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 Table of Contents  
COMMENTARY
Year : 2017  |  Volume : 6  |  Issue : 9  |  Page : 69-70

The resectable pancreatic ductal adenocarcinoma: To FNA or not to FNA? A diagnostic dilemma, introduction


Medical Department, Caritas Krankenhaus, Uhlandstr. 7, D-97980 Bad Mergentheim, Germany; Ultrasound Department, First Affiliated Hospital of Zhengzhou University Zhengzhou, Henan Province, China, Germany

Date of Submission12-Jul-2017
Date of Acceptance31-Aug-2017
Date of Web Publication29-Dec-2017

Correspondence Address:
Dr. Christoph F Dietrich
Department of Internal Medicine 2, Caritas-Hospital Bad Mergentheim, Uhlandstr. 7, D-97980 Bad Mergentheim
Germany
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/eus.eus_63_17

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How to cite this article:
Dietrich CF. The resectable pancreatic ductal adenocarcinoma: To FNA or not to FNA? A diagnostic dilemma, introduction. Endosc Ultrasound 2017;6, Suppl S3:69-70

How to cite this URL:
Dietrich CF. The resectable pancreatic ductal adenocarcinoma: To FNA or not to FNA? A diagnostic dilemma, introduction. Endosc Ultrasound [serial online] 2017 [cited 2018 Oct 17];6, Suppl S3:69-70. Available from: http://www.eusjournal.com/text.asp?2017/6/9/69/221932



In most patients (up to 95%), pancreatic ductal adenocarcinoma (PDAC) is diagnosed late with locally advanced or metastatic disease [1],[2] with a low overall 5-year survival rate <5%.[3],[4] In addition and due to the fact, that the prevalence of differential diagnosis (e.g., pancreatic neuroendocrine neoplasia and metastases) is reported to be low (<5%). Current guidelines [5],[6],[7] and international consensus guidelines [8] recommend radical surgery for all small solid pancreatic lesions (SPL) unless contraindications are present or a strong suspicion of a specific diagnosis other than PDAC is raised due to patients history or ambiguous imaging results. In principle, all small SPL are presumed to be PDAC if not otherwise proven; and therefore, radical surgery is recommended without prior histological or cytological verification.[8],[9]

The role of conventional imaging methods, for example, ultrasound, computed tomography (CT), and magnetic resonance imaging in the differential diagnosis of pancreatic masses was reported to be disappointing.[4],[8],[10] Today, improved imaging techniques allow detection of smaller SPL other than PDAC, and this might change management.[9],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22] Therefore, in patients with small SPL the differential diagnosis could be evaluated to determine the indication for radical surgery.[23] This has been strengthened by the inclusion of endoscopic ultrasound (EUS) in the National Comprehensive Cancer Network guidelines.[24] Preoperative diagnosis of T1 carcinoma (<20 mm) is rare (<5%). In an analysis of 13.131 PDAC cases, only 3.11% were staged as stage T1a.[2] In large retrospective cohort studies of patients with small SPL (≤10 mm or ≤15 mm) diagnosed using EUS-guided fine-needle aspiration (FNA), only 4.3%–22.5% were finally diagnosed as PDAC.[9],[25]

EUS-FNA is currently considered the method of choice to diagnose small SPL, also providing tissue sampling. EUS-FNA is 80%–90% sensitive and nearly 100% specific for the diagnosis of pancreatic malignancy.[26],[27],[28],[29] EUS and EUS-FNA accurately diagnosed pancreatic cancer in 23 of 25 patients (92%) in whom the mass was undetected by CT [22] and in 92% of patients without a definite mass on CT.[25] The risk of adverse events caused by EUS-FNA of SPL is very low and inversely related to tumor size.[30] EUS-FNA is an invasive procedure with a small, but not negligible risk profile in regard to bleeding, perforation, and tumor cell seeding.[31],[32],[33],[34] EUS-FNA currently may be regarded the “gold-standard” of the final diagnosis in small SPL and in SPL with inconclusive CT findings.

