Pancreatic Cancer

AC of the pancreas is the fifth leading cause for cancer-related death in the United States. Despite improvements in medical and surgical therapy, the overall 5-year survival still remains at 4%. The most favorable outcome is among surgical patients with small tumors without nodal, vascular, or systemic metastasis. These patients have 5-year survivals that range up to 25%. Optimally, earlier detection and precise preoperative staging would best stratify patients who would most likely benefit from surgery while sparing the remaining patients from exploratory or palliative-only surgery.

Detection

EUS is considered as one of the most useful diagnostic procedures among the body imaging tools for detecting pancreatic cancer. EUS was shown to be superior (sensitivity 98%) to other imaging modalities, including CT, in 146 patients with pancreatic cancer (Table 5-1) (Hunt and Faigel, 2002). With the more recent introduction of spiral CT with dual phase contrast, the detection rate for CT is improving. However, recent comparisons between dualphase spiral CT and EUS still favor EUS.

Diagnosis with EUS-Guided FNA

The ability to obtain cytological specimens by EUS-guided FNA has overcome the difficulty in differentiating between benign versus malignant lesion seen on EUS alone. The application of EUS-guided FNA to the pancreas in particular has great clinical utility. CT- or US-guided percutaneous FNA are the more common methods for diagnosing pancreatic cancer. The sensitivity of percutaneous FNA ranges from 45 to 100%, with a specificity of up to 100%. However, obtaining a tissue diagnosis with CT or US guidance is limited by the ability to visualize the lesion. in our previous multicenter trial, 56% of patients with pancreatic carcinoma had CT scans that did not demonstrate a mass or revealed nonspecific enlargement of the pancreas. Endoscopic retrograde cholangiopancreatography (ERCP) with cytologic brushing also has a rel atively low yield, with sensitivities between 30 and 56%. The overall sensitivity, specificity, diagnostic accuracy, negative predictive values, and postive predictive values of EUS-guided FNA for pancreatic cancer were 83%, 90%, 85%, 80%, and 100%. This was superior to CT alone (without FNA) (56%, 37%, 50%, 28%, and 65%, respectively [p < .05]). There were 4 complications in 164 patients (2%), including 2 major (perforation, bleeding) and 2 minor (fever). Comparison among the four centers showed that institutions in which a cytologist was present during the procedure had a significantly higher number of passes, cytologic yield, sensitivity, and diagnostic accuracy. Advantages of EUS-guided FNA include procuring a tissue diagnosis while also obtaining additional TN staging information, the avoidance of additional diagnostic testing and/or surgery, and the prognostic information relating to accurate TN staging. A large single institution study of EUS-guided FNA, including 144 pancreatic lesions, had a sensitivity, specificity, and diagnostic accuracy of 82%, 100%, and 85%, respectively. More recently, helical or spiral CT has improved imaging of the pancreas. However, preliminary studies still show superiority of EUS versus spiral CT. The most difficult diagnosis to make for any imaging test, including EUS-guided FNA, is the differentiation between pancreatic carcinoma and chronic pancreatitis. Although a positive FNA is almost 100% accurate, a negative FNA is about 80% accurate.

We believe that all patients thought to have operable disease based on initial CT imaging should undergo EUS ± FNA prior to surgical intervention. At the same time, considering the possibility of a false negative result (up to 20%, especially in the setting of chronic pancreatitis), we believe that surgical intervention should not be precluded in a patient with a high suspicion of resectable pancreatic carcinoma and a negative FNA cytology.

EUS-guided FNA of pancreatic lesions is also worthwhile in patients with a prior negative tissue diagnosis by ERCP or CT of the abdomen. Gress and colleagues (2001) reported his experience with EUS-guided FNA of pancreatic mass lesion in 102 patients who had negative cytological tissue diagnosis by ERCP sampling or CT-guided FNA. Among those patients, 57 of the 61 patients (93.4%) with a final diagnosis of pancreatic cancer had positive cytology results for AC EUS-guided FNA. The false positive results were zero.

We have reviewed a series of 44 consecutive patients who

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