Evidence-based diagnosis and staging of pancreatic cancer

Only 20% of patients who present with pancreatic cancer will be amenable to potentially curative resection. Therefore, it is necessary to reliably identify patients who might benefit from major surgical intervention by employing the appropriate staging methods. In this review, the pros and cons of each imaging technique are discussed and an algorithm for single and combined use of the different imaging modalities is proposed. To date, contrast-enhanced multi-detector row helical CT (MDR-CT) together with endoscopic ultrasound (EUS) remain the first staging methods of choice. MDR-CT has a high sensitivity for identifying vascular invasion and EUS is able to detect lesions as small as 2-3 mm. ERCP is performed mainly in patients with biliary obstruction with the option for therapeutic intervention during the same session. MRI with MR-angiography, MRCP, PET/CT and staging laparoscopy are additional modalities which might give further information in cases of equivocal findings by MDR-CT and EUS. The role of tumour markers such as CA 19-9 and CEA is reserved for monitoring and diagnosing post-surgery recurrence. Cytological or histological confirmation should usually be performed in patients that are not eligible for surgery prior to the commencement of palliative radio- or chemotherapy. In the routine clinical setting, MDR-CT and EUS play the predominant roles by providing the most cost-effective and accurate means for diagnosing and staging most cases of pancreatic cancer.     

Endoscopic ultrasonography in diagnosis and staging of pancreatic cancer

The accuracy of endoscopic ultrasonography (EUS) for diagnosis of pancreatic cancers was evaluated in consecutive 232 patients with possible pancreatic cancer, and that for assessment of their locoregional spread was evaluated in 28 patients with pancreatic cancer subjected to pancreatectomy, in comparison with the accuracies of transabdominal ultrasonography (US) and computed tomography (CT). EUS was found to be significantly more accurate than US or CT and was especially useful for detecting small pancreatic cancers of less than 2 cm in diameter. With EUS, pancreatic cancers could be detected as a hypoechoic mass with a relatively unclear margin and irregular internal echoes. EUS was also more sensitive than CT and US for detecting venous and gastric invasions: it was more useful for detecting direct invasion of pancreatic cancers when the tumors were less than 3 cm in diameter. These findings indicate that EUS is an accurate method for diagnosis of pancreatic cancer and assessment of their locoregional spread and is particularly useful for detecting small tumors.     

Endoluminal ultrasound diagnosis and operative management of rectal endometriosis

PURPOSE: Endorectal ultrasound was performed in patients with endometriosis to evaluate the role of this technique for rectal wall involvement and to evaluate the position of preoperative diagnosis in the operative management of rectal endometriosis. METHODS: Sixteen patients with suspected fixation of endometriomas to the rectal wall during bimanual examination were included in the study. Endorectal ultrasound was performed using a real time unit with a 7.5 MHz endorectal transducer. The probe was introduced via a rectoscope into the rectum up to the rectosigmoid. RESULTS: Endometriosis was confirmed histopathologically in all patients. In six patients rectal wall involvement was diagnosed, in two patients endometriomas were adjacent to the rectal wall, and in eight patients rectal wall involvement could be excluded. Preoperative diagnosis was confirmed in all patients during operation. Laparotomy was performed in those patients with preoperatively diagnosed rectal wall involvement, whereas the remaining patients were treated laparoscopically. Endometriomas with rectal wall involvement were treated in five of six patients with resection of the affected bowel predominantly by low anterior resection. CONCLUSIONS: Preoperative endorectal ultrasound is a reliable technique to visualize perirectal endometriomas and to assess rectal wall involvement. Based on preoperative endosonographic diagnosis, an operative management was established with laparotomy and resection of the affected bowel in cases of rectal wall involvement.     

