Endoscopic ultrasonography for surveillance of individuals at high risk for pancreatic cancer

Abstract

Pancreatic cancer is a highly lethal disease with a genetic susceptibility and familial aggregation found in 3%-16% of patients. Early diagnosis remains the only hope for curative treatment and improvement of prognosis. This can be reached by the implementation of an intensive screening program, actually recommended for individuals at high-risk for pancreatic cancer development. The aim of this strategy is to identify premalignant precursors or asymptomatic pancreatic cancer lesions, curable by surgery. Endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA) seems to be the most promising technique for early detection of pancreatic cancer. It has been described as a highly sensitive and accurate tool, especially for small and cystic lesions. Pancreatic intraepithelial neoplasia, a precursor lesion which is highly represented in highrisk individuals, seems to have characteristics chronic pancreatitis-like changes well detected by EUS. Many screening protocols have demonstrated high diagnostic yields for pancreatic pre-malignant lesions, allowing prophylactic pancreatectomies. However, it shows a high interobserver variety even among experienced endosonographers and a low sensitivity in case of chronic pancreatitis. Some new techniques such as contrast-enhanced harmonic EUS, computer-aided diagnostic techniques, confocal laser endomicroscopy miniprobe and the detection of DNA abnormalities or protein markers by FNA, promise improvement of the diagnostic yield of EUS. As the resolution of imaging improves and as our knowledge of precursor lesions grows, we believe that EUS could become the most suitable method to detect curable pancreatic neoplasms in correctly identified asymptomatic at-risk patients.© 2014 Baishideng Publishing Group Inc. All rights reserved. Key words: Endoscopic ultrasonography; Pancreatic cancer; SurveillanceCore tip: In the era of early diagnosis and screening programs, endoscopic ultrasound (EUS) represents the most promising tool able to identify pancreatic precursor neoplasms in high risk individuals. If compared to other imaging techniques, it is highly accurate to diagnose small pancreatic cancer and pre-malignant lesions, with very low rate of complications and limitations. Here are reported the current role of EUS in various international screening programs and its future possible developments.

Pancreatic ductal adenocarcinoma epidemiology and risk assessment: Could we prevent? Possibility for an early diagnosis

“…Familial pancreatic cancer is defined as kindreds with at least two first-degree relatives with pancreatic cancer with an as yet unidentified genetic abnormality. [ 8 9 ] In contrast, hereditary pancreatic cancer implies patients with inherited cancer syndromes with a known germline mutation associated with an increased risk of pancreatic cancer. These gene mutations include syndromes such as Lynch syndrome (MLH1, MLH2, MLH6, PMS2), familial breast and ovarian cancer (BRCA1 and BRCA2), familial adenomatous polyposis (FAP), familial atypical multiple mole melanoma (CDKN2A), Peutz–Jeghers (STK11/LKB1) but also hereditary pancreatitis (HPs) (PRSS1, SPINK1, ATM).…”

The role of endoscopic ultrasound in pancreatic cancer screening

“…Screening for PC in the general population is not cost-effective as it accounts for an overall low incidence with 3% new cases each year and a lifetime risk of 1.3% in the United States. [ 63 64 ] It is estimated that 5%-10% of PCs arise as a result of genetic susceptibility and/or familial aggregation. [ 51 65 ] A 2007 consensus conference on inherited diseases of the pancreas proposed that screening for PC be restricted to individuals with a >10-fold increased risk of the disease.…”

Screening to Detect Precursor Lesions of Pancreatic Adenocarcinoma in High-risk Individuals: A Single-center Experience

“…The best hope for improvement of survival is prevention or very early detection. 1 Primary prevention methods, such as cessation of smoking, reduction of alcohol intake, and proper exercise and dietary regimens, have been historically difficult to implement. Focused prevention methods, including detection of precursor lesions or early-stage pancreatic cancer (PC), might contribute to the prevention of this deadly disease.…”