Value of cytodiagnosis using endoscopic nasopancreatic drainage for early diagnosis of pancreatic cancer: establishing a new method for the early detection of pancreatic carcinoma in situ

Endoscopic Ultrasonography Diagnosis of Early Pancreatic Cancer

Early diagnosis of pancreatic cancer (PC) can improve patients’ prognosis. We aimed to investigate the utility of endoscopic ultrasonography (EUS) for the early diagnosis of PC. This study included 64 patients with PC at an early stage treated at Onomichi General Hospital between January 2007 and January 2020. Diagnostic procedures included contrast computed tomography (CT), magnetic resonance cholangiopancreatography, EUS fine-needle aspiration, and endoscopic retrograde cholangiopancreatography (ERCP) for pancreatic juice cytology. The mean age was 71.3 years. In all, 32 patients were stage 0, and 32 were stage I. As for image findings, the main pancreatic duct (MPD) stenosis was detected in several cases, although CT and MRCP seldom detected tumors. EUS had a high detection rate for stage 0 tumor lesions. The median observation period was 3.9 years. In cases with stage 0, the 1 year and 5 year survival rates were 100% and 78.9%, respectively. In cases with stage I, the 1 year and 5 year survival rates were 96.4% and 66.7%, respectively. EUS has the highest sensitivity among all imaging modalities for detecting small pancreatic tumors. Cases with MPD dilation or stenosis, especially with tumors that cannot be identified on CT and MRI, should have EUS performed. In some cases, EUS was not able to detect any tumor lesions, and ERCP-based pancreatic juice cytology should be useful for pathological diagnosis.

Focal parenchymal atrophy of pancreas: An important sign of underlying high-grade pancreatic intraepithelial neoplasia without invasive carcinoma, i.e., carcinoma in situ

OBJECTIVES

Diagnosing high-grade intraepithelial neoplasia without invasion, traditionally referred to as carcinoma in situ (CIS), is essential for improving prognosis. We examined the imaging findings of patients with and without CIS to identify significant aspects for the diagnosis of CIS.

METHODS

Forty-six patients strongly suspected of early pancreatic cancer without nodule on imaging (CIS group, n = 27; non-malignant group, n = 19) were retrospectively evaluated according to ten factors of computed tomography/magnetic resonance imaging (CT/MRI), endoscopic ultrasonography (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) using hierarchical cluster and univariate analyses.

RESULTS

Two clusters were formed by hierarchical cluster analysis. One cluster consisted of 83.3% CIS cases with similar image findings such as focal pancreatic parenchymal atrophy (FPPA) on CT/MRI, main pancreatic duct (MPD) stricture surrounded by hypoechoic areas on EUS, and MPD stricture with upstream MPD dilation on ERCP. On univariate analysis, the CIS and non-malignant groups had FPPA on CT/MRI in 15 (55.6%) and 3 (15.8%) cases (p = 0.013), and MPD stricture surrounded by hypoechoic areas on EUS in 20 (74.1%) and 4 (21.1%) cases (p = 0.001), respectively. MPD stricture surrounded by hypoechoic areas was observed in 80% (12/15) of CIS cases with FPPA on CT/MRI and correlated with FPPA. Moreover, FPPA and MPD stricture surrounded by hypoechoic areas had histopathologically observed fibrosis or fat replacement due to pancreatic parenchymal atrophy.

CONCLUSIONS

FPPA and MPD stricture surrounded by hypoechoic areas are significant findings for the diagnosis of CIS.

How Does Ultrasound Manage Pancreatic Diseases? Ultrasound Findings and Scanning Maneuvers

As ultrasound (US) is simple and less invasive than other imaging modalities, this technique is widely used for mass screening. However, visualizing the entire pancreas due to complicated anatomy, obesity and overlying gas can be difficult. US plays a key role in the diagnosis of pancreatic carcinoma (PC), of which tumors smaller than 10 mm (TS1a) and pancreatic carcinoma <i>in situ</i> are expected to have good prognosis. To detect these forms of PC, main pancreatic duct (MPD) dilatation (3 mm or more) and pancreatic cysts (5 mm or larger) are US findings of high-risk individuals (HRIs), and these subjects should be observed periodically. Scanning maneuvers are also important for both screening for PC and follow-up of HRIs. As lesions in the groove area and ventral pancreas do not affect the MPD or extrahepatic bile duct, we should pay attention to these areas. Visualization of the tail is also challenging due to gas and stool in the alimentary tract. As the position of the pancreas changes depending on the body posture, and several different body positions should be employed, such as the right lateral decubitus, sitting, and upright positions, rather than only applying strong compression with the transducer. In cases with poor visualization, the liquid-filled stomach method is highly recommended.

Carcinoma in situ of the pancreas with fibrosis area around the carcinoma: A case report

RATIONALE

Pancreatic cancer (PC) has the worst prognosis among all carcinomas. However, patients with carcinoma in situ (CIS) of the pancreas, usually, have a good prognosis. Many previous reports have mentioned the high frequency of fibrosis around CIS. In some cases, the fibrosis is detected on endoscopic ultrasonography (EUS), but there are few past reports of fibrosis detected on computed tomography (CT).

PATIENT CONCERNS

We encountered a case of fibrosis around CIS detected by CT. A 74-year-old man was being followed for chronic hepatitis C. On a contrast-enhanced CT (CE-CT), a space-occupied lesion (7 mm in size) in the pancreatic head was identified in the delayed phase.

DIAGNOSIS

It was shown to be a hypo echoic lesion in EUS, and EUS-fine-needle aspiration was performed. Cytological examination revealed abnormal cells suspicious for a neuroendocrine tumor.

INTERVENTIONS

Consequently, a pancreaticoduodenectomy was performed. Histopathological examination showed CIS in the branch duct with 10 mm of fibrosis around CIS. The fibrotic area corresponded to the mass detected by preoperative CE-CT.

OUTCOMES

He had no relapse of PC but died 2 years later from another cause.

LESSONS

This case highlights the importance of identifying the enhanced area in the delayed phase on CE-CT, as this can be fibrosis around CIS.