In the two following papers, the pros and cons of FNA before surgery in resectable PDAC are discussed.



 
  References Top

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2.
Yu J, Blackford AL, Dal Molin M, et al. Time to progression of pancreatic ductal adenocarcinoma from low-to-high tumour stages. Gut 2015;64:1783-9.  Back to cited text no. 2
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D'Onofrio M, Zamboni GA, Malagò R, et al. Resectable pancreatic adenocarcinoma: Is the enhancement pattern at contrast-enhanced ultrasonography a pre-operative prognostic factor? Ultrasound Med Biol 2009;35:1929-37.  Back to cited text no. 3
    
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Network NCC. NCCN Clinical Practice Guidelines in Onkology (NCCN Guidelines): Pancreatic Adenocarcinoma; 2015. Available from: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp. [Last Accessed on 2017 Jul 29].  Back to cited text no. 4
    
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Seufferlein T, Bachet JB, Van Cutsem E, et al. Pancreatic adenocarcinoma: ESMO-ESDO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012;23 Suppl 7:vii33-40.  Back to cited text no. 5
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Tempero MA, Arnoletti JP, Behrman S, et al. Pancreatic adenocarcinoma. J Natl Compr Canc Netw 2010;8:972-1017.  Back to cited text no. 7
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Asbun HJ, Conlon K, Fernandez-Cruz L, et al. When to perform a pancreatoduodenectomy in the absence of positive histology? A consensus statement by the International Study Group of Pancreatic Surgery. Surgery 2014;155:887-92.  Back to cited text no. 8
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Dietrich CF, Sahai AV, D'Onofrio M, et al. Differential diagnosis of small solid pancreatic lesions. Gastrointest Endosc 2016;84:933-40.  Back to cited text no. 9
    
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Network NCC, editor. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Neurodendocrine Tumors; 2015. Available from: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp. [Last Accessed on 2017 Jul 29].  Back to cited text no. 10
    
11.
Piscaglia F, Nolsøe C, Dietrich CF, et al. The EFSUMB guidelines and recommendations on the clinical practice of contrast enhanced ultrasound (CEUS): Update 2011 on non-hepatic applications. Ultraschall Med 2012;33:33-59.  Back to cited text no. 11
    
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D'Onofrio M, Barbi E, Dietrich CF, et al. Pancreatic multicenter ultrasound study (PAMUS). Eur J Radiol 2012;81:630-8.  Back to cited text no. 12
    
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ASGE Standards of Practice Committee, Eloubeidi MA, Decker GA, et al. The role of endoscopy in the evaluation and management of patients with solid pancreatic neoplasia. Gastrointest Endosc 2016;83:17-28.  Back to cited text no. 13
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Braden B, Jenssen C, D'Onofrio M, et al. B-mode and contrast-enhancement characteristics of small nonincidental neuroendocrine pancreatic tumors. Endosc Ultrasound 2017;6:49-54.  Back to cited text no. 14
    
15.
Dietrich CF, Braden B, Hocke M, et al. Improved characterisation of solitary solid pancreatic tumours using contrast enhanced transabdominal ultrasound. J Cancer Res Clin Oncol 2008;134:635-43.  Back to cited text no. 15
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16.
Dietrich CF, Ignee A, Braden B, et al. Improved differentiation of pancreatic tumors using contrast-enhanced endoscopic ultrasound. Clin Gastroenterol Hepatol 2008;6:590-7.e1.  Back to cited text no. 16
    
17.
Müller MF, Meyenberger C, Bertschinger P, et al. Pancreatic tumors: Evaluation with endoscopic US, CT, and MR imaging. Radiology 1994;190:745-51.  Back to cited text no. 17
    
