Endoscopic ultrasonography in diagnosis and staging of pancreatic cancer

Endoscopic ultrasound (EUS) and the management of pancreatic cancer

Pancreatic cancer is one of the leading causes of cancer-related mortality in western countries. Early diagnosis of pancreatic cancers plays a key role in the management by identification of patients who are surgical candidates. The advancement in the radiological imaging and interventional endoscopy (including endoscopic ultrasound (EUS), endoscopic retrograde cholangiopancreatography and endoscopic enteral stenting techniques) has a significant impact in the diagnostic evaluation, staging and treatment of pancreatic cancer. The multidisciplinary involvement of radiology, gastroenterology, medical oncology and surgical oncology is central to the management of patients with pancreatic cancers. This review aims to highlight the diagnostic and therapeutic role of EUS in the management of patients with pancreatic malignancy, especially pancreatic ductal adenocarcinoma.

Contrast-enhanced harmonic endoscopic ultrasonography for evaluating the response to chemotherapy in pancreatic cancer

BACKGROUND AND AIMS

Contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) is used for the diagnosis of pancreatic cancer (PC). Here, we examined the usefulness of CH-EUS for evaluating therapeutic responses in PC.

METHODS

The study included 23 patients with PC who received chemotherapy. Patients underwent contrast-enhanced computed tomography (CE-CT) and CH-EUS before chemotherapy and at the time of evaluation of the therapeutic response. Patients with a ≧50% reduction in serum carbohydrate antigen 19-9 levels after chemotherapy were defined as "super responders". The incidence of an avascular area in the tumor on CH-EUS after chemotherapy was compared between "super responders" and non-super responders.

RESULTS

Nine patients were included in the "super responders" group.Tumor reduction rates did not differ significantly between CE-CT and CH-EUS in the "super responders". The appearance of an avascular area was detected in 7 of 9 super responders (77.8%) and in 4 of 14 non-super responders (28.6%), and the difference was significant (P = 0.036). The mean survival time of patients with an avascular area after chemotherapy was longer than that of without an avascular area.

CONCLUSIONS

Detection of avascular areas by CH-EUS after chemotherapy may predict long-term survival of patients with PC.

Applications of Endoscopic Ultrasonography in Pancreatic Cancer

Background

Accurate staging of pancreatic cancer is essential for surgical planning and for identification of locally advanced and metastatic disease that is incurable by surgery. Advances in endoscopic sonography (EUS), computed tomography (CT), and positron emission tomography have improved the accuracy of staging and reduced the number of incomplete surgical resections. Tissue acquisition is necessary in nonsurgical cases when chemoradiotherapy is considered. The complex regional anatomy of the pancreas makes cytologic diagnosis of malignancy at this region difficult without exploratory surgery. Although CT-guided fine-needle aspiration (FNA) is used for this purpose, reports of an increased risk of peritoneal dissemination of cancer cells and a false-negative rate of nearly 20% make this a poor choice. The ability to position the EUS-transducer in direct proximity to the pancreas by means of the stomach and duodenum, combined with the use of FNA, increases the specificity of EUS in detecting pancreatic malignancies.

Methods

The current literature regarding the accuracy of EUS with FNA in the evaluation of pancreatic cancer is reviewed.

Results

EUS accuracy ranges from 78% to 94% for tumor staging and from 64% to 82% for nodal staging. EUS also enables FNA of lesions that are too small to be identified by CT or MRI or too well encased by surrounding vascular structures to safely allow percutaneous biopsy. The accuracy for detecting invasion into the superior mesenteric artery and vein is lower than that for detecting portal or splenic vein invasion, especially for large tumors. EUS permits delivery of localized therapy such as celiac plexus neurolysis for pain control and direct intra-lesional injection of antitumor therapy.

Conclusions

EUS in combination with FNA is a highly accurate method of preoperative staging of pancreatic cancer, especially those too small to be characterized by CT or MRI, and it has the ability to obtain cytological confirmation of pancreatic cancer.

Early detection of pancreatic cancer: impact of high-resolution imaging methods and biomarkers

High-resolution imaging methods (HRIMs) and biomarkers present the second step of pancreatic cancer (PC) diagnostics in at-risk individuals. These include patients with positive risk factors, early symptoms, nonresponders to the initial antidiabetic therapy, patients older than 50 years of age with new-onset unstable diabetes requiring insulin as well as patients with long-term insulin-non-dependent diabetes and recent (up to 6 months) failure of antidiabetic therapy. The procedures should be started without delay and the co-operation between the primary and tertiary medical centers is highly desirable. An early indication of HRIMs and biomarkers is a prerequisite for the diagnosis of a resectable PC. This publication reviews the recent contribution of HRIMs and biomarkers toward an early diagnosis of PC.

Imaging of the Pancreas

The evaluation of pancreatic lesions, from solid pancreatic masses to pancreatic cysts, remains a clinical challenge. Although cross-sectional imaging remains the cornerstone of the initial evaluation of an indeterminate pancreatic lesion, advances in imaging with the advent of endoscopic ultrasound scan, elastography, contrast-enhanced endoscopic ultrasound scan, and probe-based confocal laser endomicroscopy have allowed us to visualize the pancreas in even higher resolution and diagnose premalignant and malignant lesions of the pancreas with improved accuracy. This report reviews the range of imaging tools currently available to evaluate pancreatic lesions, from solid tumors to pancreatic cysts.

Acute Pancreatitis as a Possible Indicator of Pancreatic Cancer: The Importance of Mass Detection

OBJECTIVE

The aims of this study were to assess the incidence of pancreatic cancer and the contributing factors for the diagnosis of tumors in patients with acute pancreatitis and to gain insight into how patients with acute pancreatitis should be followed up.

METHODS

Using the electronic medical database of Shizuoka General Hospital, 177 patients admitted for acute pancreatitis in the past 6 years were evaluated retrospectively for pancreatic cancer.

RESULTS

Twelve patients (6.8%) were newly diagnosed with pancreatic cancer. During the first hospitalization, 5 patients (41.7%) with a detected pancreatic mass underwent surgical treatment: the final tumor stages were IA, IIA, and IIB in 1, 2, and 2 patients, respectively. In 7 patients (58.3%) without a detected pancreatic mass at the first admission, a pancreatic mass was recognized on follow-up computed tomography (CT) in 2 patients with main pancreatic duct (MPD) dilatation, and 1 patient with recurrent acute pancreatitis. The tumor stages were IA, IIA, and IA, respectively. Among the remaining 4 patients without follow-up, the tumor stage was IV. The patient gender, age, MPD dilatation, tumor marker, and serum amylase level were not significantly associated with pancreatic cancer. The detection of a pancreatic mass on CT led to the diagnosis of pancreatic cancer.