Endoscopic retrograde cholangiopancreatography guided interventions in the management of pancreatic cancer

Pancreatic cancer is the leading cause of cancer-related morbidity and mortality with an overall five-year survival of less than 9% in the United States. At presentation, the majority of patients have painless jaundice, pruritis, and malaise, a triad that develops secondary to obstruction, which often occurs late in the course of the disease process. The technical advancements in radiological imaging and endoscopic interventions have played a crucial role in the diagnosis, staging, and management of patients with pancreatic cancer. Endoscopic retrograde cholangiopancreatography (ERCP)-guided diagnosis (with brush cytology, serial pancreatic juice aspiration cytologic examination technique, or biliary biopsy) and therapeutic interventions such as pancreatobiliary decompression, intraductal and relief of gastric outlet obstruction play a pivotal role in the management of advanced pancreatic cancer and are increasingly used due to improved morbidity and complication rates compared to surgical management. In this review, we highlight various ERCP-guided diagnostic and therapeutic interventions for the management of pancreatic cancer.

Efficacy of the physiobiological parameter-based grading system for predicting the long-term prognosis after curative surgery for resectable pancreatic cancer

BACKGROUND

Several prognostic scoring systems based on cancer-related inflammation have been developed. We aimed to evaluate the efficacy of a novel physiobiological parameter-based grading system (PGS) for predicting the long-term prognosis after curative-intent surgery for pancreatic ductal adenocarcinoma.

METHODS

One-hundred fifty-nine consecutive patients with pancreatic ductal adenocarcinoma were enrolled. Univariate and multivariate analyses were performed to identify variables associated with overall survival and recurrence-free survival. Patients were stratified according to the PGS score with a cut-off value of 40.5 being estimated by receiver-operating characteristic curve analysis. Propensity score matching analysis (PSM) was performed to compare between patients with low and high scores in the physiobiological parameter-based grading system.

RESULTS

Univariate analysis showed that CEA elevation (p = 0.032), tumor size ≥20 mm (p < 0.001), lymph node metastasis (p < 0.001), high-PGS (p < 0.001), CA19-9 elevation (p < 0.001), Prognostic nutritious index (PNI) ≤40 (p = 0.002) and positive Glasgow prognostic score (GPS) (p = 0.001) were risk factors for poor overall survival. CEA elevation (p = 0.006), Tumor size ≥20 mm (p < 0.001), lymph node metastasis (p < 0.001), high-PGS (p < 0.001), CA19-9 elevation (p < 0.001), PNI ≤40 (p = 0.017) and positive GPS (p < 0.001) were identified as risk factors for poor recurrence-free survival. The multivariate analysis revealed that tumor size ≥20 mm (p = 0.007, p = 0.008, respectively) and high PGS score (p = 0.041, p = 0.018, respectively) were independently associated with poor overall survival and recurrence-free survival. Patients with high-PGS showed a significantly worse long-term prognosis even after PSM.

CONCLUSION

The PGS is a novel nomogram that could effectively predict long-term outcomes following curative surgery in patients with pancreatic ductal adenocarcinoma.

Partial Pancreatic Parenchymal Atrophy Is a New Specific Finding to Diagnose Small Pancreatic Cancer (≤10 mm) Including Carcinoma in Situ: Comparison with Localized Benign Main Pancreatic Duct Stenosis Patients

BACKGROUND

This study aimed to evaluate and identify the specific CT findings by focusing on abnormalities in the main pancreatic duct (MPD) and pancreatic parenchyma in patients with small pancreatic cancer (PC) including carcinoma in situ (CIS).

METHODS

Nine CT findings indicating abnormalities of MPD and pancreatic parenchyma were selected as candidate findings for the presence of small PC ≤ 10 mm. The proportions of patients positive for each finding were compared between small PC and benign MPD stenosis groups. Interobserver agreement between two independent image reviewers was evaluated using kappa statistics.

RESULTS

The final analysis included 24 patients with small PC (including 11 CIS patients) and 28 patients with benign MPD stenosis. The proportion of patients exhibiting partial pancreatic parenchymal atrophy (PPA) corresponding to the distribution of MPD stenosis (45.8% vs. 7.1%, p < 0.01), upstream PPA arising from the site of MPD stenosis (33.3% vs. 3.6%, p = 0.01), and MPD abrupt stenosis (45.8% vs. 14.3%, p = 0.03) was significantly higher in the small PC group than in the benign MPD stenosis group.

CONCLUSIONS

The presence of partial PPA, upstream PPA, and MPD abrupt stenosis on a CT image was highly suggestive of the presence of small PCs including CIS.

The usefulness of serial pancreatic juice aspiration cytological examination for pancreatic cancer not diagnosed by EUS-FNAB

Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB) is safe and useful for the diagnosis of pancreatic cancer. However, sometimes a diagnosis cannot be established by EUS-FNAB. The efficacy of serial pancreatic juice aspiration cytological examination (SPACE) for pancreatic cancer was reported. SPACE may be useful in cases in which diagnosis by EUS-FNAB is difficult; however, this has not been reported previously. We herein report two cases of pancreatic cancer diagnosed by SPACE when diagnosis by EUS-FNAB was difficult. Case 1 was a 77-year-old female. She was suspected of pancreatic cancer because of new-onset diabetes. We performed EUS-FNAB to the lesion in the pancreatic body; however, diagnosis failed. We performed SPACE and diagnosed pancreatic cancer finally. Case 2 was 72 years old female. She was suspected of having pancreatic cancer because of the dilatation of the pancreatic duct. We performed EUS-FNAB twice to the lesion in the pancreatic head, however, diagnosis failed. Therefore, we performed SPACE and got final diagnosis as pancreatic cancer. From our experience, we suggest that SPACE is a useful diagnostic method for patients with pancreatic cancer that are difficult to diagnose.

Features of chronic pancreatitis by endoscopic ultrasound influence the diagnostic accuracy of endoscopic ultrasound-guided fine-needle aspiration of small pancreatic lesions

BACKGROUND AND AIM

In chronic pancreatitis (CP) patients, diagnosis of small pancreatic lesions by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is challenging. Thus, the aim of the present study was to investigate whether CP influences the diagnostic ability of EUS-FNA for pancreatic lesions ≤10 mm.

METHODS

One hundred and seventeen patients who underwent EUS-FNA for pancreatic lesions ≤10 mm in size were enrolled. Patients were classified into two groups based on features of CP observed by EUS (EUS-CP features) in accordance with the Rosemont classification. The CP group was defined as cases consistent with CP or suggestive of CP, and the non-CP group was defined as cases indeterminate for CP or normal. Factors influencing the diagnostic accuracy of EUS-FNA and CP status in pancreatic tumors were also investigated.

