Preoperative Staging and Defining Resectability

From a surgical perspective, the first objective in the management of suspected or confirmed pancreatic cancer is to determine the potential for resection. Routine exploratory laparotomy for the purpose of operatively determining resectability has been diminished by modern 3-D radiographic imaging, along with effective and sustainable nonoperative methods of palliation.

Careful correlation between preoperative CT findings and surgical results has better-defined CT criteria for resectability. The critical aspects that need be evaluated in a thorough radiographic assessment are the presence or absence of peritoneal or hepatic metastases; the potential involvement of the SMV and portal vein and the relationship of these vessels and their tributaries to the tumor; the relationship of the tumor to the SMA, celiac axis, hepatic artery, and gastroduodenal artery; and the presence of any aberrant vascular anatomy.

Unequivocal radiographic findings contraindicating resection include distant metastases, major venous thrombosis of the portal vein or SMV extending for several centimeters, and circumferential encasement of the SMA, celiac axis or proximal hepatic artery. Recent revisions of the National Comprehensive Cancer Network (NCCN) guidelines were an attempt to distinguish locally advanced unresectable tumors from potentially resectable tumors.22 Ambiguity exists in these guidelines because of the lack of clarity in defining clearly resectable situations from “borderline resectable” tumors and because of the subjective criteria used to define “borderline” tumors relative to locally advanced, unresectable lesions. The NCCN guidelines do offer a definition of what should be considered a radiographically resectable tumor. Patients without distant metastases and no evidence of tumor extension to the SMV and portal vein and clear fat planes around the celiac axis, the hepatic artery, and SMA should be categorized as having localized and resectable cancers.

More refined and objective criteria have been proposed by the M. D. Anderson Cancer Center Pancreas Cancer Group in an attempt to better define the term “borderline resectable” and to guide treatment decisions regarding the use of neoadjuvant therapy and the high likelihood of vein resection and reconstruction as a means to improve the rate of a complete and margin-negative resection.23 Radiographic findings of tumor abutment on the portal vein or SMV with or without venous deformity, and limited encasement of the mesenteric vein and portal vein (i.e., short segment occlusion with suitable vessel for anastomosis above and below) represent the extent of venous involvement that would categorize a tumor as borderline resectable.

Radiographic findings suggesting borderline arterial involvement as defined by M. D. Anderson Cancer Center include encasement of a short segment of the hepatic artery, without evidence of tumor extension to the celiac axis and/or tumor abutment of the SMA involving < 180° of the artery circumference. In patients without clinically important major comorbidities, and in the absence of radiographic findings to suggest metastatic disease or locally advanced unresectable disease as outlined above, surgical resection should be considered feasible and likely to be achievable. Whether these resections would result in a higher-than-expected rate of margin-positive resections, and whether such resections would affect survival would best be determined by careful examination of outcomes relative to extent of vascular involvement using objective criteria to determine categorization of extent of disease.


Consensus Statement



1.

Tumors considered localized and resectable should demonstrate the following:

a.

No distant metastases.




b.

No radiographic evidence of SMV and portal vein abutment, distortion, tumor thrombus, or venous encasement.




c.

Clear fat planes around the celiac axis, hepatic artery, and SMA.











2.

Tumors considered borderline resectable include the following:

a.

No distant metastases.




b.

Venous involvement of the SMV/portal vein demonstrating tumor abutment with or without impingement and narrowing of the lumen, encasement of the SMV/portal vein but without encasement of the nearby arteries, or short segment venous occlusion resulting from either tumor thrombus or encasement but with suitable vessel proximal and distal to the area of vessel involvement, allowing for safe resection and reconstruction.




c.

Gastroduodenal artery encasement up to the hepatic artery with either short segment encasement or direct abutment of the hepatic artery, without extension to the celiac axis.




d.

Tumor abutment of the SMA not to exceed >180° of the circumference of the vessel wall.

Pretreatment assessment of resectable and borderline resectable pancreatic cancer: expert consensus statement.

https://www.giejournal.org/article/S0016-5107(11)02166-3/pdf

EUS-guided FNA for diagnosis of solid pancreatic neoplasms: a meta-analysis

https://www.giejournal.org/article/S0016-5107(10)02295-9/pdf

Assessment of morbidity and mortality associated with EUS-guided FNA: a systematic review

This article is part of a combined publication that expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about endoscopic ultrasound (EUS)-guided sampling in gastroenterology, including EUS-guided fine needle aspiration (EUS-FNA) and EUS-guided trucut biopsy (EUS-TCB), of submucosal tumors, diffuse esophageal/gastric wall thickening, pancreatic solid masses and cystic-appearing lesions, mediastinal lesions unrelated to lung or esophageal cancer, cancer of the esophagus, stomach, and rectum, lymph nodes of unknown origin, adrenal gland masses, and focal liver lesions. False-positive cytopathological results and needle tract seeding are also discussed. The present Clinical Guideline describes the results of EUS-guided sampling in the different clinical settings, considers the role of this technique in patient management, and makes recommendations on circumstances that warrant its use. A two-page executive summary of evidence statements and recommendations is provided. A separate Technical Guideline describes the general technique of EUS-guided sampling, particular techniques to maximize the diagnostic yield depending on the nature of the target lesion, and sample processing. The target readership for the Clinical Guideline mostly includes gastroenterologists, oncologists, internists, and surgeons while the Technical Guideline should be most useful to endoscopists who perform EUS-guided sampling.

