or ultrasound-guided FNA biopsy. The

CT scan takes many pictures of a part of the body

from different angles using x-rays. An ultrasound is

a test that uses sound waves to take pictures of the

inside of the body. Your doctor will use the pictures

from these imaging tests to find the tumor in your

pancreas and guide the needle to the right spot. For

this type of biopsy you will be given local anesthesia.

It is called local because this anesthesia causes a

loss of feeling in a small area of the body.

Besides FNA, a biopsy of the tumor may also be

done during surgery or laparoscopy. During ERCP,

samples may be removed from the pancreatic duct.

In this case, the samples are removed with a small

brush at the end of the endoscope. These samples

are called brushings.

A biopsy is often done in less than 1 hour. It is

generally a safe test. Before a biopsy, you may be

asked to stop eating, stop taking some medicines, or

stop smoking. You may have some pain after a CT

or ultrasound-guided FNA biopsy. After an EUS-FNA

biopsy, your throat may be sore and you may feel

bloated. Talk to your doctor about any side effects

you have.

Cancer staging

The cancer stage is a rating by your doctors of

how far the cancer has grown and spread. Which

treatment is best for you depends on how far the

cancer has spread. There are two ways that may

be used to stage or classify pancreatic cancer.

The AJCC (






ommittee on



system groups pancreatic cancer into five stages

(stage 0 – stage IV). The stages are defined by the

growth of the primary tumor and its spread to other

sites in the body. In the AJCC system, cancer may

be staged twice. Thus, it is based on tests before

surgery and then based on tests of tissue removed

during surgery. Some doctors use this staging

system to plan treatment.

However, most NCCN doctors do not use the AJCC

staging system. Rather, they classify pancreatic

cancer and plan treatment based on the results of

imaging and other tests done before surgery. Imaging

tests provide the key information used to determine

the clinical stage of pancreatic cancer.