Advances in lung cancer diagnosis and staging: endobronchial ultrasound

Background:  Endobronchial ultrasound (EBUS) is an accurate and relatively less invasive procedure for the diagnosis of lung lesions and mediastinal lymph node staging for lung cancer. We aimed to evaluate the clinical utility and safety of this new EBUS service established in our hospital.
Methods:  Consecutive patients who underwent EBUS–transbronchial lung biopsy (EBUS–TBLB) for biopsy of peripheral pulmonary lesions or for transbronchial needle aspiration (TBNA) of mediastinal lymph node enlargement were included in this audit. Demographic and clinical data were obtained prospectively. Diagnostic yield from the results of EBUS was compared to other clinical information obtained.
Results:  Thirty-eight patients underwent EBUS over a 10-month period. The yield from EBUS–TBLB was 62%. The average size of the lung lesions biopsied was 3.5 cm and 62% were located in the upper lobes. Malignancy was diagnosed in 14 cases and a benign aetiology in four. The yield from EBUS–TBNA was 88% and the average size of the lymph nodes was 2.3 cm. The lymph nodes were all located in the subcarinal station except for two that were in the lower paratracheal station. Malignancy was diagnosed in 10 cases on TBNA and 4 cases had benign pathology. There was one complication seen (small pneumothorax).
Conclusion:  EBUS is safe and an effective method for both, diagnosis of peripheral pulmonary lesions and staging for lung cancer.     

An evidence-based approach to the diagnosis and staging of pancreatic cancer.

Technology has revolutionized the diagnosis and staging of pancreatic malignancy. Previously, staging of disease was accomplished by exploratory laparotomy. Now, however, tumor size, lymph node and vascular involvement and the presence of metastases can be reliably assessed prior to operation using a widely available series of diagnostic tests, facilitating a preoperative assessment of tumor resectability. Appropriate use of these tests often spares patients with unresectable disease the need for operative intervention. As part of our staging algorithm we routinely employ a combination of clinical suspicion, a high-resolution helical CT scan and a serum CA 19-9 level. Endoscopic ultrasonography is useful in the patient in whom CT findings are equivocal, or in whom a tissue diagnosis is desired. Laparoscopy is reserved for patients with suspected advanced disease despite imaging findings to the contrary. Using this strategy, pancreatic malignancy may be diagnosed as expeditiously and as cost-effectively as is possible given current technology.     

Value of ultrasound examination in differential diagnosis of pancreatic lymphoma and pancreatic cancer

AIM： To investigate the value of clinical manifestations and ultrasound examination in the differential diagnosis of pancreatic lymphoma and pancreatic cancer. METHODS： The clinical and ultrasonic characteristics of 12 cases of pancreatic lymphoma and 30 cases of pancreatic cancer were retrospectively analyzed. RESULTS： Statistically significant differences were found in the course of disease, back pain, jaundice, carcino-embryonic antigen （CEA） and CA19-9 increase, palpable abdominal lump, superficial lymph node enlargement, fever and night sweats, lesion size, bile duct expansion, pancreatic duct expansion, vascular involvement, retroperitoneal （below the renal vein level） lymph node enlargement, and intrahepatic metastasis between pancreatic lymphoma and pancreatic cancer. There were no significant differences in age of onset, gender ratio, weight loss, nausea and vomiting, lesion position, the echo of the lesion, and the blood flow of the lesion. CONCLUSION： Pancreatic lymphoma should be considered for patients with long lasting symptoms, superficial lymph node enlargement, palpable abdominal lump, fever and night sweats, relatively large lesions, and retroperitoneal （below the level of the renal vein） lymph node enlargement. A diagnosis of pancreatic cancer should be considered more likely in the patients with relatively short disease course, jaundice, back pain, CEA and CA19-9 increase, relatively small lesions, bile duct expansion, obvious pancreatic duct expansion, peripheral vascular wrapping and involvement, or intrahepatic metastases.     