/pdf/indications-results-and-clinical-impact-of-endoscopic-zboac6c54m.pdf

Indications, results, and clinical impact of endoscopic ultrasound (EUS)-guided sampling in gastroenterology: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.

Pancreatic cancer is a growing source of cancer related death, yet has poor survival rates which have not improved in the last few decades. Its high mortality rate is attributed to pancreatic cancer biology, difficulty in early diagnosis and the lack of standardised international guidelines in assessing suspicious pancreatic masses. This review aims to provide an update in the current state of play in pancreatic cancer diagnosis and to evaluate the benefits and limitations of available diagnostic technology. The main modalities discussed are imaging with computed tomography, magnetic resonance imaging, endoscopic ultrasound and positron emission tomography and tissue acquisition with fine needle aspiration. We also review the improvements in the techniques used for tissue acquisition and the opportunity for personalised cancer medicine. Screening of high risk individuals, promising biomarkers and common mimickers of pancreatic cancer are also explored, as well as suggestions for future research directions to allow for earlier detection of pancreatic cancer. Timely and accurate diagnosis of pancreatic cancer can lead to improvements in the current poor outcome of this disease.

Challenges in diagnosis of pancreatic cancer

https://www.giejournal.org/article/S0016-5107(05)00082-9/pdf

A first report of tumor seeding because of EUS-guided FNA of a pancreatic adenocarcinoma

https://www.fertstert.org/article/S0015-0282(15)01953-6/pdf

Chronic endometritis in women with recurrent pregnancy loss and recurrent implantation failure: prevalence and role of office hysteroscopy and immunohistochemistry in diagnosis.

Retinoblastoma and p53 gene product expression in breast carcinoma: Immunohistochemical analysis and clinicopathologic correlation

Background and Aim

Endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNA) is traditionally carried out with the stylet, as it is believed to prevent blockage or contamination of the needle by tissue coming from the gastrointestinal wall. However, this recommendation has not been demonstrated on an empirical basis. The aim of the present study was to compare the yield of EUS-FNA in a very large series of patients with (S+) and without (S–) the stylet.



Methods

Until 2004, the stylet was used for EUS-FNA in our center. After that, the stylet was never used. The results of all EUS-FNA in solid lesions carried out by one endosonographer with the same needle type were compared before and after stylet use was stopped.



Results

3364 EUS-FNA procedures (in 3078 patients) in solid lesions were included (1483 S+ and 1881 S–). There was no significant difference between the S+ and S– results for any variable other than the number of passes required. The number of passes was significantly lower in the S– group when sampling lymph nodes, wall lesions and when carrying out biopsies through the gastric or rectal wall. However the statistical differences disappeared after controlling for malignancy, location and lesion size.



Conclusion

This very large comparative study showed no benefit in diagnostic yield when using the stylet for EUS-FNA.

Comparison of endoscopic ultrasonography-guided fine-needle aspiration cytology results with and without the stylet in 3364 cases.

Background and Aim

Previous studies comparing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) results with different gauge needles have all been carried out with the stylet in place and show no clear advantage to the larger 22-G needle. Similar data for stylet-free EUS-FNA (SF-EUS-FNA) are unavailable. The aim of the present study was to determine whether diagnostic yield and specimen adequacy is superior with the 22-G needle as compared to the 25-G needle.



Methods

All patients ≥18 years referred for solid-lesion EUS-FNA were eligible. Patients with suspected diagnosis of lymphoma, gastrointestinal stromal tumor, sarcoidosis, significant coagulopathy (international normalized ratio >1.5 or platelets <50 000/mm3), use of clopidogrel within 7 days of EUS, and pregnancy were excluded. The two needles were compared regarding diagnostic yield, sample adequacy, bloodiness, ease of puncture, visibility, number of passes, failures, and complications.



Results

One hundred and twenty consecutive patients were included and 126 lesions were sampled. Sensitivity, specificity, positive predictive value and negative predictive value for the 22-G SF-EUS-FNA were 83%, 100%, 100% and 56%, respectively, and for the 25-G SF-EUS-FNA were 88.8%, 100%, 100% and 76.5%, respectively (P = NS). There were no significant differences between the 22-G and the 25-G FNA needles in sample adequacy, bloodiness, ease of puncture, FNA failure, visibility, number of passes and complications; and no significant differences between either needle were found in relation to lesion site.



Conclusion

For SF-EUS-FNA, the larger 22-G needle offers no advantage over the smaller 25-G needle.

Gilles Gariepy

Papers

A first report of tumor seeding because of EUS-guided FNA of a pancreatic adenocarcinoma

Chronic endometritis in women with recurrent pregnancy loss and recurrent implantation failure: prevalence and role of office hysteroscopy and immunohistochemistry in diagnosis.

Retinoblastoma and p53 gene product expression in breast carcinoma: Immunohistochemical analysis and clinicopathologic correlation

Comparison of endoscopic ultrasonography-guided fine-needle aspiration cytology results with and without the stylet in 3364 cases.

Randomized controlled trial comparing stylet-free endoscopic ultrasound-guided fine-needle aspiration with 22-G and 25-G needles.