TABLE 52 Endoscopic Ultrasonography TStage Accuracy for Pancreatic Cancer

Author Number of Patients Staged by EUS Number of Surgical Patients Staging Accuracy Accuracy (%)

Buscail 73 26 19/26 73

Gress 151 75 64/75 85

TABLE 5-3. Endoscopic Ultrasonography N-Stage Accuracy for Pancreatic Cancer

Author Number of Patients Staged by EUS Number of Surgical Patients Staging Accuracy Accuracy (%)

Buscail 73 26 18/26 69

Gress 151 71 51/71 72

superior to CT in its overall utility in pancreatic cancer. A recent review of studies comparing EUS to helical CT by Hunt and Faigel (2002) is summarized in Table 5-4. This review shows that the pooled data among the four recent studies show superiority of EUS to helical CT in detection of pancreatic tumor (97% versus 73%), accuracy for resectability (91% versus 83%), and sensitivity for vascular invasion (91% versus 64%). Therefore, EUS is still the most accurate modality for tumor detection, with a relatively high accuracy for local staging. In addition, as a single modality, EUS, especially when combined with EUS-guided FNA has been shown to be cost efficient by Harewood and colleagues (2002).

M-Staging by EUS

It has long been thought that EUS cannot be used for metastatic staging of pancreatic cancer. Recent studies are showing that EUS combined with FNA may be quite effective at assessing the majority of the liver, detecting and tak ing tissue samples of suspected metastatic lesions within both the left and right lobe. In addition, EUS/FNA can also sample scant amounts of ascitic fluid to assess peritoneal metastasis. Newer generation echoendoscopes will be able to penetrate further into the liver and potentially assess the entire liver for possible metastasis. If this occurs, EUS may become even more effective in the diagnosis and staging of these patients. Furthermore, therapeutic interventions with EUS-guided celiac nerve block and/or simultaneous ERCP with stent placement for palliation of jaundice could be performed during the same session. Thus, based on the studies presented, I recommend the algorithm in Figure 5-2 for patients with suspected AC of the pancreas. Patients with suspected pancreatic cancer should first undergo a helical CT with pancreas protocol. If there is an obvious mass with liver metastasis or unequivocal vascular invasion, a CT-guided biopsy should be performed and palliative therapy offered. If the CT shows a mass that appears resectable, or the CT is equivocal or negative, then the patient should undergo

TABLE 5-4. Summary of Studies Comparing Endoscopic Ultrasonography With Helical Computed Tomography for Pancreatic Cancer

Detection Accuracy for Resectability Sensitivity for Vascular Invasion

TABLE 5-4. Summary of Studies Comparing Endoscopic Ultrasonography With Helical Computed Tomography for Pancreatic Cancer

Detection Accuracy for Resectability Sensitivity for Vascular Invasion

Series

EUS

CT

EUS

CT

EUS

CT

Legmann

21/21

25/21

20/22

19/22

6/1

1/1

Midwinter

33/34

26/34

25/30

23/30

13/16

9/16

Tierney

-

-

30/31

25/31

16/16

10/16

Mertz

29/31

16/31

16/16

13/16

6/6

3/6

Total

91%

13%

91%

83%

91%

64%

p value*

< .001

-

.02

-

< .001

-

CT = computed tomography; EUS = endoscopic ultrasonography *Fisher exact test.

CT = computed tomography; EUS = endoscopic ultrasonography *Fisher exact test.

Clinical suspicion pancreatic cancer

Helical CT

FIGURE 5-2. Algorithm for diagnosis and staging of pancreatic cancer. CT = computed tomography; EUS = endoscopic ultrasonography; FNA = fine needle aspiration.
FIGURE 5-3. Outcomes of rectal cancer based on endoscopic ultrasography (EUS) staging. CT = computed tomography; FNA = fine needle aspiration.

EUS/FNA. The EUS/FNA can further stratify those patients found to be unresectable from those who are resectable. Those who are resectable by EUS/FNA should undergo surgical exploration/resection. Using this algorithm approximately 50% of patients who were assessed as "resectable" by CT were found to be unresectable by EUS. Fourteen of the 23 patients assessed as "resectable" by EUS were able to undergo curative resections at surgery with a significantly longer survival compared to all other groups (p < .01). The chapter on pancreatic cancer contains more information on this topic (see Chapter 142, "Pancreatic Cancer Therapy").

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

Get My Free Ebook


Post a comment