RESULTS

Diagnostic ability of EUS-FNA (overall cases, non-CP vs CP) had sensitivity (80.4%, 96.7% vs 57.1%; P < 0.001), specificity (100%, 100% vs 100%; P > 0.05), and accuracy (91.5%, 98.6% vs 80.4%; P = 0.001). In multivariate analysis of factors influencing the accuracy of EUS-FNA, CP significantly lowered the accuracy (P = 0.048; odds ratio [OR] = 9.21). Among pancreatic cancer patients, the number of CP patients was significantly higher than the number of patients with benign lesions (P = 0.023). In multivariate analysis, lobularity without honeycombing was more frequently observed in cases of pancreatic cancer (P = 0.018; OR, 12.65).

CONCLUSION

Endoscopic ultrasound-guided FNA offers high accuracy for small pancreatic lesions ≤10 mm. However, in cases with CP, the diagnostic ability of EUS-FNA is significantly reduced.

Value of endoscopy for early diagnosis of pancreatic carcinoma

Despite recent advances in diagnostic imaging modalities, most cases of pancreatic carcinoma are discovered at an unresectable stage, resulting in poor prognosis. Early diagnosis is essential to ensure curative treatment and improve the prognosis of pancreatic carcinoma. Imaging modalities with high diagnostic ability are necessary for the early diagnosis of pancreatic carcinoma. Endoscopic ultrasonography is a reliable and efficient diagnostic modality because it provides superior spatial resolution and should be incorporated into screening programs in patients at high risk of pancreatic carcinoma. Endoscopy facilitates cytopathological diagnosis based on samples collected via endoscopic ultrasonography-guided fine-needle aspiration and endoscopic retrograde cholangiopancreatography. Cytodiagnosis with endoscopic naso-pancreatic drainage is useful in patients with carcinoma in situ. In this review, we highlight the potential role of endoscopy in the early diagnosis of pancreatic carcinoma. We provide an overview of the endoscopy tools used for the diagnosis of pancreatic carcinoma, discuss the diagnostic ability of these tools for small carcinomas and carcinomas in situ, and propose a strategy for endoscopy-based screening of early pancreatic carcinoma.

Carcinoma in situ of the pancreas with pancreatic duct stricture persistent for 4 years diagnosed by serial pancreatic juice aspiration cytologic examination (SPACE)

Serial pancreatic juice aspiration cytologic examination (SPACE) by nasopancreatic tube placement can give us an opportunity to diagnose early-stage pancreatic cancer with higher sensitivity and specificity compared with conventional pancreatic cytology by one-time pancreatic juice aspiration or pancreatic duct brushing. We performed SPACE in a patient with persistent pancreatic duct stricture (PDS) with gradually advancing pancreatic parenchyma atrophy (PPA) in the pancreas tail. The result of SPACE was suggestive of pancreatic carcinoma, and distal pancreatectomy was performed. Histopathological examination of the resected specimen revealed carcinoma in situ of the pancreas. The present case could indicate that any PDS becomes a candidate for SPACE especially in a patient with PPA, although the PDS remains unchanged for a long period.

Predictive Value of Localized Stenosis of the Main Pancreatic Duct for Early Detection of Pancreatic Cancer

Background/Aims:

In this study, we aimed to evaluate the predictive value of localized stenosis of the main pancreatic duct (MPD) for early detection of pancreatic cancer.

Methods:

Among 689 patients who underwent endoscopic retrograde pancreatography from January 2008 to September 2018, 19 patients with MPD findings were enrolled. These patients showed findings for indicating suspicious pancreatic cancer at an early stage (FiCE); FiCE was defined as a single, localized stenosis in the MPD without a detectable mass (using any other imaging methods) and without other pancreatic diseases, such as definite chronic pancreatitis, intraductal papillary mucinous neoplasm, and autoimmune pancreatitis. Final diagnoses were established by examining resected specimens or through follow-up examinations after an interval of >5 years.

Results:

Among 19 patients with FiCE, 11 underwent surgical resection and 8 were evaluated after a >5-year observation period. The final diagnosis of the MPD stenosis was judged to be pancreatic cancer in 9 patients (47%), including 3 with intraepithelial cancer, and to be a non-neoplastic change in 10. The sensitivity, specificity, and accuracy of preoperative pancreatic juice cytology were 75%, 100%, and 88%, respectively.

Conclusions:

The predictive value of FiCE for pancreatic cancer prevalence was 47%. Histological confirmation with pancreatic juice cytology is necessary before surgical resection.

Early Detection of Pancreatic Cancer in Patients With Chronic Liver Disease Under Hepatocellular Carcinoma Surveillance

OBJECTIVE

To evaluate whether patients with hepatitis B virus (HBV)- and hepatitis C virus (HCV)-related chronic liver disease were diagnosed as having pancreatic cancer (PC) at an early stage during abdominal imaging surveillance for hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

We retrospectively examined 447 patients with PC diagnosed at Ehime University Hospital and affiliated centers (2011-2013). Data were collected regarding HBV and HCV status, likelihood of PC diagnosis, and Union for International Cancer Control (UICC) stage. Intergroup comparisons were performed using the χ² test.

RESULTS

The UICC stage distribution in the HCC surveillance group (n=16) was stage 0 (n=2, 12.5%), stage IA (n=3, 18.8%), stage IB (n=2, 12.5%), stage IIA (n=2, 12.5%), stage IIB (n=2, 12.5%), stage III (n=1, 6.3%), and stage IV (n=4, 25%). The UICC stage distribution in the nonsurveillance group (n=431) was stage 0 (n=4, 0.9%), stage IA (n=28, 6.5%), stage IB (n=27, 6.3%), stage IIA (n=86, 20.0%), stage IIB (n=48, 11.1%), stage III (n=56, 13.0%), and stage IV (n=182, 42.2%). The HCC surveillance group had significantly more patients with stage 0 disease than with stages IA through IV (P=.02). Similar results were observed when including stages IA (P=.007) and IB (P=.004) as early stages but not stage IIA (P=.10). A dilated pancreatic duct led to a PC diagnosis in all 6 patients with stage 0 disease.

CONCLUSION

Patients with HBV- and HCV-related chronic liver disease had an early PC diagnosis during HCC surveillance. Careful evaluation of the pancreas is warranted during HCC surveillance.

