The Clinical Point of View
Abstract
Surgeons frequently find pancreatic head mass when operating. The obvious difficulty is to make the correct preoperative differential diagnosis between chronic pancreatitis and pancreatic tumor. The first step is to reach a diagnosis, with some certainty, prior to the operation. The second step in the case of a tumor is the accurate staging and deciding whether or not it is resectable. On the one hand, time and cost must be considered; on the other hand, the therapy must be decided. Obtaining information about the characteristics of the pancreatic disease (nature, size, exact location) and establishing the tissue diagnosis preoperatively may simplify the decision to operate and the operation itself. In the case of chronic pancreatitis, the aim of the operation is to eliminate pain and other symptoms, while in the case of cancer, the purpose is to remove the malignant tissue. In most patients, it is possible to identify the disease on the basis of previous examinations together with preoperative diagnostic techniques such as exploration, palpation and fine-needle aspiration biopsy. Chronic pancreatic head mass should be operated upon with Beger’s or Frey’s procedure while pancreatic head tumors should be treated by means of head resection with the aim of preserving the pylorus or the Whipple procedure may be used. When the diagnosis is in doubt, a radical approach is thought to be best. Our conclusion is that there is no diagnostic method capable of making a definitive differential diagnosis as to the nature of the pancreatic head mass. Further study is required as to the extent to which differential diagnosis should be investigated.
Image: 1st Surgical Department, Semmelweis University. Budapest, Hungary.
Downloads
References
Parker SL, Tong T, Bolden S ,Wingo PA. Cancer statistics, 1996. CA Cancer J Clin 1966; 46:5-27.
Rosewitz S, Weidenmann B. Pancreatic carcinoma. Lancet 1997; 349:485-9.
Evans JD, Morton DG, Neoptolemos JP. Chronic pancreatitis and pancreatic carcinoma Postgrad Med J 1997; 73:543-8.
Rocca G, Gaia E, Iuliano R, Caselle MT, Rocca N, Calcamuggi G, Emanuelli G. Increased incidence of cancer in chronic pancreatitis. J Clin Gastroenterol 1987; 9:175-9.
Talamini G, Falconi M, Bassi C, Sartori N, Salvia R, Caldiron E et al. Incidence of cancer in the course of chronic pancreatitis. Am J Gastroenterol 1999; 94:1253-60.
Ammann RW, Knoblauch M, Mohr P, Deyhle P. High incidence of extrapancreatic carcinoma in chronic pancreatitis. Scand J Gastrenterol 1980; 15:395-9.
Ectors N, Maillet B, Aerts R, Geboes K, Donner AM, Borchard F. et al. Non-alcoholic duct destructive chronic pancreatitis. Gut 1997; 41:263-8.
van Gulik TM, Reeders JW, Bosma A, Moojen TM, Smits NJ, Allema JH, et al. Incidence and clinical findings of benign, inflammatory disease in patients resected for presumed pancreatic head cancer. Gastrointest Endosc 1997; 46:417-23.
Moussa AR, Levine B. The diagnosis of early pancreatic cancer. Cancer 1981; 47:1688-97.
Zografos GN, Bean AG, Williamsin CN. Chronic pancreatitis and neoplasia: Correlation or coincidence. HPB Surgery 1997; 10:235-9.
Mossner J. Diagnose und differentialdiagnose des pankreakarzinoms. Schweiz. Rundschau Med Prax 1997; 86:397-400.
Mergener K, Baillie J. Chronic pancreatitis. Lancet 1977; 350:1379-85.
Geenen JE, Rolny P. Endoscopic management of pancreatic disease Baillieres Clin Gastroenterol 1991; 5:155-62.
Yamamoto H, Watahiki H, Suzuki M, Iwai T, Momo S, Takeuchi T, et al. Clinical efficacy of MRCP for diagnosis of patients with pancreatic neoplasm. Jap J Clin Med 1998; 56:2911-7.
