Pretreatment Biopsy

At M. D. Anderson, we advocate reasonable efforts to achieve a pretreat-ment tissue diagnosis for patients presenting with what we believe to be a localized, resectable periampullary neoplasm. This approach is designed to separate the diagnostic and therapeutic phases of pancreatic cancer treatment, and such an approach has advantages for both patients and physicians. For patients in particular, a pretreatment biopsy-based diagnosis allows them to consider referral to a regional center that specializes in pancreatic cancer treatment. This appears to be quite reasonable in view of the established relationship between institutional pancreatec-tomy volume and both short-term operative mortality and long-term cancer outcome.

We have used endoscopic ultrasonography (EUS)- and CT-guided fine-needle aspiration (FNA) for tissue diagnosis of suspected pancreatic neoplasms. In recent years, EUS-guided FNA has often been combined with endoscopic retrograde cholangiopancreatography (ERCP) and endo-biliary stent placement. This combination allows for relief of jaundice and tissue diagnosis in a 2-step procedure.

Our current use of EUS-guided FNA for tissue diagnosis is based on significant experience using this technique. We recently reported our experience with a series of 233 patients with suspected but undiagnosed periampullary neoplasms (Raut et al, 2003). Among 216 patients with a final diagnosis of carcinoma, EUS-guided FNA cytology findings consistent with malignancy were obtained in 197 (sensitivity, 91%). In comparison, all 15 patients with a final diagnosis of a benign disorder had no malignant cells or had cytology findings considered to be inconclusive for malignancy (specificity, 100%). Four patients experienced complications of the pretreatment EUS-guided biopsies (2 duodenal perforations and 1 case each of pancreatitis and abdominal pain). On the basis of our recent experience, we believe that EUS-FNA is a safe, reliable way to establish a tissue diagnosis before treatment, allowing consideration of investigational treatment approaches that generally require a pretreatment tissue diagnosis.

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