Evaluation of efficacy of pancreatic juice cytology for risk classification according to international consensus guidelines in patients with intraductal papillary mucinous neoplasm; a retrospective study

OBJECTIVES

Pancreatic juice cytology (PJC) for intraductal papillary mucinous neoplasm (IPMN) is a possible tool to enhance preoperative diagnostic ability by improving risk classification for malignant IPMN, but its efficacy is controversial. This study evaluated the efficacy of PJC for risk classification according to international guidelines.

METHODS

We retrospectively analyzed 127 IPMN patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) preoperatively. PJC was performed in 125 of the 127 cases. High-risk stigmata (HRS, n = 57), worrisome features (WF, n = 64), and other characteristics (n = 6) were classified according to the 2017 international guidelines.

RESULTS

Among the 127 IPMN patients, 71 (55.9%) had malignant IPMN (invasive and non-invasive intraductal papillary mucinous carcinoma). The accuracy of WF for classifying malignant IPMN was increased by the addition of PJC, but the accuracy of HRS was not (WF to WF + PJC: 33.1% [42/127] to 48.8% [61/125], HRS to HRS + PJC: 65.4% [83/127] to 52.8% [66/125]). Post-ERCP pancreatitis (PEP) occurred in 32 (25.2%) of 127 IPMN patients. Severe PEP was not detected. Significant risk factors for PEP were female sex, obesity, and endoscopic naso-pancreatic drainage (ENPD) (P = .03, P = .0006, and P = .02, respectively). In patients with ENPD tube placement, a main pancreatic duct size of <5 mm was a significant risk factor for PEP (P = .02).

CONCLUSION

PJC could increase the accuracy of WF for classifying malignant IPMN. The additive effect of PJC for risk classification may be limited, however, and it is not recommended for all IPMN cases due to the high frequency of PEP.

Endoscopic ultrasound findings and pathological features of pancreatic carcinoma in situ

Background and study aims Few studies have evaluated detection of pancreatic carcinoma in situ (PCIS). We evaluated findings of endoscopic ultrasound (EUS) and pathological features of PCIS.

Patients and methods We histopathologically studied 16 patients with PCIS following EUS. Diagnostic features evaluated retrospectively included stricture of the main pancreatic duct (MPD) on EUS, presence or absence of hypoechoic areas surrounding the MPD stricture on EUS, the noncancerous part (pancreas of background) on EUS and histopathology, and histological findings adjacent to the area of PCIS.

Results On EUS, stricture of the MPD was found in 15 patients (93.8 %). Hypoechoic areas surrounding the MPD stricture were observed in 9 patients (56.3 %), including three (18.8 %) with a 10- to 11-mm hypoechoic mass. EUS findings of the noncancerous part indicated chronic pancreatitis in six patients (37.5 %), pancreatic fatty infiltration in seven (43.8 %), early chronic pancreatitis in two (12.5 %), and normal pancreas in one (6.3 %). Histological findings of the noncancerous part (proximal to the MPD stricture) indicated chronic pancreatitis in 13 patients (81.3 %) and pancreatic fatty infiltration in five patients (31.3 %). Histopathologically, subepithelial inflammatory cell infiltration and fibrosis were present in all 16 patients with PCIS.

Conclusions PCIS frequently causes localized changes in inflammation and fibrosis around the pancreatic duct. PCIS often accompanies chronic pancreatitis and pancreatic fatty infiltration in the background of the pancreas. EUS offers sufficient resolution to demonstrate pancreatic changes of PCIS.

Roles of ERCP in the Early Diagnosis of Pancreatic Cancer

It has been reported that endoscopic retrograde cholangiopancreatography (ERCP) is of value in evaluating precise pancreatograms of the pancreatic duct (PD). Recently, institutions have tended to perform magnetic resonance cholangiopancreatography (MRCP) for the diagnosis of PD due to post-ERCP pancreatitis (PEP). In small pancreatic cancer (PC), including PC in situ (PCIS) which is undetectable on cross sectional images, endoscopic ultrasonography (EUS) and MRCP serve important roles in detecting local irregular stenosis of the PD or small cystic lesions. Subsequently, ERCP and associated serial pancreatic juice aspiration cytologic examination (SPACE) obtained by endoscopic nasopancreatic drainage (ENPD) may be useful in the diagnosis of very early-stage PC. Further prospective multicenter studies are required to establish a standard method of SPACE for the early diagnosis of PC.

Advances in Early Detection of Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease. PDAC is the fourth leading cause of death in the United States and Japan based on epidemiological data. Early detection of PDAC is very important to improve the prognosis of PDAC. Early detection of pancreatic ductal adenocarcinoma (PDAC) requires further examination after selecting cases with risk factors for the condition, such as family history, hereditary pancreatic carcinoma syndrome, intraductal papillary mucinous neoplasms, or chronic pancreatitis. The Japan Study Group on the Early Detection of Pancreatic Cancer has investigated and clarified the clinicopathological features for the early diagnosis of PDAC. In Japan, an algorithm for the early diagnosis of PDAC, which utilized the cooperation of local clinics and regional general hospitals, has been a breakthrough in the detection of early-stage PDAC. Further approaches for the early diagnosis of PDAC are warranted.

Proposal for Endoscopic Ultrasonography Classification for Small Pancreatic Cancer

Backgrounds: Endoscopic ultrasonography (EUS) is used to observe the stricture of the main pancreatic duct (MPD) and in diagnosing pancreatic cancer (PC). We investigate the findings on EUS by referring to the histopathological findings of resected specimens. Materials and Methods: Six patients with carcinoma in situ (CIS) and 30 patients with invasive carcinoma of 20 mm or less were included. The preoperative EUS findings were classified as follows. A1: Simple stricture type—no findings around the stricture; A2: Hypoecho stricture type—localized hypoechoic area without demarcation around the stricture; A3: Tumor stricture type—tumor on the stricture; B: Dilation type—the dilation of the pancreatic duct without a downstream stricture; C: Parenchymal tumor type—tumor located apart from the MPD. Results: Classes A1 and A2 consisted of 2 CISs, and 4 invasive carcinomas included two cases smaller than 5 mm in diameter. Most of the cancers classified as A3 or C were of invasive carcinoma larger than 5 mm in diameter. All cancers classified as B involved CIS. Serial pancreatic-juice aspiration cytologic examination (SPACE) was selected for all types of cases, with a sensitivity of 92.0%, while EUS-guided fine needle aspiration cytology (EUS-FNA) was only useful for invasive carcinoma, and its sensitivity was 66.7%. Conclusions: Stricture without a tumor could be a finding for invasive PC and pancreatic duct dilation without a downstream stricture could be a finding indicative of CIS. Carcinoma smaller than 5 mm in diameter could not be recognized by EUS. SPACE had a high sensitivity for diagnosing small PC.

