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Contribution of Endoscopic Ultrasound (EUS) to Preoperative Staging in Resected Pancreatic and Periampullary Neoplasms
Paul R Sturrock1, John Hayward1, Mary Sullivan1, Jennifer Tseng1, Wahid Wassef1, Dana Andersen2, Giles Whalen1
1University of Massachusetts, Worcester, MA;2Johns Hopkins University School of Medicine, Baltimore, MD
Objective: To determine the contribution of routine EUS “ultrastaging” to preoperative determination of tumor extent, staging and resectability in patients who underwent operation with intent to resect.
Design: Retrospective case series review
Setting: Academic Medical Center
Patients: 73 consecutive operated patients with pancreatic and periampullary neoplasms 69 of whom had had EUS obtained preoperatively as a matter of staging policy.
Interventions: Preoperative EUS
Main outcome measure: Comparison of preoperative prediction with findings at operation and surgical pathology.
Results: 3 patients underwent laparotomy without resection for a resectability rate of 95%. Operations included Whipple procedures (42 patients), distal pancreatectomy (13), total and central pancreatectomy (9) and Beger and enucleations (5). 81% of 58 patients with malignant tumors had R0 resections. Pathologically measured tumor size was more accurately predicted by CT (66%) than by EUS (34%), which was more likely to over-stage (56%) than to under-stage (24%) when inaccurate. 12/73 (17%) patients required portal/mesenteric vein resection. CT scan predicted vascular involvement with a 50% sensitivity and 98% specificity, while EUS was as specific (98%) but less sensitive (50%) in those 12 patients. Involved lymph nodes were predicted in 3 patients by EUS (100% accuracy). EUS-guided FNA was a valuable diagnostic adjunct, although 18% of these were falsely negative for malignancy.
Conclusion: Routine EUS in patients with tumors judged resectable was associated with high rates of resectability and margin negative resection for malignant tumors. EUS plays an important role in the diagnosis of suspected tumors of the pancreas and periampullary region, but may not more accurately predict tumor size or extent than a high quality pancreas protocol CT scan.
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