CONCLUSION

Acute pancreatitis should be considered as a possible diagnostic indicator of pancreatic cancer. Various factors associated with acute pancreatitis and pancreatic cancer were not predictive of a diagnosis of pancreatic cancer. Only the detection of a pancreatic mass led to the early diagnosis of pancreatic cancer. Patients hospitalized for acute pancreatitis should be followed up with a diagnostic imaging modality.

Increased risk of pancreatic adenocarcinoma after acute pancreatitis

BACKGROUND & AIMS

Acute pancreatitis (AP) is often the initial presentation of pancreatic cancer (pancreatic adenocarcinoma [PaCa]). We evaluated the risk of PaCa after AP.

METHODS

We performed a retrospective study of patients with AP who sought care in the Veterans Health Administration from 1998 through 2007. We excluded patients with pre-existing PaCa or recurrent AP and those who had the first episode of acute pancreatitis, from 1998 through 2000.

RESULTS

Of 495,504 patients with Veterans Health Administration inpatient and outpatient records, 5720 were diagnosed with AP (1.15%) and 710 were diagnosed with PaCa (0.14%), from 2000 through 2007. Seventy-six patients had AP within 2 years before being diagnosed with PaCa (10.7% of all patients with cancer diagnosed during that period). The risk for PaCa was greatest in the first year after AP (14.5 per 1000 patient-years) and then decreased rapidly. Risk for PaCa was negligible in patients <40 years old. The incidence of PaCa within the first year after AP was 7.69 per 1000 patient-years in fifth decade of life and reached 28.67 after the seventh decade. Time to diagnosis of PaCa after AP was ≤2 months for 34 patients, 3-12 months for 35 patients, 13-24 months for 7 patients, and >24 months for 10 patients.

CONCLUSIONS

A significant number of patients with PaCa initially present with AP; the diagnosis of cancer is often delayed by up to 2 years. We suggest that PaCa be routinely considered as a potential etiology of AP in patients ≥40 years old.

Performance characteristics of endoscopic ultrasound in the staging of pancreatic cancer: a meta-analysis

CONTEXT

The optimal approach to pre-operative imaging assessment of pancreatic cancer is unknown.

OBJECTIVE

The aim of this meta-analysis was to assess accuracy and performance characteristics of EUS in determining nodal staging, vascular invasion, and prediction of resectability of pancreatic cancer. A secondary aim was to perform head to head comparison of performance characteristics between EUS and CT for nodal staging, vascular invasion and resectability.

DESIGN

Data from EUS studies were pooled according to bivariate generalized random effects model. Pooled estimates for CT were obtained from studies which performed head to head comparison between EUS and CT.

PATIENTS

Patients with pancreatic cancer undergoing pre-operative imaging assessment.

INTERVENTION

EUS.

MAIN OUTCOME MEASURE

Pooled sensitivity, specificity, positive and negative predictive values of EUS for nodal staging, vascular invasion and resectability.

RESULTS

Forty-nine studies were considered of which 29 met inclusion criteria with a total of 1,330 patients. Pooled summary estimates for EUS-nodal staging were 69% for sensitivity and 81% for specificity. For vascular invasion, sensitivity was 85% and specificity was 91%. The sensitivity and specificity for resectability was 90% and 86%, respectively. CT scan showed lower sensitivity than EUS for nodal staging (24% vs. 58%) and vascular invasion (58% vs. 86%); however, the specificities for nodal staging (88% vs. 85%) and vascular invasion (95% vs. 93%) were comparable in studies where both imaging techniques were performed. The sensitivity and specificity of CT in determining resectability (90% and 69%) was similar to that of EUS (87% and 89%).

CONCLUSIONS

EUS is an accurate pre-operative tool in the assessment of nodal staging, vascular invasion and resectability in patients with pancreatic cancer.

Current status on the diagnosis and evaluation of pancreatic tumor in Asia with particular emphasis on the role of endoscopic ultrasound

In Asia, the incidence of pancreatic cancer in some countries has been increasing. Owing to most cases being diagnosed late, prognosis for pancreatic cancer remains dismal. It is clear that the future for pancreatic cancer lies in early detection. While the possible presence of pancreatic masses is often first raised by non-invasive abdominal imaging, such as computerized tomography and magnetic resonance imaging, smaller lesions and locoregional lymph node metastases are often not detectable by these means. Endoscopic ultrasonography (EUS) offers a higher sensitivity (93-100%) for detection of small potentially curable pancreatic masses than other existing imaging modalities. It is also recommended for the evaluation of portal vein confluence, portal vein, celiac axis, and superior mesentric artery origin, and exclusion of resectability. Due to the closer proximity of EUS to the target structure, and lower rate of needle tract seeding, EUS-guided fine-needle aspiration of pancreatic mass is considered the most suitable tissue acquisition technique. Lastly, EUS also enables the performance of endoscopic interventions. Its performance can be further enhanced with newer techniques, including contrast-enhanced ultrasound and elastrography. It is anticipated that in the near future, molecular technologies may make it possible to detect microscopic amounts of cancer in tissue or blood, predict relapse and survival after therapy, as well as determine optimal therapy.

The management of gastrointestinal tract malignancies

Surgery is the mainstay of treatment for many patients with malignancies of the gastrointestinal (GI) tract. The coordination of patient care and timing of surgical intervention require a multidisciplinary approach. It is not unusual for GI malignancies to be discovered in a hospital setting; patients with these malignancies are frequently admitted and discharged from nonsurgical services. Therefore, it is imperative that all physicians involved in the care of patients with GI malignancies have knowledge regarding the workup and surgical treatment of GI tract lesions. This article is a brief overview of the workup and surgical management of malignancies of the GI tract.

Pancreatic metastasis arising from a BRAF(V600E)-positive papillary thyroid cancer: the role of endoscopic ultrasound-guided biopsy and response to sorafenib therapy

BACKGROUND

Lungs and bones are the most common sites for distant metastases from papillary thyroid cancer (PTC). Metastases to the pancreas are extremely rare. Here we present a man with pancreatic metastases from PTC, report our experience with sorafenib therapy, and discuss the role of endoscopic ultrasound (EUS)-guided biopsy in its diagnosis.

