The Role of Endoscopic Ultrasound in Pancreatic Cancer Staging in the Era of Neoadjuvant Therapy and Personalised Medicine

Abstract

Precise staging of pancreatic cancer is crucial for treatment choice. In clinical practice, this includes the TNM staging and determination of tumour resectability, based on a multimodality imaging workup. International guidelines recommend multi-detector computed tomography (CT), with a dedicated pancreatic protocol, as the first-line tool for TNM staging and evaluation of tumour-vessel relationships. In non-metastatic disease upon initial CT assessment, both magnetic resonance imaging and endoscopic ultrasound (EUS) may add relevant information, potentially changing treatment sequence. EUS may have distinct advantages in pancreatic cancer diagnosis and staging when compared with other modalities, being particularly valuable in the determination of portal venous confluence involvement (particularly in small and ill-defined/isoattenuating tumours on CT), in locoregional nodal staging and in the detection of ascites. As we step forward to a more frequent use of neoadjuvant chemotherapy and to personalised medicine, the importance of EUS-guided fine-needle biopsy (EUS-FNB) also increases. The recent availability of third-generation biopsy needles significantly increased the diagnostic yield of EUS-guided tissue acquisition, providing diagnostic cell blocks in approximately 95% of cases with only two dedicated passes and allowing ancillary testing, such as immunohistochemistry and molecular profiling of the tumour. In this article, the authors present an updated perspective of the place of EUS and EUS-FNB in the staging algorithm of pancreatic cancer. Data supporting the increasing role of neoadjuvant therapy and the importance of a patient-tailored treatment selection, based on tumoural subtyping and molecular profiling, are also discussed.

The Initial Journey of Patients with Metastatic Pancreatic Cancer (PaCTO Project): A Nationwide Survey among Portuguese Specialist Physicians

“…This approach has surpassed percutaneous sampling techniques, as it provides tissue core biopsies, allowing histological assessment. New generation FNB needles demonstrated a diagnostic accuracy of over 95% for solid pancreatic lesions and provide samples appropriate for ancillary testing, such as immunohistochemistry and tumor molecular profiling [25,31].…”

Diagnostic and Therapeutic Indications for Endoscopic Ultrasound (EUS) in Patients with Pancreatic and Biliary Disease—Novel Interventional Procedures

“…The authors believe that EUS should be integrated, using an evidence-based approach, into the diagnostic and therapeutic spectrum of multidisciplinary pancreas centers as soon as possible. The literature has provided convincing evidence of its usefulness in diagnostics and as a valuable addition to the therapeutic armamentarium [ 6 , 94 , 95 ].…”

Role of Endoscopic Ultrasound in Diagnosis of Pancreatic Ductal Adenocarcinoma

“…There are four types of vascular involvement in pancreatic cancer: type 1, clear invasion with the encasement of a vessel by a tumor; type 2, a tumor that is in contact with a vessel with the loss of the hyperechoic vessel layer with or without vessel irregularity or luminal narrowing; type 3, a tumor that contacts a vessel without the loss of the hyperechoic vessel layer; and type 4, clear non-invasion with distance between the tumor and vessel [21]. Apart from that, tumor thrombus within the vessel or the presence of collaterals surrounding the tumor can also be found [22] (Figure 1). For N staging, a meta-analysis has also shown that EUS has a better sensitivity (58% vs. 24%) and a similar specificity (85% vs. 88%) to those of CT in detecting lymph node involvement [23,24].…”