eMedicine Specialties > Radiology > Gastrointestinal
Pancreas, Adenocarcinoma: Follow-up
Updated: Apr 13, 2007
Intervention
Endoscopic retrograde cholangiopancreatography
Pancreatography is abnormal in 95% of patients. ERCP has a sensitivity of 95% and a specificity of 85% for pancreatic malignancy.
Most pancreatic carcinomas arise from the ductal epithelium and produce complete or partial ductal obstruction. The pancreatic duct may show significantly dilated ducts proximal to the point of obstruction with abrupt cutoff of contrast column. Incomplete filling can be distinguished from obstruction as the contrast column gradually tapers and fades away. Nonfilling of the duct because of technique is an important cause of false-positive findings. The pancreatic ducts between the obstruction and the papilla of Vater are usually normal. This important finding may help to distinguish pancreatic carcinoma from pancreatitis. The ducts from point of obstruction to papilla of Vater are usually abnormal in pancreatitis.
Pancreas divisum, a congenital variation seen in approximately 10% of the population, is another cause of false-positive findings. Injection into the major papilla will opacify a short segment of duct in the head of pancreas. When the minor papilla is injected separately, the remainder of the larger part of the pancreatic ductal system opacifies. This is due to an embryologic failure of fusion of a portion of the head of pancreas with the rest of the gland.
Involvement of both the pancreatic and CBD, termed double-duct sign, was originally described as being specific for carcinoma. It also may be seen in pancreatitis. Features that suggest a neoplasm are biductal lesions in close proximity less than 1 cm apart, abrupt stricture with irregular margins, and complete or high-grade obstruction of the CBD.
The CBD may show a rat-tail or nipplelike occlusion. Widely separated strictures and smooth narrowing indicate benign disease. Pancreatography also may show acinar defects. An ultrathin pancreatoscope is used for diagnostic pancreatoscopy, which does not necessitate sphincterotomy. Intraductal tumor increasingly has been demonstrated by this technique.
The use of noninvasive imaging such as MRCP has gained a considerable foothold in recent years in the preassessment of ductal morphology to diagnose pancreatic malignancy. MRCP is as sensitive as ERCP, and it may prevent inappropriate explorations of the pancreatic and bile ducts in patients with suspected pancreatic cancer in whom interventional endoscopic therapy is unlikely. In a study of 124 patients, the sensitivity of MRCP was 84% with a specificity of 97% for the diagnosis of pancreatic cancer.
Biliary obstruction by malignant disease from pancreas resulting in jaundice will require biliary stenting. Controversy continues regarding the best route of drainage. When endoscopic stenting fails or is contraindicated, percutaneous biliary drainage is recommended.
Percutaneous transhepatic biliary drainage (PTBD)
When endoscopic biliary drainage is unsuccessful or is contraindicated, percutaneous transhepatic biliary drainage (PTBD) is recommended. The risk of complications is increased in comparison with that of the endoscopic technique. The 30-day mortality rate in the percutaneous group of patients is 33%, compared with 15% for the endoscopic group. The overall long-term survival is approximately equivalent whether drainage is performed endoscopically or percutaneously.
PTBD poses an increased risk of hemobilia, intrahepatic hematoma, cholangitis, hemoperitoneum, biliary peritonitis, and pleuritis. Broad-spectrum antibiotic coverage is recommended. Cephalosporins are more potent than other drugs in prophylactic use. Infective cholangitis is a complication of PTBD in approximately 4% of patients.
In an early review, researchers thought that the operative mortality and morbidity of patients undergoing pancreatic resection could be reduced with preoperative percutaneous biliary drainage. However, a randomized study failed to confirm this impression.
In summary, intubation via an endoscopic route in patients with cardiovascular, renal, or other metabolic conditions allows time to prepare them for potentially curative surgery. For other patients, biliary drainage prior to planned surgery offers no significant advantage.
Therapeutic biliary stent placement
Results of prospective randomized studies suggest that biliary stenting may replace surgical intervention in most patients. In patients who have advanced disease and who are candidates for neoadjuvant therapy, stent placement may be preferable to surgical intervention. Furthermore, no evidence suggests that laparoscopic cholecystojejunostomy is better than endoscopic or percutaneous biliary drainage.
Pancreatic cancer screening
Evidence is inconclusive that early detection in subgroups at risk for pancreatic cancer would improve survival. No reliable screening tests are available for detecting early pancreatic cancer in asymptomatic patients. Imaging techniques are not suitable as screening tests because of many factors, including cost and/or their invasive nature. Tumor markers are nonspecific. Screening for pancreatic cancer is not recommended at this time.
Pancreatic biopsy
For a final diagnosis, histologic or cytologic confirmation is needed. The reported sensitivity and diagnostic accuracy are high for both histologic and cytologic examinations. Specificity is near to 100% in most published series. These studies are from centers of excellence. However, in practice, obtaining a diagnosis by means of percutaneous biopsy can be problematic, and in some patients malignancy is confirmed on follow-up images, which demonstrate an increase in the size of a lesion or by hepatic metastases.
Percutaneous FNA biopsy does pose a small but real risk of tumor implantation along the biopsy track of the needle. It has a clear advantage in patients with advanced disease in whom the diagnosis is to be established without subjecting the patient to surgery. A Tru-cut biopsy using 18-gauge needle can be safely and effectively performed under guidance.
Microscopic confirmation is required in all patients in whom chemotherapy, radiation therapy, or both are planned. For attempted radical surgery, biopsy is not mandatory if the clinical suspicion of cancer is high and the surgical team has documented low postoperative morbidity and mortality rates. FNAC does not allow sufficient yield to characterize the subtype of the pancreatic carcinoma. The morbidity of pancreatic fistula from FNAC can be reduced by using a transduodenal approach.
The sensitivity of EUS-guided FNA is 75-97%, similar to that of CT-guided FNA. Pancreatic mass FNA is highly sensitive and specific (94-100%) for lesions smaller than 3 cm in diameter. Similar high specificity is found with EUS-guided FNA of lymph nodes. An FNA specimen is almost always adequate.
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Further Reading
Keywords
pancreatic exocrine tumor, pancreatic carcinoma