Yeaton P, Sears RJ, Ledent T, Salmon I, Kiss R, Decaestecker C. Discrimination between chronic pancreatitis and pancreatic adenocarcinoma using artificial intelligence-related algorithms based on image cytometry-generated variables. Cytometry 1998; 32:309-16.
Inui K, Nakazawa S, Okushima K, Nakamura Y. Endoluminal ultrasonography for pancreatic diseases. Gastroent Clin North Am 1999; 28. 778-81.
Gaa J, Wendl K, Tesdal IK, Meier-Willersen HJ, Lehmann KJ, Bohm C, et al. Kombinierter einsatz vor MRT, MRCP und kontrastverstarkter 2phasen 3D-MRA in der diagnostik von pankreastumoren: Erste Klinische Ergebnisse. ROFO 1999; 170:528-33.
Barish MA, Yucel EK, Ferrucci JT. Current concepts: Magnetic resonance cholangiopancreatography. New Engl J Med 1999; 341:258-64.
Zimny M, Bares R, Fass J, Adam G, Cremerius U, Dohmen B, et al. Fluorine-18 fluorodeoxyglucose positron emission tomography in the differential diagnosis of pancreatic carcinoma: a report of 106 cases. Eur J Nucl Med 1997; 24:678-82.
Jung M, Zipf A, Schoonbroodt D, Herrmann G, Caspary WF. Is pancreatoscopy of any benefit in clarifying the diagnosis of pancreatic duct lesions?. Endoscopy 1998; 30:273-80.
Hutwitz M, Sawicki M, Samara G, Passaro E. Diagnostic and prognostic molecular markers in cancer. Am J. Surg 1992; 164:299-306.
Ryan ME, Baldauf MC. Comparison of flow cytometry for DNA content and brush cytology for detection of malignancy in pancreatobiliary strictures. Gastrointest Endosc 1994; 40:44-52.
Strasberg SM, Middleton WD, Teefey SA, McNevin MS, Drebin JA. Management of diagnostic dilemmas of the pancreas by ultrasonographycally guided laparoscopic biopsy. Surgery 1999; 126:736-41.
Nouts A, Levy P, Voitot H, Bernades P. Valeur diagnostique de l'antigene serique Ca 19-9 au cours de la pancreatitite chronique et de l'adenocarcinome pancreatique. Influence de leurs complications. Gastroent Clin Biol 1998; 22:152-9.
Horváth LZ, Flautner LE, Tihanyi TF, Schumann B. The role of multivariate tumor marker analysis in the differential diagnosis of pancreatic carcinoma and chronic pancreatitis. Br J Surg 1998; 85(Suppl. 2):138-9.
Barthelemy PH, Bouisson M, Escourrou J, Vaysse N, Rumeau JL, Pradayrol L. Identification of K-ras mutations in pancreatic juice in the early diagnosis of pancreatic cancer. Ann Intern Med 1995; 123:188-91.
Hahn SA, Schutte M, Hoque AT, Moskaluk CA, da Costa LT, Rozenblum E, et al.: DPC4, a candidate tumor suppressor gene at human chromosome 18q21.1. Science 1996; 271:350-3.
Wilentz RE Chung CH, Sturm PDJ, Musler A, Sohn TA, Offerhaus GJA, et al. K-ras mutations in the duodenal fluid of patients with pancreatic carcinoma. Cancer 1998; 82:96-103.
Copyright (c) 2000 István Pulay, Tibor F Tihanyi, Lajos Flautner
This work is licensed under a Creative Commons Attribution 4.0 International License.
As a member of Publisher International Linking Association, PILA, iMedPub Group’s JOP follows the Creative Commons Attribution License and Scholars Open Access publishing policies. Journal of the Pancreas is the Council Contributor Member of Council of Science Editors (CSE) and following the CSE slogan Education, Ethics, and Evidence for Editors.