When you need pancreas cancer surgery even without definite diagnosis of pancreas cancer?? What does international study group on pancreas cancer say??

When you need pancreas cancer surgery even without definite diagnosis of pancreas cancer?? What does international study group on pancreas cancer say??

Surgery (PANCREATODUODENECTOMY ) provides the best chance for a cure in pancreatic cancer and remains the treatment of choice for suspected pancreatic malignancies. In patients with a suspected, clinically operable pancreatic malignancy, the need pathologic confirmation before proceeding with surgery remains debatable.

Confirming pathologic diagnosis was considered more important in the past because of the high Complications associated with surgery. Over the past decade, the need for histologic confirmation before resection has become less important as PD has become a much safer procedure and as more sophisticated imaging has allowed for a greater degree of diagnostic accuracy.

Furthermore, issues relating to biopsy-related complications, potential inaccuracy and a false negative result, potential delay in treatment, and risk of cancer spread, as well as the added cost, must also be taken into account when considering the role of preoperative biopsy.

To, overcome this problem, many pancreatic experts around the world gathered and collected their data, results of these data are shown below.

Results:

Of the all pancreatic surgeries done for suspected but not confirmed cancers only 5-13% was diagnosed as non cancerous and rest 87-95% was cancerous.

Preoperative biopsies in 95% of patients who detected cancer in postoperative settings were inaccurate. Complications such as hemorrhage, duodenal perforation, acute pancreatitis, infection, or tumor seeding as may occur after percutaneous biopsy.

Among noncancerous pathology as shown in figure majority was pancreatitis (77%).

Pancreatitis: In the absence of preoperative histologic confirmation of cancer, one of the

Common challenges are differentiating a malignant from an inflammatory mass. Difficulty arises because both pancreatic cancer and Chronic Pancreatitis have considerable overlap with regard to clinical presentation and imaging. In this subset of patients, it is important to differentiate CP from Auto Immune Pancreatitis after surgery for a presumed malignancy, the incidence of Auto Immune Pancreatitis (AIP) within the benign specimens is reported to be 30–43%. This is an important subset of patients to recognize preoperatively before resection, because treatment with steroids is likely to prevent an unnecessary operative resection.

Two subtypes of AIP have been described:

Type 1 AIP occurs more predominantly in older patients, is most commonly associated with increased levels of serum immunoglobulin (Ig)G4 and IgG4-positive plasma cells;

Type 1 AIP is also easier to diagnose histologically.

Type 2 AIP is more prevalent in younger patients, more difficult to diagnose histologically, and less often associated with an increase of serum levels of IgG4.

Endoscopy Ultra sonography guided biopsy, serum levels of IgG4, and HISORt  (Histology, Imaging, Other organ involvement, and Response to therapy) are used for diagnosis,  but confirming AIP preoperatively can remain a challenge.When in doubt, a short-term trial with steroids might be the best option to differentiate AIP from a cancer.

In contrast, the presence of Chronic Pancreatitis (CP) is more readily diagnosed preoperatively, but the difficulty involves differentiating if and when a patient with CP develops a malignancy. The International Pancreatitis Study Group cites a risk of developing cancer in CP at 4% over a 20-year period.

Preoperative differentiation between a mass effect from CP and an actual cancer is often difficult even with the use of state-of-the-art imaging and biopsy. In contrast with patients with AIP, PD would be considered an appropriate treatment for the majority of symptomatic patients with

CP and the presence of a head mass, even in the absence of malignancy.

Neuroendocrine cancer.: The diagnosis of pancreatic neuroendocrine tumors (PNET) is facilitated by the presence of symptoms and identification of the hormonal abnormalities when present; however, 15–40% ofPNETs are nonfunctioning (NFPNET).  Although there is general consensus that the hormonally active PNETs should be treated by resection, controversy exists regarding the indications for resection of smallNF-PNETs.  Because imaging studies are performed more frequently, the Incidental finding of smaller NF- PNET has become more common. Historically, however, NF-PNETs

have usually been large and present at an advanced stage when first diagnosed.  Survival after resection is affected primarily by the presence of metastases with a median survival of 23 months, compared with 124 and 70 months for those patients with localized or regional disease, respectively.

 Currently, PNETs are being found more frequently with advanced cross-sectional imaging. In these patients, pathologic confirmation is usually required to confirm that the lesion is a PNET. EUS-FNA is indicated in this subset of patients with suspected PNETand can provide cytologic confirmation.

 In general, most pancreatic surgeons agree that operative resection is the treatment of choice for NF-PNETs > 2 cm or that present rapid growth(> 0.5 cm per year). NF-PNETs that are < 2 cm are likely to be benign or intermediate-risk lesions; it is reported that only 6% of them are malignant when incidentally discovered.  In this subgroup of patients, an initial course of nonoperative management with close follow-up may be a consideration.

Following consensus guidelines are recommended for surgical treatment in non-confirmed pancreatic cancer.

Ø  In the presence of a solid mass in the head of the pancreas that is suspicious for malignancy, biopsy

proof is not required before proceeding with surgery when AIP is not suspected (strong recommendation).

Ø  Before the beginning of chemotherapy or chemoradiation  objective confirmation of malignancy is

mandatory (strong recommendation). In these patients, ERCP brushing is preferred in the presence of jaundice, because placement of an endobiliary stent is indicated. Otherwise EUS biopsy is the diagnostic modality

of choice (strong recommendation).

Ø  In patients with CP in whom a malignancy is suspected, resection is indicated even in the absence of histologic proof of malignancy (strong recommendation).

Ø  When a diagnosis of AIP is highly suspected, measurement of serum levels of IgG4 plus a biopsy is recommended (strong recommendation). EUS-guided Trucut biopsy is preferred. If biopsy results are not diagnostic or suspicious for malignancy, a short course of steroid treatment (4–6 weeks) is recommended (qualified recommendation).