PANCREAS NEWS
Am J Gastroenterol 2000; 95:2261-70
Rosch T, Schusdziarra V, Born P, Bautz W, Baumgartner M, Ulm K, Lorenz R, Allescher HD, Gerhardt P, Siewert JR, Classen M
Department of Internal Medicine, Technical University of Munich. Munich, Germany
JOP expert comment (R Pezzilli: pezzilli@orsola-malpighi.med.unibo.it)
This is one of the few studies in which the imaging techniques such as endoscopic retrograde cholangiopancreatography (ERCP), computed tomography (CT), and endoscopic ultrasonography (EUS) have been compared using clinical evaluation which included laboratory tests.
In this study, clinical and imaging information (EUS, ERCP and CT) was collected for 184 in-patients who were referred over a 5-yr period for evaluation of suspected pancreatic disease. On the basis of patient history, laboratory tests and the results of routine transabdominal ultrasonography (TUS), a gastroenterologist, unaware of any of the other procedures or the final diagnosis, made a presumptive clinical diagnosis. CT and ERCP images and EUS videotapes were then analyzed by three different and independent examiners, who had the same clinical information except for the TUS results, but were completely blinded to the results of the other examinations and the diagnoses. The final diagnoses were obtained by surgery, histology, and cytology, plus a follow-up of at least 1 yr (mean 35 months) in all non-cancer cases. The figures for the sensitivity and specificity of the three imaging procedures were 93% and 94%, respectively, for EUS; 89% and 92% for ERCP; and 91% and 78% for CT (P<0.05 for the specificity of clinical assessment vs all three imaging tests, P>0.05 for comparison of the three imaging procedures). In the differential diagnosis between cancer and chronic pancreatitis as well as between malignant and inflammatory tumors, there were no differences in clinical assessment and the three imaging tests.
In conclusion, in patients where pancreatic disease is suspected, little additional sensitivity in the diagnosis of pancreatic disease is provided by sophisticated imaging procedures such as EUS, ERCP, and CT in comparison with clinical assessment including laboratory values and TUS. However, the specificity can be substantially improved. To confirm the diagnosis, one of the three examinations is needed, depending on the suspected disease and local expertise. The imaging procedures should be performed in a stepwise fashion for specific purposes, such as exclusion of pancreatic disease and the planning of treatment in chronic pancreatitis and pancreatic cancer.
A similar study involving magnetic resonance should be planned, in order to obtain new information on this technique in comparison with the others, commonly used in clinical practice.
Am J Gastroenterol 2000; 95:2255-60
Fritscher-Ravens A, Izbicki JR, Sriram PV, Krause C, Knoefel WT, Topalidis T, Jaeckle S, Thonke F, Soehendra N
Department of Interdisciplinary Endoscopy, University Hospital Eppendorf. Hamburg, Germany
JOP expert comment (G Uomo: uomogir@libero.it)
Organ preserving pancreatic resections are considered whenever malignant disease is ruled out. In tumors of low malignant potential such as cystadenomas and neuroendocrine tumors, the diagnosis is rarely established preoperatively.
The authors studied the feasibility of cytodiagnosis using endosonography-guided fine-needle aspiration, in determining the operative approach, in 78 patients with focal pancreatic lesions. These patients underwent EUS-FNA and the final diagnosis was confirmed by histology, cytology, or clinical follow up (>9 months). Patients with tumors of low malignant potential were managed by customized pancreatic resections. The final diagnosis was malignant tumors in 36 patients, tumors of low malignant potential in nine and benign tumors in 31 No complications occurred. With six false-negative and no false-positive results, the accuracy, sensitivity, specificity, and positive and negative predictive values were 92%, 84%, 100%, 100%, and 86%, respectively. Five patients with low malignant tumors underwent duodenum-preserving pancreatic head resection, three underwent mid-segment resection, and one a pylorus-preserving pancreatoduodenectomy.
The results of this study show that EUS-FNA is useful in the preoperative cytodiagnosis of pancreatic tumors of low malignant potential and it extends the indication for organ-preserving pancreatic resections and, finally, avoids the unnecessary sacrifice of adjacent organs.