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EUS or Multidetector CT for Detecting and Staging Pancreatic Cancer?

Until we have an optimal preoperative imaging modality, EUS or multidetector CT is mandatory for preoperative staging of pancreatic cancer.

Accurate preoperative staging is essential for determining which patients with pancreatic cancer are candidates for surgical cure. Recommendations for staging have evolved from angiography to computed tomography (CT) and endoscopic retrograde cholangiopancreatography (ERCP), to endoscopic ultrasonography (EUS). EUS has been shown to be superior to standard CT for detection and staging, to be equivalent or superior to dual-phase helical CT for local staging, but to be inferior to CT for staging liver and distant organ involvement. Now, with the development of multidetector CT technology, the question arises: Does EUS still have a role for preoperative staging of pancreatic cancer?

To answer this question, investigators at a referral center compared the diagnostic accuracy of EUS with that of multidetector CT in patients with suspected pancreatic cancer. This prospective observational study was not blinded or randomized, and only 104 of 120 enrolled patients underwent both diagnostic procedures. Surgical exploration findings, surgical pathology stage, or imaging-defined unresectability was used as the gold standard for defining surgical resectability for cure.

Eighty of the 104 patients who underwent both diagnostic tests before surgery had pancreatic cancer; 53 underwent surgery with intent to cure, but only 25 tumors were resectable. Preoperative EUS and multidetector CT correctly staged 88% and 92% of these 25 tumors, respectively. Of the 28 tumors determined by surgical exploration to be unresectable, 68% and 64% were correctly staged by preoperative EUS and multidetector CT, respectively. EUS was significantly more sensitive than CT for detecting pancreatic mass (98% vs. 86%) and for tumor staging accuracy (67% vs. 41%).

Comment: Despite important clinical advances in preoperative imaging, our tools are still less than optimal for accurate staging of pancreatic cancer. The greatest need is to correctly identify the few patients who have the possibility of surgical cure and to provide some chance for improved survival. Although the nearly 90% accuracy of both tests provides some comfort, both tests miss 10% of patients who may not be offered the chance for cure because of overstaging. Further imaging developments should seek to improve staging specificity at the expense of sensitivity to maximize detection of curable candidates, even if some patients must undergo surgery unnecessarily. Until we have an optimal preoperative imaging modality, EUS or multidetector CT is mandatory for preoperative staging of pancreatic cancer. The choice should be determined by local expertise and availability. Future studies should use surgical findings as the gold standard to maximize the validity of the results.

— M. Brian Fennerty, MD

Published in Journal Watch Gastroenterology December 15, 2004

Citation(s):

DeWitt J et al. Comparison of endoscopic ultrasonography and multidetector computed tomography for detecting and staging pancreatic cancer. Ann Intern Med 2004 Nov 16; 141:753-63.

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