PATIENT FINDINGS

A 56-year-old man underwent total thyroidectomy, right-modified neck dissection, and radioactive iodine (RAI) remnant ablation for PTC at age 47 years (in 2002). Between 2002 and 2007, he had three more neck surgeries, two RAI therapies, and external beam radiotherapy for persistent and subsequently metastatic PTC. In 2008, a computed tomography/positron emission tomography (CT/PET) scan showed an 18F-fluorodeoxyglucose (FDG)-avid pancreatic focus. Magnetic resonance imaging (MRI) revealed a pancreatic nodule at the same location. An EUS-guided biopsy confirmed the diagnosis of pancreatic metastasis from PTC, and molecular studies showed positive BRAF(V600E) mutation. He was treated with sorafenib for 6 months. Although a lung CT scan done 2 months after initiation of sorafenib suggested stability of the disease, MRI studies done at 3 and 6 months showed clear progression with an increase in the size of the lung and pancreatic metastases. Subsequently, he developed liver, bone, and omental metastases. He died in July 2011, 9 years and 8 months after the initial diagnosis of PTC and 20 months after discovery of the pancreatic metastasis.

SUMMARY

A middle-aged man with PTC developed lung metastases despite multiple surgeries and RAI therapies. Seven years after the initial diagnosis, a pancreatic metastasis was accidentally discovered. Both the metastasis and the primary thyroid tumor are positive for BRAF(V600E) mutation. The lung and pancreatic metastases progressed while the patient was receiving sorafenib for 6 months, and the patient died 20 months after diagnosis of pancreatic metastasis.

CONCLUSION

PTC rarely metastasizes to the pancreas. In this patient, an FDG PET scan and EUS-guided biopsy played important roles in the diagnosis. PTC metastases to the pancreas usually occur in otherwise advanced disease. In the patient presented here, sorafenib may have slowed disease progression but the overall utility of tyrosine kinase inhibitors in pancreatic metastases from PTC is not clear.

Endosonography in solid and cystic pancreatic tumors

Pancreatic tumors being either benign or malignant can be solid or cystic. Although diverse in presentation, their imaging features share commonalities and it is often difficult to distinguish these tumors. Endoscopic ultrasonography (EUS) is the most sensitive of the imaging procedures currently available for characterizing pancreatic tumors, and is especially good in identifying the smaller sized tumors. Additional applications inclusive of EUS-guided fine needle aspiration (EUS-FNA) are useful in tissue sampling and preoperative staging of pancreatic tumors.Although diagnostic capabilities have greatly evolved with advances in EUS and tissue processing technology (cytology, tumor markers, DNA analysis), differentiation of benign and malignant neoplasms, neoplastic and non-neoplastic (chronic pancreatitis) conditions, continues to be challenging.Recent innovative applications include contrast-enhanced EUS with Doppler mode, contrast-enhanced harmonic EUS, 3-dimensinal EUS, and EUS elastography. Incorporation of these methods has improved the differential diagnosis of pancreatic tumors. Finally, a multi-disciplinary approach involving radiology, gastroenterology and surgical specialties is often necessary for accurate diagnosis and management of solid and cystic pancreatic tumors.

EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain

BACKGROUND

Primary upper endoscopy (EGD) and transabdominal US (TUS) are often performed in patients with upper abdominal pain.

OBJECTIVE

Primary: Determine whether the combination of EGD and EUS was equivalent to EGD plus TUS in the diagnostic evaluation of upper abdominal pain. Secondary: Compare EUS versus TUS in detecting abdominal lesions, and compare EGD by using an oblique-viewing echoendoscope versus the standard, forward-viewing endoscope in detecting mucosal lesions.

DESIGN

Prospective, paired design.

SETTING

Six academic endoscopy centers.

PATIENTS

This study involved patients with upper abdominal pain referred for endoscopy.

INTERVENTION

All patients had EGD, EUS, and TUS. The EGD was done using both an oblique-viewing echoendoscope and the standard, forward-viewing endoscope (randomized order) by two separate endoscopists in a blinded fashion, followed by EUS. TUS was performed within 4 weeks of EGD/EUS, also in a blinded fashion.

FOLLOW-UP

telephone interviews and chart reviews.

MAIN OUTCOME MEASUREMENTS

Diagnose possible etiology of upper abdominal pain and detect clinically significant lesions.

RESULTS

A diagnosis of the etiology of upper abdominal pain was made in 66 of 172 patients (38%). The diagnostic rate was 42 of 66 patients (64%) for EGD plus EUS versus 41 of 66 patients (62%) for EGD plus TUS, which was statistically equivalent (McNemar test; P = .27). One hundred ninety-eight lesions were diagnosed with either EUS or TUS. EUS was superior to TUS for visualizing the pancreas (P < .0001) and for diagnosing chronic pancreatitis (P = .03). Two biliary stones were detected only by EUS. Two hundred fifty-one mucosal lesions were similarly diagnosed with EGD with either the standard, forward-viewing endoscope or the oblique-viewing echoendoscope (kappa = 0.48 [95% CI, .43-.54]). EGD with the standard, forward-viewing endoscope was preferred for biopsies.

LIMITATIONS

No cost analysis.

CONCLUSION

The combination of EGD with EUS is equivalent to EGD plus TUS for diagnosing a potential etiology of upper abdominal pain. EUS is superior to TUS for detecting chronic pancreatitis. EGD combined with EUS should be considered in the first-line diagnostic evaluation of patients with upper abdominal pain.

Contrast-enhanced harmonic EUS with novel ultrasonographic contrast (Sonazoid) in the preoperative T-staging for pancreaticobiliary malignancies

OBJECTIVE

Sonazoid is a new second-generation microbubble contrast for ultrasonography. In this pilot study, the diagnostic role of contrast-enhanced harmonic imaging endoscopic ultrasonography (CH-EUS) with Sonazoid was prospectively evaluated in preoperative T-staging of pancreaticobiliary malignancies.

PATIENTS AND METHODS

Patients with suspected pancreaticobiliary malignancies underwent CH-EUS by a single examiner. After the lesions were observed carefully with conventional harmonic imaging EUS (H-EUS), CH-EUS was performed with intravenous injection of Sonazoid. A reviewer who was blinded reviewed the recordings of H-EUS and CH-EUS and assessed the T-staging. The accuracy of H-EUS and CH-EUS for T-staging was compared to the results of surgical histopathology in patients who underwent surgery.

