Pancreatic diseases, including pancreatic cancer, remain difficult to diagnose at an early stage and are still associated with a poor prognosis. In recent years, high-risk groups for pancreatic cancer have been increasingly defined, highlighting the growing importance of targeted screening strategies. Among available modalities, transabdominal ultrasonography is highly valuable because it is noninvasive, easy to perform, and suitable for repeated examinations. It plays a particularly important role in detecting pancreatic abnormalities in routine health checkups and gastrointestinal cancer screening programs.

In this article, we provide an overview of the diagnostic pathway from screening to detailed evaluation of pancreatic diseases—focusing primarily on pancreatic cancer—using transabdominal ultrasonography, and we discuss its utility and limitations in light of the latest evidence.

In recent years, imaging findings of early pancreatic cancer have gradually been elucidated, and the number of cases of carcinoma in situ and small pancreatic cancers detected through imaging examinations has been increasing. However, many of these imaging findings are subjective, making uniform and consistent diagnosis difficult. In addition, even when early pancreatic cancer is suspected based on imaging findings, further endoscopic evaluation is required, and there remain numerous challenges in diagnosis and clinical management. A thorough understanding of the imaging findings characteristic of early pancreatic cancer, together with recognition of these limitations and challenges, is essential for achieving early diagnosis of pancreatic cancer.

In this article, to facilitate understanding of the morphology of the pancreas and its positional relationships with surrounding organs, visual explanations are provided using CT-based volume-rendered images, and key points of ultrasound anatomy that should be mastered are presented, focusing especially on the pancreatic head, a common site for pancreatic cancer. Furthermore, as measures to enhance visualization, techniques such as changing the patient's position, utilizing high-frequency probes, and concomitant use of Doppler examination are specifically introduced using actual case images. Cases that had been overlooked are also discussed, along with explanations of points requiring attention. In addition, we present ultrasound images depicting focal pancreatic parenchymal atrophy and visualization of the main pancreatic duct obtained with a high-frequency probe. During transabdominal ultrasound examination of the pancreas, the groove region, uncinate process, and pancreatic tail are particularly prone to poor visualization, making it a challenge for sonographers to improve examination accuracy.

Invasive pancreatic ductal carcinoma arises in the pancreatic duct epithelium, destroys the main pancreatic duct wall, and invades the pancreatic parenchyma. Therefore, the disappearance of linear hyperechoic areas in the pancreatic duct wall is an ultrasound finding that strongly suggests pancreatic cancer. However, even if a tumor occurs within the pancreatic parenchyma, if the main pancreatic duct is compressed strongly, it may appear as if the pancreatic duct is interrupted. Furthermore, if the ultrasound waves hit the tumor boundary at an angle or are not focused, a tumor with a smooth boundary may appear rough.

When pancreatic cancer is discovered using ultrasound, seven items must be evaluated: (1) tumor diameter, (2) whether the tumor is contained within the pancreas, (3) whether there is vascular invasion (abdominal aorta, celiac artery, superior mesenteric artery, common hepatic artery to proper hepatic artery, portal vein to superior mesenteric vein), (4) whether there is lymph node metastasis, (5) whether there is distant metastasis, (6) whether there is ascites, and (7) intrahepatic bile duct diameter (if accompanied by obstructive jaundice). This allows for an understanding of the patient’s condition at the first step after discovery, and also leads to an assessment of the stage of the disease and the feasibility of resection.

The presence of focal pancreatic atrophy, main pancreatic duct stenosis, and distal pancreatic duct dilation is a strong indication of intraepithelial carcinoma.

To evaluate these correctly, it is important to ensure that the ultrasound waves hit the target object perpendicularly.

Since December 2021, our institution has implemented a pancreatic cancer screening program incorporating endoscopic ultrasonography (EUS). We analyzed the initial experience of 76 participants who had undergone the screening as of March 2025. Screening began with MRI/MRCP, followed by blood tests and intravenous access, after which EUS was performed under sedation. The median age of participants was 61.5 years (range, 30-81), including 42 men and 34 women. One participant discontinued MRI/MRCP due to claustrophobia, but EUS was successfully completed in all cases. Morphological abnormalities of the pancreas were observed in 34 participants (44.7%), with pancreatic cysts being the most common finding (26 participants, 34.2%) and a median cyst diameter of 5 mm (range, 2-118 mm). EUS identified suspected pancreatic cancer in one participant, with a lesion measuring 4 mm. All participants with pancreatic abnormalities underwent further evaluation in our gastroenterology department. The participant with the suspected pancreatic cancer ultimately underwent surgical resection, and the final diagnosis was high-grade pancreatic intraepithelial neoplasia (PanIN). This report describes a novel approach for early detection of pancreatic cancer in a community hospital setting.

