Carcinoma of the Head of the Pancreas versus Chronic Pancreatitis: Diagnostic Dilemma with Significant Consequences

Abstract

Although carcinoma of the head of the pancreas and chronic pancreatitis are usually easy to distinguish on clinical presentation and subsequent investigation, there can be enough overlap in the presenting features and on imaging studies that differentiation is sometimes extremely difficult. As this confusion may lead to either major pancreatic resection for benign disease, or rejection of surgery for a potentially curable lesion, all attempts to arrive at a correct diagnosis should be pursued. This article provides an update of investigative techniques in pancreatic disease, and offers an algorithm for the clinical approach to the patient who appears to present with this diagnostic and therapeutic dilemma.

Periductal stromal collagen topology of pancreatic ductal adenocarcinoma differs from that of normal and chronic pancreatitis

“…Recent advances in the sensitivity and specificity of preoperative imaging modalities such as computer tomography, magnetic resonance imaging, positron emission tomography, endoscopic ultrasonography, and endoscopic retrograde cholangiopancreatography have played an important role in enhancing pancreatic ductal adenocarcinoma diagnosis, detailing the relationship of lesions to nearby anatomical structures, and determining the course of management. 2 Despite these advances, only 10-15% of patients are diagnosed at a localized disease stage when surgical resection is possible as a potential curative therapy. However, postsurgical recurrence rates are high with 5-year survival rate of only 10%, and the disease has a notable resistance to adjuvant therapeutic strategies.…”

Upregulation and redistribution of integrin α6β4 expression occurs at an early stage in pancreatic adenocarcinoma progression

“…The overlap in the clinical presentation and histopathological features between chronic pancreatitis and pancreatic cancer can lead to confusion in the diagnosis and management of both diseases. 9 While histological parameters are useful, more specific markers are needed to detect pancreatic cancer at an early stage and distinguish pancreatic cancer from chronic pancreatitis. The quest for such markers has led to the use of high throughput technology such as genetic profiling and proteomics.…”

The role of Movat pentachrome stain and immunoglobulin G4 immunostaining in the diagnosis of autoimmune pancreatitis

“…[15][16][17] This approach conflicts with evolving knowledge that pancreatic cancer is rarely curable by surgery, 18 and has been based upon the following: (1) advances in imaging have improved radiologic pancreatic cancer diagnosis, (2) pancreaticoduodenectomy (Whipple resection) can have low mortality in high volume centers, (3) decisions to operate are more often dictated by clinical findings than histopathology, (4) unsampled cancer can never be excluded by focal biopsies, and (5) good medical therapy was previously lacking for benign masses/ obstruction. [19][20][21] This approach must now be reevaluated in light of autoimmune pancreatitis and its mimicry of cancer, its increasingly specific diagnostic tests, and its dramatic response to steroid therapy. As the most common cause of unnecessary Whipple resection for benign disease, 3 accurate preoperative diagnosis of autoimmune pancreatitis is important.…”