RESULT

Twenty-six patients underwent surgical resection and could be included in the study. The final diagnosis were pancreatic cancer in 11, bile duct cancer in 7, gallbladder cancer in 4 and ampullary cancer in 4. The overall accuracy of H-EUS and CH-EUS for T-staging were 69.2 (18/26) and 92.4% (24/26), respectively (p < 0.05). There were disagreement in six cases between H-EUS and CH-EUS. CH-EUS staged correctly in all of these six cases, whereas H-EUS misdiagnosed the depth of invasion in one case of gallbladder cancer and one case of ampullary cancer, and invasion of portal vein in two cases of pancreatic cancer and two cases of bile duct cancer.

CONCLUSION

The depth of invasion of biliary cancer and vascular invasion of pancreatic and biliary cancer could be demonstrated more clearly with CH-EUS compared to H-EUS. CH-EUS has the potential to improve the diagnostic accuracy of preoperative T-staging of pancreaticobiliary malignancies.

Diagnosis of pancreatic tumors by endoscopic ultrasonography

Pancreatic tumors are highly diverse, as they can be solid or cystic, and benign or malignant. Since their imaging features overlap considerably, it is often difficult to characterize these tumors. In addition, small pancreatic tumors, especially those less than 2 cm in diameter, are difficult to detect and diagnose. For characterizing pancreatic tumors and detecting small pancreatic tumors, endoscopic ultrasonography (EUS) is the most sensitive of the imaging procedures currently available. This technique also provides good results in terms of the preoperative staging of pancreatic tumors. EUS-guided fine needle aspiration (EUS-FNA) has also proved to be a safe and useful method for tissue sampling of pancreatic tumors. Despite these advantages, however, it is still difficult to differentiate between benign and malignant, solid or cystic pancreatic tumors, malignant neoplasms, and chronic pancreatitis using EUS, even when EUS-FNA is performed. Recently, contrast-enhanced EUS with Doppler mode (CE-EUS) employing ultrasound contrast agents, which indicate vascularization in pancreatic lesions, has been found to be useful in the differential diagnosis of pancreatic tumors, especially small pancreatic tumors. However, Doppler ultrasonography with contrast-enhancement has several limitations, including blooming artifacts, poor spatial resolution, and low sensitivity to slow flow. Consequently, an echoendoscope was developed recently that has a broad-band transducer and an imaging mode that was designed specifically for contrast-enhanced harmonic EUS (CEH-EUS) with a second-generation ultrasound contrast agent. The CEH-EUS technique is expected to improve the differential diagnosis of pancreatic disease in the future. This review describes the EUS appearances of common solid and cystic pancreatic masses, the diagnostic accuracy of EUS-FNA, and the relative efficacies and advantages of CE-EUS and CEH-EUS along with their relative advantages and their complementary roles in clinical practice.

The role of endoscopic ultrasonography in the evaluation of pancreatico-biliary cancer

Accurate staging of pancreatico-biliary cancer is essential for surgical planning and for identification of locally advanced and metastatic disease that is incurable by surgery. The complex regional anatomy of the pancreatico-biliary system makes histologic diagnosis of malignancy at this region difficult. The ability to position the endoscopic ultrasound transducer at endoscopy in direct proximity to the pancreas and the bile duct, combined with the use of fine-needle aspiration, enables accurate preoperative staging of cancer, especially cancer too small to be characterized by CT or MRI. Endoscopic ultrasonography (EUS) identifies patients unlikely to be cured by surgery due to vascular invasion or regional nodal metastasis, thereby limiting procedure-related morbidity and mortality. This article focuses on the utility and recent advances of EUS in the evaluation of pancreatico-biliary cancer.

Absence of a dilated duct predicts benign disease in suspected pancreas cancer: a simple clinical rule

BACKGROUND

Pancreatic cancer can be difficult to diagnose. Fine-needle aspiration (FNA) biopsies may be negative even when malignancy is present.

AIMS

To identify endosonographic features predictive of malignancy that will separate patients into high- and low-risk groups, in whom a negative FNA effectively rules out malignancy.

METHODS

Patients presenting for endoscopic ultrasound (EUS) evaluation for suspected pancreatic mass were prospectively enrolled. If a mass or abnormal lymph nodes were present, sampling via fine-needle aspiration (FNA) was performed. The characteristics of patients with cancer were compared to the characteristics of patients without cancer using Chi-square testing and t-tests.

RESULTS

Seventy-three patients were enrolled. Thirty-three patients had cancer and 40 had benign disease. On multivariate analysis, only vascular or organ invasion and dilation of the pancreatic duct (PD) were significantly associated with cancer. PD dilation was examined as a stand-alone feature. The presence of a dilated PD placed patients into a group with a 65% prevalence of malignancy. In the non-dilated PD group, the prevalence of malignancy was only 17%, and in this group, the negative predictive value of FNA was 100%, compared to an NPV of 73% in the entire cohort.

CONCLUSIONS

The most significant negative predictive endosonographic finding in patients with suspected pancreatic cancer is a non-dilated PD. If a patient with suspected pancreatic cancer does not have a dilated PD and the FNA is negative for malignancy, the likelihood of cancer is low.

Endosonography in the management of biliopancreatic disorders

Over the past two decades, endoscopic endosonography (EUS) has evolved into an indispensible diagnostic and therapeutic utility in the diagnosis and treatment of patients with pancreatobiliary disease. In this article, we summarise its current potential and provide an update of the latest literature.

Diagnosis of pancreatic tumors by endoscopic ultrasound-guided fine-needle aspiration

AIM: To evaluate the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic solid tumors larger or smaller than 3 cm, and cystic lesions.

METHODS: From January/1997 to December/2006, 611 patients with pancreatic tumors were subjected to EUS-FNA. The final diagnosis was obtained either by surgery (356 cases) or after a mean clinical follow-up of 11.8 mo in the remaining patients.

RESULTS: There were 405 solid tumors, 189 cystic lesions and 17 mixed. Pancreatic specimens for cytological assessment were successfully obtained by EUS-FNA in 595 (97.4%) cases. There were 352 (57.6%) malignancies and 259 (42.4%) benign tumors. Among the malignancies, pancreatic adenocarcinomas accounted for 67% of the lesions. Overall, the sensitivity, specificity, positive and negative predictive values, and accuracy of EUS-FNA were, respectively, 78.4%, 99.2%, 99.3%, 77.2% and 87.2%. Specifically for solid tumors, the same parameters for neoplasms larger and smaller than 3 cm were, respectively, 78.8% vs 82.4%, 100% vs 98.4%, 100% vs 99%, 54.8% vs 74.1% and 83.1% vs 87.8%. For cystic lesions, the values were, respectively, 72.2%, 99.3%, 97.5%, 91% and 92.2%.