High-grade PanIN presenting with localised stricture of the main pancreatic duct: A clinicopathological and molecular study of 10 cases suggests a clue for the early detection of pancreatic cancer

AIMS

This study aimed to identify the pathological features of high-grade PanIN that presents with imaging-detectable abnormalities.

METHODS AND RESULTS

Ten cases of isolated, main-duct, high-grade PanIN as the primary clinical presentation were identified. All patients presented with stenosis of the main pancreatic duct, with two being associated with extensive upstream duct dilatation (>5 mm in diameter). Pancreatic juice cytology suggested adenocarcinoma in all seven cases examined. In resected specimens, high-grade PanIN was present chiefly in the main pancreatic duct, with longitudinal extension ranging between 3 and 40 mm in length (median = 18 mm). In four cases, in which hypoechoic or hypovascular masses were observed on imaging, radiopathology correlations suggested that they represented parenchymal atrophy and subsequent fibrosis around affected ducts, but not invasive malignancy. On immunohistochemistry, the loss of p16 expression was found in five (50%), p53 overexpression in two (20%) and loss of SMAD4 expression in none (0%). KRAS mutations were detected in nine cases, with two dominant clones being found in three by ultrasensitive droplet digital polymerase chain reaction, suggesting the genetic heterogeneity of dysplastic cells composing individual lesions. Mutant GNAS was also observed in one case.

CONCLUSIONS

Isolated high-grade PanIN may present with pancreatic duct stenosis. Therefore, intensive investigations including pancreatic juice cytology will be required for patients with unexplained pancreatic duct stenosis. The abnormal expression of p53 and SMAD4 is infrequent, while GNAS may be mutated in premalignant lesions mainly affecting the main pancreatic duct, similar to KRAS.

Pancreatic Duct Stricture That Rapidly Progressed to Pancreatic Ductal Adenocarcinoma and Formed a Mass within 3 Months: A Case Report

The natural growth rate of pancreatic carcinoma in situ with pancreatic duct stricture remains unclear. Herein, we present a case with pancreatic duct stricture that rapidly grew to form a mass lesion within 3 months. A 74-year-old woman was referred to us for the investigation of a pancreatic duct dilatation. Initial images did not reveal any clear mass lesions near the pancreatic duct stricture. Pancreatic juice cytology showed suspicious findings. Distal pancreatectomy was recommended; however, the patient refused to undergo surgical treatment at that time. Images taken 3 months later demonstrated a nodular pancreatic body mass which was identified as a moderately to poorly differentiated tubular adenocarcinoma. Previous reports have suggested that pancreatic carcinoma in situ and small pancreatic ductal adenocarcinoma require at least 1–2 years to progress to an advanced mass. This case suggests that pancreatic carcinoma in situ may grow rapidly and indicates a need for close follow-up in patients with pancreatic duct strictures, even if the pathological evidence is not confirmed.

Prospective Follow-up Study of the Recurrence of Pancreatic Cancer Diagnosed at an Early Stage: The Value of Endoscopic Ultrasonography for Early Diagnosis of Recurrence in the Remnant Pancreas

OBJECTIVES

Most patients with pancreatic cancer (PC) demonstrate recurrences in the form of metastatic disease. We prospectively evaluated recurrence in PC cases diagnosed at an early stage.

METHODS

Thirty cases of PC stage 0 or IA were prospectively followed for at least 1 year after initial surgery. We performed blood tests and contrast-enhanced computed tomography (CT) every 3 to 6 months. Endoscopic ultrasonography (EUS) was performed if CT revealed abnormal findings in the remnant pancreas (RP).

RESULTS

The median follow-up period was 53.9 months. Pancreatic cancer recurred in the RP (n = 8) and liver (n = 1). Computed tomography revealed mass lesions in 5 cases, a cystic lesion in 2 cases, and pancreatic duct dilatation in 1 case. Endoscopic ultrasonography detected mass lesions in 3 cases without a detectable mass on CT. The sensitivity of EUS-guided fine-needle aspiration and pancreatic juice cytology was 75%. Five of 8 cases underwent total resection of the RP, with pathologic findings revealing stage IA in 1 case, stage II in 1 case, and stage III in 3 cases.

CONCLUSIONS

Careful long-term follow-up including EUS should be performed in resected PC cases diagnosed at an early stage to check recurrence in the RP.

Early Diagnosis to Improve the Poor Prognosis of Pancreatic Cancer

Pancreatic cancer (PC) has a poor prognosis due to delayed diagnosis. Early diagnosis is the most important factor for improving prognosis. For early diagnosis of PC, patients with clinical manifestations suggestive of PC and high risk for developing PC need to be selected for examinations for PC. Signs suggestive of PC (e.g., symptoms, diabetes mellitus, acute pancreatitis, or abnormal results of blood examinations) should not be missed, and the details of risks for PC (e.g., familial history of PC, intraductal mucin producing neoplasm, chronic pancreatitis, hereditary pancreatitis, or life habit) should be understood. Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) can be performed for diagnosing PC, but the diagnostic ability of these examinations for PC is limited. Endoscopic diagnostic procedures, such as endoscopic ultrasonography, including fine-needle aspiration, and endoscopic retrograde pancreatocholangiography, including Serial Pancreatic-juice Aspiration Cytologic Examination (SPACE), could be recommended for a detailed examination to diagnose pancreatic carcinoma earlier.

Multicenter study of early pancreatic cancer in Japan

BACKGROUND/OBJECTIVES

The diagnosis of early-stage pancreatic ductal adenocarcinoma (PDAC) is still challenging. We conducted a multicenter study to clarify the clinical features of early-stage PDAC in Japan.

METHODS

We collected patients with stage 0 and stage I PDAC according to the sixth edition of the Japanese Classification of Pancreatic Carcinoma. We retrospectively analyzed the clinical profiles including opportunities for medical examination, imaging modalities and findings, methods of cytological diagnosis, and prognosis according to the stages at diagnosis.