Objective (Background):

Pancreatic cancer continues to have a poor prognosis, with a 5-year survival rate of approximately 8%. Because tumor formation progresses slowly and early symptoms are minimal, many patients are diagnosed at an advanced stage. In contrast, favorable outcomes have been reported in micro-pancreatic cancers measuring ≤1 cm and in carcinoma in situ (PanIN, Stage 0). These findings highlight the need for screening strategies capable of detecting abnormalities during the pre-mass-forming phase. MRI/MRCP is useful for identifying subtle early changes such as main pancreatic duct stenosis, irregularity of branch ducts, and diffusion restriction on DWI/ADC maps.

Methods:

Although conventional abdominal ultrasonography provides poor visualization of the pancreatic tail, the water-ingestion method stabilizes the acoustic window and is expected to improve detection of cystic lesions. Our institution implemented a pancreatic cancer screening program combining water-ingestion ultrasonography with MRI/MRCP. A total of 36 individuals underwent this combined protocol. Screening results and subsequent diagnostic outcomes were evaluated.

Results:

Cystic pancreatic lesions were identified in 5-6 of the 36 participants. In addition, a multimodal diagnostic approach including tumor markers enabled detection of a 5-mm micro-pancreatic cancer that showed no ductal abnormality on MRCP but was visualized only as focal diffusion restriction on DWI/ADC imaging. The lesion was successfully resected by robot-assisted distal pancreatectomy, achieving curative resection.

Conclusions:

A diagnostic system centered on MRI, particularly DWI/ADC evaluation, and a screening protocol incorporating water-ingestion ultrasonography are highly effective for detecting early pancreatic cancer, including lesions in the pre-mass-forming stage. The ability to identify a microcarcinoma as small as 5 mm demonstrates the clinical value of this multimodal strategy, which may contribute to improving outcomes by enabling earlier diagnosis and treatment.

Screening for gastric cancer in Japan using the double-contrast method formally began in 1966. However, there was no epidemiological evidence on reduction of mortality from gastric cancer at that time. Japan’s Ministry of Health and Welfare provided cancer research grants to look for the evidence. Consequently, two case-control studies revealed a reduction in gastric cancer mortality among participants who underwent X-ray screening. After a case-control study on screening using fecal occult blood test revealed a reduction in colorectal cancer mortality in Japan, the strategy of colorectal cancer screening was adopted in the national strategy in 1987. Thus, epidemiological studies have made much more sense in formulating new public policy in Japan.

Pancreatic ductal adenocarcinoma (PDAC) is a representative malignancy with a poor prognosis, and its incidence has been increasing in recent years. To improve outcomes, it is essential to diagnose PDAC at an early, resectable stage. Various efforts and clinical trials designed to overcome these clinical challenges have been reported. Given that PDAC often remains asymptomatic until it progresses, early detection requires efficient surveillance of high-risk individuals and the establishment of reliable biomarkers for early diagnosis.Intraductal papillary mucinous neoplasm (IPMN) has been identified not only as a premalignant lesion but also as a high-risk condition for the development of concomitant PDAC. The 2024 revision of the international evidence-based guidelines for IPMN (Kyoto Guidelines) discusses the risk of PDAC in patients with IPMN and provides recommendations for surveillance strategies. However, to date, age remains the only recognized risk factor for concomitant PDAC with IPMNs. Therefore, continued surveillance is required for the majority of pancreatic cysts, even among patients with low-grade IPMN. To enhance early diagnosis of PDAC, further refinement of high-risk groups within cohorts of patients with IPMN or pancreatic cysts is urgently needed. In addition to IPMN, familial pancreatic cancer and hereditary tumor syndromes are also recognized as genetic predispositions that place patients at high risk of developing PDAC. For these populations, implementing regular surveillance in combination with the development of novel biomarkers is expected to pave the way for the early diagnosis of PDAC in the future.

Objective: We investigated whether providing an informational leaflet to examinees undergoing colorectal cancer (CRC) screening at Seirei Center for Health Promotion and Preventive Medicine would contribute to improving follow-up colonoscopy uptake.

Subjects and Methods: We targeted examinees with a positive fecal immunochemical test at our facility and compared changes in follow-up colonoscopy uptake, using 3,313 cases tested between April 2018 and March 2020 before introduction of the leaflet (pre-intervention group) and 3,415 cases tested after introduction of the leaflet (post-intervention group).