CONCLUSION: EUS-FNA can be used to sample pancreatic tumors in most patients. Even though the negative predictive value is inadequate for large solid tumors, the results are rather good for small solid tumors, especially concerning the sensitivity, negative predictive value and diagnostic accuracy. Among all pancreatic lesions, EUS-FNA for cystic lesions can reveal the best negative predictive value and diagnostic accuracy, both higher than 90%.

Assessment of pancreatic neoplasms: review of biopsy techniques

Pancreatic cancer is the 4th leading cause of cancer death annually. Recent technological advances in imaging have led to non-uniformity in the evaluation of pancreatic neoplasms. The following article describes the history behind various biopsy techniques and the rationale for obtaining a biopsy of a pancreatic neoplasm and discusses the benefits and disadvantages of the various pancreatic biopsy techniques, including fine needle aspiration biopsy, Tru-cut needle biopsy, endoscopic brushings/cytology, and endoscopic ultrasound guided biopsies. A treatment algorithm for pancreatic neoplasms is then presented.

Endoscopic ultrasound in patients with obstructive jaundice and inconclusive ultrasound and computer tomography findings

The clinical work-up of patients with presumed pancreaticobiliary obstruction is usually straightforward including laboratory investigation, abdominal ultrasound and computer tomography. Ultrasound and computer tomography may, however, yield inconclusive findings regarding underlying cause. We report a case series (n = 10) demonstrating the usefulness of endoscopic ultrasound in the work-up of patients with inconclusive ultrasound and computer tomography findings, clinically suspected of pancreaticobiliary cancer.

Comparison of endoscopic ultrasound and computed tomography for the preoperative evaluation of pancreatic cancer: a systematic review

BACKGROUND & AIMS

It is uncertain whether computed tomography (CT) or endoscopic ultrasound (EUS) is superior for the detection, staging, and resectability of pancreatic cancer. We therefore performed a systematic literature review to determine which test is more accurate.

METHODS

We identified relevant studies from MEDLINE (1986-2004) and evaluated study quality, which was measured on the basis of guidelines for assessing studies of diagnostic tests. Quantitative outcomes data were abstracted from the studies.

RESULTS

Eleven studies with 678 patients satisfied inclusion criteria. Nine studies assessed tumor detection, all of which concluded that the sensitivity of EUS was superior to CT. Four of 5 studies that assessed tumor staging accuracy and 5 of 8 that assessed nodal staging accuracy concluded that EUS was superior to CT. Among the 4 studies that assessed resectability, 2 showed no difference between EUS and CT, and 1 favored each modality. Three of 11 studies met all but one of the quality criteria. The most important and frequent study limitations were lack of a consecutive series of patients and biased patient selection for surgery. Quantitative comparisons among studies were precluded by differences in tumor staging classifications, surgical selection, CT and EUS techniques, and reporting of operating characteristics.

CONCLUSIONS

The published literature comparing EUS and CT for preoperative assessment of pancreatic cancer is heterogeneous in study design, quality, and results. All studies have methodologic limitations that potentially affect validity. Prospective studies with state-of-the-art imaging are needed to further define the role of each test.

Evidence-based diagnosis and staging of pancreatic cancer

Only 20% of patients who present with pancreatic cancer will be amenable to potentially curative resection. Therefore, it is necessary to reliably identify patients who might benefit from major surgical intervention by employing the appropriate staging methods. In this review, the pros and cons of each imaging technique are discussed and an algorithm for single and combined use of the different imaging modalities is proposed. To date, contrast-enhanced multi-detector row helical CT (MDR-CT) together with endoscopic ultrasound (EUS) remain the first staging methods of choice. MDR-CT has a high sensitivity for identifying vascular invasion and EUS is able to detect lesions as small as 2-3 mm. ERCP is performed mainly in patients with biliary obstruction with the option for therapeutic intervention during the same session. MRI with MR-angiography, MRCP, PET/CT and staging laparoscopy are additional modalities which might give further information in cases of equivocal findings by MDR-CT and EUS. The role of tumour markers such as CA 19-9 and CEA is reserved for monitoring and diagnosing post-surgery recurrence. Cytological or histological confirmation should usually be performed in patients that are not eligible for surgery prior to the commencement of palliative radio- or chemotherapy. In the routine clinical setting, MDR-CT and EUS play the predominant roles by providing the most cost-effective and accurate means for diagnosing and staging most cases of pancreatic cancer.

Interventional endoscopic ultrasound in pancreatic diseases

During the last 15 years, endoscopic ultrasound (EUS) has become an important imaging procedure for diagnosis and management of pancreatic diseases. The clinical interest of EUS is now enhanced by interventional procedures. Noteworthy, fine-needle aspiration biopsy is one of the most important contributions of EUS, in particular for the investigation of patients with pancreatic cancer and cystic tumors. EUS-guided fine-needle aspiration appears to be a safe and reliable technique to obtain tissue from pancreatic masses with a low risk of complications. EUS became also a therapeutic procedure, especially applied for celiac plexus neurolysis, pseudocyst drainage, and pancreaticogastrostomy. Further developments are expected by improvement of needle devices such as pancreatic pseudocyst drainage kits. In the future, EUS might be also a support for local application of new treatments of pancreatic tumors, such as gene or cellular therapy products. In this review, we discuss the current clinical applications of interventional EUS and the future development for diagnosis and management of pancreatic diseases.

Preoperative assessment of pancreatic tumors using magnetic resonance imaging, endoscopic ultrasonography, positron emission tomography and laparoscopy

BACKGROUND

The appropriate preoperative evaluation of a pancreatic tumor remains a matter of debate.

METHODS

We retrospectively evaluated an institutional strategy including magnetic resonance imaging (MRI), endoscopic ultrasonography (EUS), positron emission tomography (PET) and laparoscopy (LAP) for detection and staging of pancreatic tumors suspected to be malignant.

RESULTS

In a consecutive series of 59 patients screened by MRI, PET, EUS and LAP between July 1998 and November 2002, 48 patients were found to bear pancreatic adenocarcinoma and surgery was performed in 27 of them. For tumor detection, the sensitivity of EUS was superior to MRI and PET (98 vs. 87.5 and 87.5%, respectively, p = 0.13). MRI best assessed loco-regional staging, i.e. arterial involvement. For the detection of distant metastases, the sensitivity of all preoperative examinations taken separately was low. When laparotomy was performed with a curative intent according to all four examinations, occult metastasis or carcinomatosis was discovered in 7/27 patients and the overall predictive value of resectability was thus 74%. Five-year and median survival were significantly better in resected vs. non-resected patients (39% and 26 months vs. 0% and 8 months, p = 0.0006).