RESULTS

Two hundred cases with Stage 0 and stage I PDAC were reported from 14 institutions, which accounted for approximately 0.7% and 3% of all PDAC cases, respectively. Overall, 20% of the early-stage PDAC cases were symptomatic. Indirect imaging findings such as dilatation of the main pancreatic duct were useful to detect early-stage PDAC. In particular, local fatty changes may be specific to early-stage PDAC. For preoperative pathologic diagnosis, cytology during endoscopic retrograde cholangiopancreatography was more commonly applied than endoscopic ultrasound fine-needle aspiration. Although the overall prognosis was favorable, new PDAC lesions developed in the remnant pancreas in 11.5% cases.

CONCLUSIONS

This multicenter study revealed several key points concerning the diagnosis and management of early-stage PDAC, including screening of asymptomatic cases, importance of indirect imaging findings, application of cytology during endoscopic retrograde cholangiopancreatography, and the risk of carcinogenesis in the remnant pancreas.

Acute pancreatitis-onset carcinoma in situ of the pancreas with focal fat replacement diagnosed using serial pancreatic-juice aspiration cytologic examination (SPACE)

A 59-year-old woman was admitted for acute pancreatitis. Abdominal computed tomography and magnetic resonance imaging revealed a swollen pancreatic parenchyma with dilatation of the main pancreatic duct (MPD) of the pancreas tail, which was separated from the normal pancreas body side by a locally atrophic part of the pancreas. Magnetic resonance cholangiopancreatography showed MPD stricture in the pancreas tail with dilatation of the upstream MPD. Endoscopic ultrasonography revealed that the MPD stricture of the pancreas tail was surrounded by a blurred and hypoechoic area. Endoscopic retrograde cholangiopancreatography was performed for serial pancreatic-juice aspiration cytologic examination (SPACE). The result indicated adenocarcinoma. Distal pancreatectomy was performed, and the histopathological examination showed high-grade PanIN (carcinoma in situ of the pancreatic duct) of the pancreas tail with atrophy and fibrosis of the pancreatic parenchyma, and local fat replacement adjacent to the lesion. The final histopathological diagnosis was carcinoma in situ of the pancreatic duct of the pancreas tail. Acute pancreatitis and local fatty change of the pancreatic parenchyma with MPD stricture are important clinical manifestations of pancreatic carcinoma in situ (PCIS) and performing SPACE in cases of MPD stricture without a recognizable mass is preferable for a diagnosis of PCIS.

Early detection of sporadic pancreatic cancer: time for change

Sporadic pancreatic cancer amounts to ∼90% of all pancreatic cancers. It is a gloomy depressive disease and the most recalcitrant malignancy, with a very low 5-year survival (3-6%). At present, diagnostic methods are commonly applied, as used half a century ago, after the appearance of local and systemic symptoms (abdominal and back pain, cholestasis, painless jaundice, fatigue, anorexia, weight loss, anemia, peripheral phlebitis, and cachexia). Unfortunately, these symptoms are harbingers of an advanced disease. The subsequent imaging methods may offer additional information on the location, size, and morphology of the lesion, but they do not influence the prognosis. Radical surgery may be offered to 15-20% of patients. The relapses after surgery are frequent and chemotherapy may be palliative. Preventive programs represent the only possibility of improvement. We propose the first multistep and multidisciplinary preventive program for early detection of sporadic pancreatic cancer for the differential identification of average-risk patients who probably have the disease from those who do not.

Comparison of guidelines for intraductal papillary mucinous neoplasm: What is the next step beyond the current guidelines?

Management of intraductal papillary mucinous neoplasm is controversial, and several guidelines have aimed to establish an adequate strategy for surgical resection and surveillance. We compared various intraductal papillary mucinous neoplasm guidelines and considered new matters that are pivotal for improved treatment of intraductal papillary mucinous neoplasm. We identified and compared 11 published guidelines, three of which were major guidelines that mainly referred to the diagnosis and treatment of intraductal papillary mucinous neoplasm (International Association of Pancreatology 2012 guidelines, European Study Group on Cystic Tumours of the Pancreas 2013 guidelines, and American Gastroenterological Association 2015 guidelines). The main concerns of these three guidelines were indication for surgery and follow up of non-resected lesions. Among the differences between the three guidelines, the period of surveillance recommended was the most controversial matter. Meanwhile, several nomograms have been proposed to improve the diagnosis of intraductal papillary mucinous neoplasm from the level of experts' experiences to that of rational systems. We discuss the adequate strategy of surveillance for intraductal papillary mucinous neoplasm with and without pancreatectomy and nomograms aiming to predict the risk of malignancy in patients with intraductal papillary mucinous neoplasm.

Early diagnosis of pancreatic cancer: Current trends and concerns

Early detection of pancreatic cancer (PC) is essential for a better prognosis. Some recent studies have demonstrated that a slight dilatation of the main pancreatic duct (MPD) and small cystic lesions were detected initially in most cases diagnosed at an early stage. Detecting these abnormal findings in cases with high risk factors through an effective screening system including image diagnosis, some biological markers, or familial cancer registrations should contribute to early diagnosis of PC. It has been reported that endoscopic ultrasonography (EUS) is essential for detecting tumors <10 mm with a favorable prognosis. Additionally, EUS‐guided fine‐needle aspiration biopsy is useful for confirming final histological diagnosis. For the diagnosis of stage 0 PC, local irregular stenosis of MPD should be an important initial abnormal sign detected by EUS or magnetic resonance cholangiopancreatography. Cytodiagnosis multiple times using pancreatic juice obtained by endoscopic nasopancreatic drainage should be essential for the final diagnosis. Recently, activities of regional networks between specialist doctors in medical centers and general practitioners for early diagnosis of PC have been reported in Japan. In the future, these activities may play an important role in the early diagnosis of PC.

Early detection of pancreatic cancer: impact of high-resolution imaging methods and biomarkers

High-resolution imaging methods (HRIMs) and biomarkers present the second step of pancreatic cancer (PC) diagnostics in at-risk individuals. These include patients with positive risk factors, early symptoms, nonresponders to the initial antidiabetic therapy, patients older than 50 years of age with new-onset unstable diabetes requiring insulin as well as patients with long-term insulin-non-dependent diabetes and recent (up to 6 months) failure of antidiabetic therapy. The procedures should be started without delay and the co-operation between the primary and tertiary medical centers is highly desirable. An early indication of HRIMs and biomarkers is a prerequisite for the diagnosis of a resectable PC. This publication reviews the recent contribution of HRIMs and biomarkers toward an early diagnosis of PC.