胰腺癌的影像学诊断及术前可切除性和分期的影像学评估

胰腺癌是一种高病死率的侵袭性恶性肿瘤。多层螺旋CT血管成像作为首选的胰腺成像手段,可评判胰周主要血管是否受侵、受侵范围和程度,为肿瘤分期、手术可切除性评估等提供可靠依据。MRI为CT的一种重要补充检查手段,对疾病诊断、肝转移和预后评估有重要的指导价值。胰腺癌血管侵犯情况是术前评估胰腺癌是否可切除的主要指标。淋巴结转移、远处转移、胰腺癌周围神经受侵及肝动脉变异等因素均会影响患者预后。指出胰腺癌患者的术前影像学评估对治疗方案制订、术式选择及预后判断具有指导意义。     

Role of endoscopic ultrasound in the molecular diagnosis of pancreatic cancer

Pancreatic ductal adenocarcinoma remains one of the most deadly types of tumor. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a safe, cost-effective, and accurate technique for evaluating and staging pancreatic tumors. However, EUS-FNA may be inconclusive or doubtful in up to 20% of cases. This review underlines the clinical interest of the molecular analysis of samples obtained by EUS-FNA in assessing diagnosis or prognosis of pancreatic cancer, especially in locally advanced tumors. On EUS-FNA materials DNA, mRNA and miRNA can be extracted, amplified, quantified and subjected to methylation assay. Kras mutation assay, improves diagnosis of pancreatic cancer. When facing to clinical and radiological presentations of pseudo-tumorous chronic pancreatitis, wild-type Kras is evocative of benignity. Conversely, in front of a pancreatic mass suspected of malignancy, a mutated Kras is highly evocative of pancreatic adenocarcinoma. This strategy can reduce false-negative diagnoses, avoids the delay of making decisions and reduces loss of surgical resectability. Similar approaches are conducted using analysis of miRNA expression as well as Mucin or markers of invasion (S100P, S100A6, PLAT or PLAU). Beyond the diagnosis approach, the prediction of response to treatment can be also investigated form biomarkers expression within EUS-FNA materials.     

Indications for staging laparoscopy in pancreatic cancer

Background

To identify indications for staging laparoscopy (SL) in patients with resectable pancreatic cancer, and suggest a pre-operative algorithm for staging these patients.

Methods

Relevant articles were reviewed from the published literature using the Medline database. The search was performed using the keywords ‘pancreatic cancer’, ‘resectability’, ‘staging’, ‘laparoscopy’, and ‘Whipple''s procedure’.

Results

Twenty four studies were identified which fulfilled the inclusion criteria. Of the published data, the most reliable surrogate markers for selecting patients for SL to predict unresectability in patients with CT defined resectable pancreatic cancer were CA 19.9 and tumour size. Although there are studies suggesting a role for tumour location, CEA levels, and clinical findings such as weight loss and jaundice, there is currently not enough evidence for these variables to predict resectability. Based on the current data, patients with a CT suggestive of resectable disease and (1) CA 19.9 ≥150 U/mL; or (2) tumour size >3 cm should be considered for SL.

Conclusion

The role of laparoscopy in the staging of pancreatic cancer patients remains controversial. Potential predictors of unresectability to select patients for SL include CA 19.9 levels and tumour size.     

Bronchoscopy for the diagnosis and staging of lung cancer

Bronchoscopy is an invaluable tool utilized for the diagnosis, staging, and management of lung cancer. Advancements in computer technology and engineering have allowed for the emergence of newer modalities to evaluate endobronchial, parenchymal, and mediastinal pathology. Established techniques such as white light video bronchoscopy and its ancillary procedures (forceps biopsy, brush biopsy, bronchoalveolar lavage, bronchial washings, and transbronchial needle aspiration) are discussed here, with their accuracy described in relation to tumor location, size, and type. Newer technologies such as autofluorescence bronchoscopy, narrow band imaging, endoscopic ultrasound, endobronchial ultrasound, electromagnetic navigation, optical coherence tomography, and confocal fluorescent laser microscopy are introduced and put into perspective. Special emphasis has been placed on their role in the early detection and staging of lung cancer. Some technology requires further study to delineate its role in the disease, whereas other modalities are emerging as the new gold standard in evaluation of lung cancer. The future holds great promise with further miniaturization of equipment and improvements in computer processing power that may allow for in vivo pathological evaluation of abnormal tissue.     