CONCLUSIONS

MRI can be recommended has the first examination in patients bearing pancreatic tumors, complemented by EUS if the findings of MRI are non-conclusive. For detection of distant metastasis, only the combination of all preoperative examination was proved to be more accurate than a single technique.

Ultrasonography, computed tomography and magnetic resonance imaging for diagnosis and determining resectability of pancreatic adenocarcinoma: a meta-analysis

OBJECTIVE

To compare ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) in the diagnosis and determination of resectability of pancreatic adenocarcinoma.

METHODS

Articles reporting US, CT, or MRI data of patients with known or suspected pancreatic adenocarcinoma and at least 20 patients verified with histopathology, surgical findings, or follow-up were included. A bivariate random effects approach was used to calculate sensitivity and specificity for diagnosis and resectability of pancreatic adenocarcinoma.

RESULTS

Sixty-eight articles fulfilled all inclusion criteria. For diagnosis, sensitivities of helical CT, conventional CT, MRI, and US were 91%, 86%, 84%, and 76% and specificities were 85%, 79%, 82%, and 75% respectively. Sensitivities for MRI and US were significantly lower compared with helical CT (P = 0.04 and P = 0.0001). For determining resectability, sensitivities of helical CT, conventional CT, MRI, and US were 81%, 82%, 82, and 83% and specificities were 82%, 76%, 78%, and 63% respectively. Specificity of US was significantly lower compared with helical CT (P = 0.011).

CONCLUSIONS

Helical CT is preferable as an imaging modality for the diagnosis and determination of resectability of pancreatic adenocarcinoma.

The role of endoscopic ultrasonography in the evaluation of pancreatico-biliary cancer

Accurate staging of pancreatico-biliary cancer is essential for surgical planning and for identification of locally advanced and metastatic disease that is incurable by surgery. The complex regional anatomy of the pancreatico-biliary system makes histologic diagnosis of malignancy at this region difficult. The ability to position the endoscopic ultrasound transducer at endoscopy in direct proximity to the pancreas and the bile duct, combined with the use of fine-needle aspiration, enables accurate preoperative staging of cancer, especially cancer too small to be characterized by CT or MRI. Endoscopic ultrasonography (EUS) identifies patients unlikely to be cured by surgery due to vascular invasion or regional nodal metastasis, thereby limiting procedure-related morbidity and mortality. This article focuses on the utility and recent advances of EUS in the evaluation of pancreatico-biliary cancer.

Prognostic predictive value of endoscopic ultrasound findings for invasive ductal carcinomas of pancreatic head

OBJECTIVES

Accurate preoperative prediction of the prognosis of patients with invasive ductal carcinoma of pancreatic head (pancreatic head cancer) is important for selecting treatment methods. We retrospectively examined the prognostic predictive values of endoscopic ultrasound (EUS) findings for patients with this disease.

METHODS

The subjects were 66 patients with pancreatic head cancer who had undergone EUS. We examined each EUS finding as a possible prognostic predictor, including heterogeneity of internal echo, irregularity of peripheral echo, clarity of boundary echo, dilatation of the main pancreatic duct (MPD), dilatation of the common bile duct, lymph node swelling, vessel invasion, and the presence of ascites, by univariate and multivariate analysis for survival.

RESULTS

Irregular peripheral echo, portal vein invasion, superior mesenteric artery/celiac artery invasion, and the presence of ascites were significant predictors of a poorer prognosis by univariate analysis for survival. In resectable cases, EUS findings of MPD dilatation and portal invasion were significant prognostic predictors by univariate analysis, and MPD dilatation was an independent prognostic predictor by multivariate analysis.

CONCLUSION

EUS may be useful for predicting the prognosis of patients with pancreatic head cancer, based on the accuracy it provides in evaluating locoregional spreading.

Endoscopic ultrasound in the diagnosis, staging, and management of gastrointestinal and adjacent malignancies

Endoscopic ultrasound (EUS) is a superior modality for local staging of gastrointestinal cancer. In interventional endosonography linear array echoendoscopes permit real-time EUS-guided puncture of target lesions for cytologic evaluation of such lesions. This article describes the basic principles of EUS, established indications pertaining to gastrointestinal cancer and other malignancies, and emerging indications for this minimally invasive technology.

Endoscopic ultrasound-guided fine needle aspiration and multidetector spiral CT in the diagnosis of pancreatic cancer

INTRODUCTION

Endoscopic ultrasound (EUS) is now established as a valuable imaging test for diagnosing and staging pancreatic cancer. But, with significant recent improvements in spiral CT scanners, particularly higher resolution and ability to reconstruct 3D images, spiral CT is now increasingly accepted as being better for pancreatic cancer staging. The debate continues, however, about the best diagnostic test or combination of tests in patients with suspected pancreatic cancer. Spiral CT is more readily available than EUS-FNA and, therefore, more frequently used. In this study, we evaluated the use of EUS-FNA in conjunction with spiral CT for suspected pancreatic cancer.

METHODS

We retrospectively evaluated 81 consecutive patients who underwent EUS and EUS-FNA for clinical suspicion of a pancreatic cancer from November 2000 to November 2001. All patients had spiral CT with a multiphasic pancreatic protocol using multidetector spiral CT scanners. In all patients, EUS-FNA and spiral CT examinations were performed less than 3 wk apart.

RESULTS

Overall, the accuracy of spiral CT, EUS, and EUS-FNA was 74% (n = 60/81, CI 63-83%), 94% (n = 76/81, CI 87-98%), and 88% (n = 73/81, CI 81-96%), respectively, for diagnosing pancreatic cancer. In patients without an identifiable mass on spiral CT, the diagnostic accuracy of EUS and EUS-FNA for pancreatic tumors was 92% (n = 23/25, CI 74-99%). Absence of a focal "mass" lesion on EUS reliably excluded pancreatic cancer irrespective of clinical presentation (NPV 100% n = 5/5, CI 48-100%). The negative predictive value of EUS-FNA was only 22% (n = 2/9, CI 3-60%) in patients with obstructive jaundice and biliary stricture. However, in patients without obstructive jaundice at initial presentation, EUS-FNA was highly accurate (accuracy 97%, n = 33/34, CI 85-100%) and was reliable for ruling out malignancy (NPV 89%, n = 8/9, CI 52-100%). Cytologic assessment of EUS-FNA specimens was 89% accurate for identifying malignancy in suspicious lesions visualized on EUS.

CONCLUSIONS

The EUS with FNA can be a valuable adjunct to newer high-resolution multidetector spiral CT for diagnostic evaluation of patients with suspected pancreatic cancer.