A comparison of 4-Fr with 5-Fr endoscopic nasopancreatic drainage catheters: A randomized, controlled trial

BACKGROUND AND AIM

Although endoscopic nasopancreatic drainage (ENPD) is useful for collecting samples for pancreatic juice cytology and for treating leakage of pancreatic juice and occlusive pancreatitis, placement of the ENPD catheter is associated with complications such as post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). We investigated whether an ENPD catheter with a smaller diameter could reduce the incidence of complications.

METHODS

Patients requiring placement of an ENPD catheter (n = 254) were enrolled and randomly assigned to one of two catheter-size groups: the 4-Fr group or the 5-Fr group. The incidence of PEP, cholangitis, and spontaneous catheter displacement and the suitability of pancreatic juice cytology samples were compared between groups. In addition, univariate and multivariate analyses were conducted on factors associated with PEP.

RESULTS

The incidence of PEP was significantly lower in the 4-Fr group compared with the 5-Fr group (4.1% vs 12.4%, respectively; P = 0.021). The rate of cholangitis and spontaneous catheter displacement and the suitability of pancreatic juice cytology samples did not differ between groups. Multivariate analysis revealed that the risk of PEP was 3.7 times higher when using a 5-Fr catheter than when using a 4-Fr catheter (P = 0.019). In addition, the risk of PEP was 4.1 times higher in patients with an intraductal papillary mucinous neoplasm than in those without (P = 0.0049) and 4.6 times higher in patients aged <65 than in those aged ≥65 (P = 0.0033).

CONCLUSIONS

A 4-Fr catheter is as useful as a 5-Fr catheter and is associated with a significantly lower incidence of PEP.

Role of the preoperative usefulness of the pathological diagnosis of pancreatic diseases

Pancreatic cancer is the fifth leading cause of cancer death and has the lowest survival rate of any solid cancer. Endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) is currently capable of providing a cytopathological diagnosis of pancreatic malignancies with a higher diagnostic power, with a sensitivity and specificity of 85%-89% and 98%-99%, compared to pancreatic juice cytology (PJC), whose sensitivity and specificity are only 33.3%-93% and 83.3%-100%. However, EUS-FNA is not effective in the cases of carcinoma in situ and minimally invasive carcinoma because both are undetectable by endoscopic ultrasonography, although PJC is able to detect them. As for the frequency of complications such as post endoscopic retrograde cholangiopancreatography pancreatitis, EUS-FNA is safer than PJC. To diagnose pancreatic cancer appropriately, it is necessary for us to master both procedures so that we can select the best methods of sampling tissues while considering the patient’s safety and condition.

Effective screening for early diagnosis of pancreatic cancer

Diagnosis of pancreatic cancer (PC) at an early stage with curative surgery should improve long-term patient outcome. At present, improving survival should lie in identifying those cases with high-risk factors or precursor lesions through an effective screening including ultrasonography, some biological markers, or national familial pancreatic cancer registration. Recently, cases with PC < 10 mm with a favorable prognosis have been reported. For the diagnoses of cases with PC < 10 mm, the rate of tumor detection was higher on endoscopic ultrasonography (EUS) than on CT or other modalities, and EUS-guided fine needle aspiration was helpful in confirming the histologic diagnosis. Additionally, for the diagnosis of cases with PC in situ, EUS and magnetic resonance cholangiopancreatography (MRCP) may play important roles in detecting the local irregular stenosis of the pancreatic duct. Cytodiagnosis of pancreatic juice using endoscopic nasopancreatic drainage multiple times may be useful in the final diagnosis.

Predictors and Diagnostic Strategies for Early-Stage Pancreatic Ductal Adenocarcinoma: A Retrospective Study

OBJECTIVES

As a strategy to diagnose early-stage pancreatic ductal adenocarcinoma (PDAC) is urgently needed, we aimed to clarify characteristics of early-stage PDAC.

METHODS

We retrospectively reviewed medical records of 299 consecutive patients who underwent R0 or R1 surgical resection for PDAC between 1994 and 2013 and compared clinical characteristics between patients with early-stage (stages 0-I by Japanese General Rules for Pancreatic Cancer) and advanced-stage (stages II-IV) disease. Diagnostic processes were also analyzed.

RESULTS

Twenty-four patients (8%) had early-stage PDAC (stage 0: 11; stage I: 13). Univariate and multivariate analyses showed that presence or history of intraductal papillary mucinous neoplasm (P < 0.01), history of pancreatitis (P < 0.01), and presence or history of extrapancreatic malignancies (P = 0.01) independently predicted detection of early-stage PDAC. Cytological examination during endoscopic retrograde pancreatography cytology was ∼65% sensitive in preoperative diagnosis of early-stage PDAC, whereas other imaging modalities were only 29% to 38% sensitive; 9 of 24 early-stage PDACs were diagnosed by endoscopic retrograde pancreatography cytology alone.

CONCLUSIONS

Endoscopic retrograde pancreatography cytology for patients with intraductal papillary mucinous neoplasm or pancreatitis may help diagnose early-stage PDAC. Surveillance of extrapancreatic malignancies might also provide opportunities to detect early-stage PDAC as a second malignancy.

Efficacy of repeated cytology of pancreatic juice obtained by endoscopic nasopancreatic drainage tube for early diagnosis of pancreatic cancer: a case series including a case of carcinoma in situ

Repeated cytology of pancreatic juice obtained by endoscopic nasopancreatic drainage (ENPD) tube has been highlighted as an early diagnostic method for small pancreatic cancer, including carcinoma in situ. We report two cases of early-stage pancreatic cancer diagnosed using repeated cytology; both cases underwent curative resection. No significant masses were found on conventional imaging in either case, with only pancreatic duct strictures being observed. ENPD tubes were placed to collect pancreatic juice in both cases. In case 1, two of five pancreatic juice samples showed adenocarcinoma. Therefore, distal pancreatectomy was performed, and a PanIN3 grade neoplasm (carcinoma in situ) was identified at the branch duct near the distal stricture. In case 2, two of seven pancreatic juice samples (collected during the second tube placement) showed adenocarcinoma. Therefore, distal pancreatectomy was performed, and a PanIN3 neoplasm was identified primarily in the pancreatic duct at a narrow section with fibrosis. Partial microinvasion (<1 mm) was observed at the branch duct. Repeated cytology of pancreatic juice obtained by ENPD tube is effective for early diagnosis of pancreatic cancer, especially in cases without mass formation. However, some issues, including the appropriate number of samples, should be addressed in large prospective studies.