18.
Shrikhande SV, Barreto SG, Goel M, et al. Multimodality imaging of pancreatic ductal adenocarcinoma: A review of the literature. HPB (Oxford) 2012;14:658-68.  Back to cited text no. 18
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19.
DeWitt J, Devereaux B, Chriswell M, et al. Comparison of endoscopic ultrasonography and multidetector computed tomography for detecting and staging pancreatic cancer. Ann Intern Med 2004;141:753-63.  Back to cited text no. 19
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20.
Dewitt J, Devereaux BM, Lehman GA, et al. Comparison of endoscopic ultrasound and computed tomography for the preoperative evaluation of pancreatic cancer: A systematic review. Clin Gastroenterol Hepatol 2006;4:717-25.  Back to cited text no. 20
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21.
D'Onofrio M, Crosara S, Signorini M, et al. Comparison between CT and CEUS in the diagnosis of pancreatic adenocarcinoma. Ultraschall Med 2013;34:377-81.  Back to cited text no. 21
    
22.
Agarwal B, Abu-Hamda E, Molke KL, et al. Endoscopic ultrasound-guided fine needle aspiration and multidetector spiral CT in the diagnosis of pancreatic cancer. Am J Gastroenterol 2004;99:844-50.  Back to cited text no. 22
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23.
Haba S, Yamao K, Bhatia V, et al. Diagnostic ability and factors affecting accuracy of endoscopic ultrasound-guided fine needle aspiration for pancreatic solid lesions: Japanese large single center experience. J Gastroenterol 2013;48:973-81.  Back to cited text no. 23
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24.
Scialpi M, Cagini L, Pierotti L, et al. Detection of small (≤2 cm) pancreatic adenocarcinoma and surrounding parenchyma: Correlations between enhancement patterns at triphasic MDCT and histologic features. BMC Gastroenterol 2014;14:16.  Back to cited text no. 24
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25.
Wang W, Shpaner A, Krishna SG, et al. Use of EUS-FNA in diagnosing pancreatic neoplasm without a definitive mass on CT. Gastrointest Endosc 2013;78:73-80.  Back to cited text no. 25
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26.
Hewitt MJ, McPhail MJ, Possamai L, et al. EUS-guided FNA for diagnosis of solid pancreatic neoplasms: A meta-analysis. Gastrointest Endosc 2012;75:319-31.  Back to cited text no. 26
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Chen G, Liu S, Zhao Y, et al. Diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration for pancreatic cancer: A meta-analysis. Pancreatology 2013;13:298-304.  Back to cited text no. 27
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Chen J, Yang R, Lu Y, et al. Diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration for solid pancreatic lesion: A systematic review. J Cancer Res Clin Oncol 2012;138:1433-41.  Back to cited text no. 28
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Puli SR, Bechtold ML, Buxbaum JL, et al. How good is endoscopic ultrasound-guided fine-needle aspiration in diagnosing the correct etiology for a solid pancreatic mass? A meta-analysis and systematic review. Pancreas 2013;42:20-6.  Back to cited text no. 29
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Katanuma A, Maguchi H, Yane K, et al. Factors predictive of adverse events associated with endoscopic ultrasound-guided fine needle aspiration of pancreatic solid lesions. Dig Dis Sci 2013;58:2093-9.  Back to cited text no. 30
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Wang KX, Ben QW, Jin ZD, et al. Assessment of morbidity and mortality associated with EUS-guided FNA: A systematic review. Gastrointest Endosc 2011;73:283-90.  Back to cited text no. 31
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Jenssen C, Alvarez-Sánchez MV, Napoléon B, et al. Diagnostic endoscopic ultrasonography: Assessment of safety and prevention of complications. World J Gastroenterol 2012;18:4659-76.  Back to cited text no. 32
    
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Jenssen C, Hocke M, Fusaroli P, et al. EFSUMB guidelines on interventional ultrasound (INVUS), Part IV – EUS-guided interventions: General aspects and EUS-guided sampling (Long version). Ultraschall Med 2016;37:E33-76.  Back to cited text no. 33
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Jenssen C, Hocke M, Fusaroli P, et al. Dietrich CF. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part IV - EUS-guided interventions: General Aspects and EUS-guided Sampling (Short Version). Ultraschall Med 2016; 37:157-69.  Back to cited text no. 34
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