Pancreatic carcinomas smaller than 3.0 cm: endosonography (EUS) in diagnosis, staging and prediction of resectability

BACKGROUND

The size of a pancreatic carcinoma determines prognosis and resection. The aim of this study was to review our clinical experience with endoscopic ultrasound (EUS) in diagnosing and staging pancreatic tumours <3.0 in diameter.

METHODS

From February 1997 to October 2000 medical records and results of abdominal ultrasound (US), spiral computed tomography (CT) and EUS with fine-needle aspiration biopsy (FNA) were reviewed in 17 patients operated for histologically proven pancreatic adenocarcinoma measuring <or= 3.0 cm in diameter. The mean age of the patients was 64 years (range 42-76 years).

RESULTS

US identified a pancreatic lesion in 11/17 (65%) patients. Spiral CT showed a total of 16/17 (94%) patients with a lesion. EUS identified pancreatic tumour in all patients (100%), and tissue was obtained from 15/17 patients (88%). Mean tumour size was 2.5 cm (range 0.8-3.0 cm). EUS accuracy in evaluating the portal vessels was 78%, superior mesenteric artery 100%, tumour stage (T) 88%, isolated node stage (N) 65% and combined TN staging was 53%. Regarding resectability, EUS sensitivity was 88%, specificity 89%, negative predictive value 89%, positive predictive value 88% and accuracy 88%. Besides cytological material, EUS-FNA histological diagnosis was possible in 12/17 patients (71%). There was only one case of mild post-procedure acute pancreatitis.

CONCLUSION

EUS-FNA is safe and has high diagnostic (100%) and local staging (88%) accuracy in pancreatic cancers <3.0 cm in diameter.

Premalignant conditions of the pancreas

Premalignant conditions of the pancreas include benign tumours of the pancreas, intraepithelial neoplasia arising within pancreatic ducts, and tumours of the neuroendocrine cells of the pancreas. In addition, there is a variety of rare genetic conditions that predispose to pancreatic exocrine malignancies such as Peutz-Jeghers syndrome, hereditary non-polyposis colorectal cancer syndrome, familial pancreatitis, germline BRCA2 mutations, and pancreatic endocrine malignancies such as type 1 neurofibromatosis (von Recklinghausen's disease) and multiple endocrine neoplasia type 1. More controversial is the concept of chronic pancreatitis and diabetes mellitus as conditions that increase the risk of pancreatic cancer. However, there is no doubt that smoking is a potentiating factor for pancreatic cancer, especially in people who have familial/genetic risk factors. This review will include the recently proposed new nomenclature and classification system for intraepithelial neoplasia in the pancreatic ducts, an overview of the various familial syndromes that are associated with an increased risk of pancreatic tumours, the surveillance programmes that have been introduced to monitor such families, and methods for early diagnosis.

Endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography imaging for pancreaticobiliary pathology: the gastroenterologist's perspective

With advances in noninvasive radiologic technology, additional adjunctive techniques are developing, and the roles for ERCP and EUS are continuously changing. In a diagnostic setting, ERCP is currently best reserved for patients with a high likelihood of needing endoscopic therapy, and EUS is especially useful for cases in which other imaging techniques have been inconclusive or are of inferior diagnostic capability. In a therapeutic setting, ERCP and EUS retain important roles in the management of both benign and malignant pancreatic and biliary disease. Certainly, technological advances also directly affect these modalities and expanded applications for ERCP and EUS for the pancreas and biliary tract are anticipated.

Gastrointestinal endoscopic ultrasonography

Although conventional endoscopy provides excellent visualization of gastrointestinal mucosa, it provides little information about intramural or nearby extramural lesions. The imaging of intraabdominal structures by conventional transabdominal ultrasound is degraded by ultrasound energy attenuation with distance. The provision of an ultrasound probe on a flexible gastrointestinal endoscope, to form an echoendoscope, provides excellent imaging of the gastrointestinal wall and of adjacent extramural structures. During the last two decades, endoscopic ultrasound, using an echoendoscope, has revolutionized the diagnosis and treatment of gastrointestinal diseases that affect the submucosa, deep bowel wall, and adjacent extramural structures. This article reviews the role of endoscopic ultrasound in the diagnosis and treatment of gastrointestinal disease, including standard and promising new applications, as well as standard and emerging new technology.

Use of a phased vector array US catheter for EUS

BACKGROUND

Existing EUS catheter probes have limited depth of penetration and lack color flow and Doppler capabilities. This study prospectively assessed the feasibility and safety of using a phased vector array US catheter in the human GI tract.

METHODS

Eleven patients underwent EUS with a steerable 9F phased vector array catheter. Images obtained with the catheter were compared with standard EUS images.

RESULTS

The GI wall layers were equally well imaged with the catheter compared with standard echoendoscopes in 90% of the cases. Images of the liver, spleen, pancreatic parenchyma, and pancreatic duct were of equal quality and resolution with both techniques in the majority of patients. Some deeper structures and blood vessels were better visualized with the catheter. No complications were encountered.

CONCLUSION

The steerable phased vector array US catheter is a safe device when used in the GI tract and offers images comparable with those obtained with a dedicated echoendoscope. Further studies are needed to determine the accuracy of tumor staging and clinical utility of this device.

Endosonography-guided fine needle aspiration biopsy in the evaluation of pancreatic masses

OBJECTIVES

Diagnosis of pancreatic tumors can be problematic. This study aimed to determine the performance of endoscopic ultrasound-guided fine needle aspiration biopsy (EUS FNA) in pancreatic malignancy when prior biopsies performed by CT guidance or ERCP were negative.

METHODS

A total of 185 patients with known or suspected pancreatic masses were prospectively evaluated with EUS FNA. Before EUS FNA, all patients were evaluated with abdominal CT (61 with CT-guided biopsy) and 91 with ERCP (41 had brushings or biopsy).

RESULTS

EUS had greater sensitivity than CT in detecting a mass (99% vs 57%, p < 0.0001). In 58 patients with negative CT-guided biopsies, EUS FNA had 90% sensitivity for malignancy, 50% specificity for benign disease and 84% accuracy. Similarly, in 36 patients with negative ERCP tissue sampling, results for EUS FNA were 94%, 67% and 92%, respectively. Complications were mild and infrequent (0.5%).

CONCLUSION

EUS FNA of pancreatic masses safely and accurately diagnoses pancreatic malignancy when prior biopsy techniques have been unsuccessful.