Diagnostic strategies for early pancreatic cancer

Diagnosis of pancreatic cancer (PC) at an early stage with curative surgery is the approach with the potential to significantly improve long-term patient outcome. Recently, some reports showed that patients with pancreatic tumors smaller than 10 mm showed a favorable prognosis. However, the rate of tumor detection on computed tomography in patients with small pancreatic tumors is low. For the diagnoses of PC with tumors smaller than 10 mm, the rate of tumor detection was higher on endoscopic ultrasonography (EUS) than on computed tomography or other modalities, and histologic diagnosis using EUS-guided fine-needle aspiration was helpful in confirming the diagnosis. For the diagnosis of PC in situ, EUS and magnetic resonance cholangiopancreatography may play important roles in detecting the local irregular stenosis of the pancreatic duct. Endoscopic retrograde pancreatography and sequential cytodiagnosis using pancreatic juice obtained by endoscopic nasopancreatic drainage multiple times was useful in the final diagnosis of PC in situ. At present, improving survival lies in identifying those individuals with high-risk factors or precursor lesions through an effective screening method. For example, these should include ultrasonography, various biological markers, or national familial pancreatic cancer registration. Additionally, the relationship between specialists in PC from medical centers and practicing physicians plays an important role in the early diagnosis of PC.

Does a family history of pancreatic ductal adenocarcinoma and cyst size influence the follow-up strategy for intraductal papillary mucinous neoplasms of the pancreas?

OBJECTIVE

This study aimed to evaluate the relationship between pancreatic ductal adenocarcinoma (PDAC) family history and PDAC development in patients followed up for intraductal papillary mucinous neoplasms (IPMNs) and to assess the cyst size relevance in determining follow-up strategies.

METHODS

We analyzed 300 patients with branch duct and mixed-type IPMN who were followed up at our facility.

RESULTS

Among the patients aged 70 years or older, the frequency of PDAC did not differ significantly between those with 1 first-degree relative with PDAC and those without a family history. Although patients with IPMNs of greater than or equal to 30 mm were followed up for a significantly shorter duration than those patients with IPMNs of less than 30 mm, the frequency of IPMN progression and malignant IPMN was significantly greater in the former. The frequency of IPMN progression and pancreatic cancer did not differ significantly according to IPMN size (<10, 10-20, and 20-30 mm) in cases without mural nodules.

CONCLUSIONS

Patients with 1 first-degree relative with PDAC can be followed up using the same criteria for patients without a family history. Special attention should be paid to IPMN progression and malignant transformation in patients with IPMNs of greater than or equal to 30 mm, but cyst size need not be considered when determining follow-up strategies for patients with IPMNs of less than 30 mm without mural nodules.

Role of endoscopic retrograde pancreatography for early detection of pancreatic ductal adenocarcinoma concomitant with intraductal papillary mucinous neoplasm of the pancreas

BACKGROUND

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is often found with distinct pancreatic ductal adenocarcinoma (PDAC) in the same pancreas. The aim of this study was to clarify whether endoscopic retrograde pancreatography (ERP) would be useful for the early detection of concomitant PDACs in patients with IPMNs.

METHODS

Medical records of 179 patients who were histologically confirmed to have IPMNs after resection between 1987 and 2011 were reviewed. The patients having concomitant PDACs were selected, and the diagnostic abilities to detect concomitant PDACs of computed tomography (CT), magnetic resonance imaging (MRI), endoscopic ultrasonography (EUS), and ERP were compared between early (stages 0-I according to Japanese General Rules for Pancreatic Cancer) and advanced (stages II-IV) PDACs.

RESULTS

A total of 23 PDACs developed synchronously or metachronously in 20 patients, and the prevalence of PDACs concomitant with IPMNs was 11.2 % (20/179). Sensitivities of CT (16 vs. 87 %), MRI (29 vs. 93 %), and EUS (29 vs. 92 %) in the early group were significantly lower than those in the advanced group (p < 0.01). On the other hand, the sensitivity of ERP in the early group was as high as that in the advanced group (86 vs. 82 %, respectively, p > 0.99). Among 7 early PDACs, 3 were diagnosed only by ERP.

CONCLUSIONS

ERP has an important role in the early diagnosis of distinct PDACs in patients with IPMNs. Further investigation is necessary to clarify the indication and the timing of ERP during management of IPMNs in term of early detection of concomitant PDACs.

Clinical usefulness of repeated pancreatic juice cytology via endoscopic naso-pancreatic drainage tube in patients with pancreatic cancer

BACKGROUND

Cytological examination of pancreatic juice obtained during endoscopic retrograde cholangiopancreatography (ERCP) is well established, but its sensitivity for pancreatic cancer has not been satisfactory. The aim of this study was to evaluate the usefulness of repeated pancreatic juice cytology (PJC) via the endoscopic naso-pancreatic drainage (ENPD) tube in patients with pancreatic cancer compared with conventional PJC.

METHODS

We retrospectively investigated 139 patients with pancreatic disease. Between April 2004 and November 2007, conventional PJC was performed in 56 patients with pancreatic cancer and 23 with benign pancreatic stricture. Between January 2008 and November 2010, ENPD was used in 40 patients with pancreatic cancer and 20 with benign pancreatic stricture. The ENPD tube was placed into the main pancreatic duct for up to 3 days, and cytological samples of pancreatic juice were collected up to 6 times in total.

RESULTS

Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the ENPD method for pancreatic cancer were 80, 100, 100, 71, and 87 %, respectively, revealing significantly higher sensitivity than the conventional method (p = 0.0001). Sensitivities according to tumor location and size were 90 % (19/21), 69 % (9/13), and 67 % (4/6) in the head, body, and tail of the pancreas, 88 % (7/8), 79 % (19/24), and 75 % (6/8) in tumors with a diameter less than 20 mm including carcinoma in situ, 21-40, and greater than 41 mm, respectively.

CONCLUSIONS

The ENPD method was found to have high diagnostic yield, especially for tumors less than 20 mm or located in the pancreatic head, and might be useful for the diagnosis of early-stage pancreatic cancer.