Results: Follow-up colonoscopy uptake improved from 67.5% in the pre-intervention group to 70.5% in the post-intervention group (p=0.009). When comparing workplace- and population-based screening, colonoscopy uptake in workplace-based screening examinees improved from 63.6% in the pre-intervention group to 67.8% in the post-intervention group (p=0.002), whereas that in population-based screening examinees showed no change, i.e., from 82.2% in the pre-intervention group to 82.8% in the post-intervention group. When compared by the presence or absence of medical explanation and health guidance on the day of the Ningen Dock (comprehensive health checkup) or health checkup, in the presence of the explanation and guidance, colonoscopy uptake increased from 76.9% in the pre-intervention group to 82.0% in the post-intervention group (p<0.001). Furthermore, in the absence of the explanation and guidance, uptake increased from 58.5% in the pre-intervention group to 63.6% in the post-intervention group (p=0.005).

Conclusions: These results suggest that provision of information using two types of leaflets can improve colonoscopy uptake, especially for colorectal cancer screening in the workplace.

Background: Long-term changes in liver fibrosis following sustained virological response (SVR) to direct-acting antiviral (DAA) therapy for hepatitis C were analyzed using MR elastography (MRE) and proton density fat fraction (PDFF).

Subjects and Methods: A total of 53 patients infected with hepatitis C virus (HCV) who achieved SVR after DAA therapy were analyzed. Changes in liver stiffness and hepatic steatosis were assessed using MRE and PDFF, respectively. A retrospective analysis was performed to determine the pre-DAA treatment factors associated with improvement in hepatic fibrosis.

Results: Liver stiffness decreased significantly over time after SVR. However, by the third year after SVR, only about half of the patients (14 patients (54%)) had a 19% or greater reduction in liver stiffness compared to their pretreatment levels. A pretreatment factor associated with the non-improvement of liver stiffness was hypertriglyceridemia (p=0.029). Liver steatosis was significantly reduced after 1 year of SVR, but after 2 years there was no significant change from pretreatment levels.

Conclusions: Liver fibrosis gradually improves after SVR, but the degree of improvement is limited in patients with dyslipidemia. In addition to HCV therapy, it is important to manage lifestyle-related diseases, such as dyslipidemia.

Objective: Early detection of pancreatic cancer requires the identification and longitudinal follow-up of high-risk individuals through health screening. This study aimed to evaluate the clinical utility of apolipoprotein A2 isoforms (APOA2-i) in a screening population.

Subjects and Methods: We retrospectively analyzed 4,404 individuals who underwent APOA2-i measurement during health checkups and 84 APOA2-i-positive individuals who subsequently received detailed imaging examinations between May 2024 and April 2025.

Results: The APOA2-i positivity rate was 5.0%. Positive individuals were independently associated with older age, lower HDL cholesterol, and lower albumin levels. Pancreatic abnormalities detected on abdominal ultrasonography (AUS) were more frequent in the positive group (4.5% vs 2.2%), and non-visualization of the pancreas was also significantly more common (10.6% vs 4.2%). Among the 84 individuals who underwent further examinations, pancreatic diseases were identified in 35.7%, including intraductal papillary mucinous neoplasm in 13.1%.

Conclusion: APOA2-i is the only blood-based biomarker capable of identifying pancreatic exocrine dysfunction, and it is useful for detecting pancreatic high-risk lesions that are difficult to identify at AUS screening alone. APOA2-i-positive individuals may represent a high-risk population for future pancreatic cancer development and require careful long-term follow-up.

Hachioji City in Tokyo introduced endoscopic gastric cancer screening in fiscal year (FY) 2018. After being used in conjunction with X-ray screening, X-ray screening was discontinued in FY 2021, the 4th year. The number of patients undergoing gastric cancer screening increased from 7,555 in FY 2017, when only X-ray screening was used, to 8,579 in FY 2022, when only endoscopy was used. During the period when both methods were used, 95% of eligible patients opted for endoscopic screening, indicating that the introduction of endoscopy contributed to an increased screening uptake rate. Over the 5-year period, a total of 37,558 patients underwent endoscopic screening for gastric cancer, leading to the detection of 151 cases, including 122 early-stage cancers (87 of which were intramucosal). Additionally, the rates for the process indices were 100%, 4.9%, 5.2%, 0.40%, and 7.7% for detailed examinationuptake rate, biopsy uptake rate, biopsy requirement rate, cancer detection rate, and positive test adequacy rate, respectively. These data compare favorably with national 5-year data spanning from FY 2018 to 2022 as well as the overall Tokyo data. We believe that establishing a high-accuracy quality control system in cooperation with the government, particularly the independently implemented dual-reading system by the Hachioji City Medical Association, will contribute to decreasing the mortality rate attributed to gastric cancer, which will benefit citizens.

This report describes the 5-year history of gastric cancer endoscopic screening introduced by Hachioji City and the Hachioji City Medical Association. It includes the background of its introduction, implementation methods, track record, and efforts to maintain and improve the quality control system.