Endoscopic retrograde cholangiopancreatography should no longer be used as a diagnostic test: the case in favour

The requirement for diagnostic endoscopic retrograde cholangiopancreatography has decreased considerably in the past 10 years. Alternative imaging techniques are now available for the diagnosis of bile duct stones, pancreatic and biliary tract malignancy and inflammatory diseases such as sclerosing cholangitis and chronic pancreatitis. The imaging techniques include endoscopic ultrasonography, magnetic resonance cholangiopancreatography and helical computed tomography. There is good evidence that these techniques have an accuracy comparable to endoscopic retrograde cholangiopancreatography in the diagnosis of diseases of the bile and pancreatic ducts. All of these methods are less invasive than endoscopic retrograde cholangiopancreatography and have extremely low or negligible complication rates. The choice of technique used depends on local availability and expertise. In future, endoscopic retrograde cholangiopancreatography will be reserved exclusively for therapeutic applications.

A resource utilization projection study of EUS

BACKGROUND

EUS has emerged as standard practice with respect to the diagnosis and staging of GI malignancies. Whether currently available resources are sufficient to meet the potential need for EUS is uncertain. This study examines the hypothetical demand for EUS in the United States.

METHODS

EUS cases performed at 3 centers with well-established expertise in EUS in 1997 were retrospectively reviewed and trends were extrapolated to national cancer statistics. Indications for EUS fell into 3 categories: (1) diagnosis/staging of esophageal, gastric, pancreatic, or rectal cancers (established indications); (2) suspected GI malignancy (obligate "rule out"); and (3) "other" (emerging indications). Hypothetical total numbers of cases in which EUS could be performed in the United States were calculated taking into consideration the expected number of GI malignancies for which EUS would be appropriate (based on cancer statistics for 2000), the fraction unresectable by CT, the fraction of elderly nonsurgical candidates, proportionate "rule out" cases, as well as "other" emerging indications.

RESULTS

The calculated hypothetical number of cases (United States) in which EUS would be indicated is 79,568 per year (10,287 esophagus, 10,666 stomach, 23,069 pancreas, and 35,546 rectal). If "other" indications remained constant at 12%, there would potentially be 89,116 EUS procedures performed per year, with a conservative estimate of 79,572 per year.

CONCLUSIONS

This model suggests that currently available EUS resources are not sufficient to meet hypothetical demand. Future considerations include the number of endoscopy units in which EUS is performed, the capacity of individual units, and the implications for training programs in the United States.

Usefulness of endoscopic ultrasonography (EUS) in diagnosing esophageal infiltration of thyroid cancer

Pre-operative evaluation of esophageal infiltration is sometimes difficult in patients with advanced thyroid cancer even with recent imaging modalities. We evaluated the accuracy of endoscopic ultrasonography (EUS) in diagnosing esophageal infiltration of thyroid cancer. Twenty-nine patients with advanced thyroid cancer underwent EUS and other imaging examinations before surgery. The diagnostic accuracy of EUS was compared with that of magnetic resonance imaging (MRI) and esophagography based on pathologic findings in 27 of the 29 cases. EUS clearly demonstrated the 5-layer structure of the esophageal wall. EUS detected cancer invasion into the muscularis propria of the esophagus correctly in 8 of 10 patients diagnosed pathologically with muscular infiltration. EUS was significantly more accurate than MRI and esophagography (88.9% vs 63.0% and 66.7%, respectively). The specificity of EUS was also significantly better than the specificities of MRI or esophagography (94.1% vs 58.8% and 64.7%, respectively). The sensitivity, positive predictive value and negative predictive value of EUS tended to be better than those of MRI and esophagography. EUS is useful in evaluating the esophageal infiltration of thyroid cancer. This method has the further advantage of detecting the exact depth of cancer invasion into the esophageal wall.

Is a preoperative multidiagnostic approach to predict surgical resectability of periampullary tumors still effective?

BACKGROUND

Multimodality staging is recommended in patients with periampullary tumors to optimize preoperative determination of resectability. We investigated the potency of currently used diagnostic procedures in order to determine resectability.

METHODS

Ninety-five consecutive patients with periampullary tumors prehospitally staged resectable underwent preoperative diagnostic tests: helical-computed tomography (CT) with maximum intensity projection of arterial vessels (MIP), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreaticography (MRCP), endoscopic ultrasonography (EUS), endoscopic retrograde cholangiopancreaticography (ERCP), digital subtraction angiography (DSA), and positron emission tomography (PET). Diagnoses were verified by surgery and histopathology.

RESULTS

In 45 patients with benign and 50 patients with malignant periampullary tumors sensitivity for tumor diagnosis was 89% to 96% in CT, MRI, EUS, and PET. Small tumors were best diagnosed by EUS (100%). Diagnosis of malignancy was made with 85% (EUS), 83% (CT), 82% (PET), and 72% (MRI) accuracy. Arterial vessel infiltration was best predicted by CT/MIP with an accuracy of 85%. For venous vessel infiltration MRI reached 85% accuracy. Accuracy rates for local nonresectability were 93% (EUS), 92% (MRI), and 90% (CT). Two and 4 of 8 patients with distant metastases were identified by CT and PET, respectively. The correct diagnosis of malignancy and determination of resectability was made by CT in 71% and by MRI in 70%. Biliary stenting reduced accuracy of CT diagnosis of malignancy from 88% to 73%.

CONCLUSIONS

CT obtained before stenting was the single most useful test, providing correct diagnosis in 88% and resectability in 71% of patients. If no tumor is depicted in CT, EUS should be added. Uncertain venous vessel infiltration can be verified by MRI or EUS. Angiography should no longer be a routine diagnostic procedure. Equivocal tumors or possible metastasis may be further examined with PET.

Current status of diagnostic and therapeutic endoscopic ultrasonography

Endoscopic ultrasonography is firmly established as an imaging modality that can be used for diagnosing and staging both malignant and nonmalignant disorders of the pancreas, gastrointestinal tract, biliary tree, and mediastinum. In the future, as more physicians are trained and as technologic developments continue to advance, endosonography will likely assume a greater role in therapeutic management.

Update on familial pancreatic cancer

Approximately 5% to 10% of patients with pancreatic cancer have one or more first-degree relatives with this disease. A subset of these individuals have a hereditary form of pancreatic cancer designated by association with such hereditary disorders as familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer, hereditary pancreatitis, or familial atypical multiple mole melanoma (FAMMM) syndrome. A subset of those FAMMM kindred with the CDKN2A (p16) germline mutation that expresses both pancreatic cancer and malignant melanoma may constitute a new hereditary pancreatic cancer-prone syndrome.