Endoluminal ultrasonography for pancreatic diseases.

Endoluminal ultrasonography was performed on 146 patients with pancreatobiliary diseases by using high-frequency, thin ultrasonic probes, and the usefulness of the new technique in diagnosis of pancreatic diseases was reported. The ultrasound probe could be inserted into the main pancreatic duct in 43 of 46 patients (93.5%), and images of the lesions could be obtained in 42 patients (91.3%). Endoluminal ultrasonography revealed a hypoechoic mass with clear margins and central echogenicity in patients with pancreatic carcinoma. Endoluminal ultrasonography showed normal pancreatic parenchyma as a fine reticular pattern and did not reveal the tumors surrounding the stenosis in patients with focal pancreatitis. Endoluminal ultrasonography in patients with intraductal papillary adenocarcinoma of the pancreas revealed cystic lesions with mural nodules more than 4 mm, mucus echoes, and solid tumors with mixed echo patterns. There were no severe complications, and acute pancreatitis occurred in none of 46 patients, but high-level serum amylase after examination occurred in 5 patients (10.9%). Endoluminal ultrasonography is useful for differential diagnosis in patients with small pancreatic tumors or cystic lesions, especially intraductal papillary tumors of the pancreas. Endoluminal ultrasonography is recommended as a precise examination for the diagnosis of cystic lesions of the pancreas or stenosis of the main pancreatic duct after ERCP and EUS.     

Current role of endoscopic ultrasound in the diagnosis and management of pancreatic cancer

Endoscopic ultrasound (EUS) has emerged as an invaluable tool for the diagnosis, staging and treatment of pancreatic ductal adenocarcinoma (PDAC). EUS is currently the most sensitive imaging tool for the detection of solid pancreatic tumors. Conventional EUS has evolved, and new imaging techniques, such as contrast-enhanced harmonics and elastography, have been developed to improve diagnostic accuracy during the evaluation of focal pancreatic lesions. More recently, evaluation with artificial intelligence has shown promising results to overcome operator-related flaws during EUS imaging evaluation. Currently, an appropriate diagnosis is based on a proper histological assessment, and EUS-guided tissue acquisition is the standard procedure for pancreatic sampling. Newly developed cutting needles with core tissue procurement provide the possibility of molecular evaluation for personalized oncological treatment. Interventional EUS has modified the therapeutic approach, primarily for advanced pancreatic cancer. EUS-guided fiducial placement for local targeted radiotherapy treatment or EUS-guided radiofrequency ablation has been developed for local treatment, especially for patients with pancreatic cancer not suitable for surgical resection. Additionally, EUS-guided therapeutic procedures, such as celiac plexus neurolysis for pain control and EUS-guided biliary drainage for biliary obstruction, have dramatically improved in recent years toward a more effective and less invasive procedure to palliate complications related to PDAC. All the current benefits of EUS in the diagnosis and management of PDAC will be thoroughly discussed.     

超声内镜对胰腺癌的诊断与治疗

随着超声内镜仪的普及,内镜超声检查术(endoscopic ultrasonography, EUS)巳成为诊断胰腺疾病的首选方法[1],尤其是EUS引导下FNA技术的应用极大地提高了胰腺肿瘤的诊断准确率,新型超声内镜仪及三维微型高频超声探头的应用提高了小胰癌的显示率.     

超声内镜对胰腺癌的诊断与治疗

随着超声内镜仪的普及，内镜超声检查术（endoscopic ultrasonography，EUS）巳成为诊断胰腺疾病的首选方法，尤其是EUS引导下FNA技术的应用极大地提高了胰腺肿瘤的诊断准确率，新型超声内镜仪及三维微型高频超声探头的应用提高了小胰癌的显示率。EUS已经历了3个重要阶段：EUS诊断（EUS imaging）；EUS穿刺活检（EUSguided FNA）；EUS注射治疗（EUS—guided fine needle injection，FNI）。现在已进入介入性EUS（Interventional EUS）时代。