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      Challenges in diagnosis of pancreatic cancer

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          Abstract

          Pancreatic cancer is a growing source of cancer related death, yet has poor survival rates which have not improved in the last few decades. Its high mortality rate is attributed to pancreatic cancer biology, difficulty in early diagnosis and the lack of standardised international guidelines in assessing suspicious pancreatic masses. This review aims to provide an update in the current state of play in pancreatic cancer diagnosis and to evaluate the benefits and limitations of available diagnostic technology. The main modalities discussed are imaging with computed tomography, magnetic resonance imaging, endoscopic ultrasound and positron emission tomography and tissue acquisition with fine needle aspiration. We also review the improvements in the techniques used for tissue acquisition and the opportunity for personalised cancer medicine. Screening of high risk individuals, promising biomarkers and common mimickers of pancreatic cancer are also explored, as well as suggestions for future research directions to allow for earlier detection of pancreatic cancer. Timely and accurate diagnosis of pancreatic cancer can lead to improvements in the current poor outcome of this disease.

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          International Cancer of the Pancreas Screening (CAPS) Consortium summit on the management of patients with increased risk for familial pancreatic cancer

          Marcia Irene Canto, Femme Harinck, Ralph H. Hruban … (2012)
          Background Screening individuals at increased risk for pancreatic cancer (PC) detects early, potentially curable, pancreatic neoplasia. Objective To develop consortium statements on screening, surveillance and management of high-risk individuals with an inherited predisposition to PC. Methods A 49-expert multidisciplinary international consortium met to discuss pancreatic screening and vote on statements. Consensus was considered reached if ≥75% agreed or disagreed. Results There was excellent agreement that, to be successful, a screening programme should detect and treat T1N0M0 margin-negative PC and high-grade dysplastic precursor lesions (pancreatic intraepithelial neoplasia and intraductal papillary mucinous neoplasm). It was agreed that the following were candidates for screening: first-degree relatives (FDRs) of patients with PC from a familial PC kindred with at least two affected FDRs; patients with Peutz–Jeghers syndrome; and p16, BRCA2 and hereditary non-polyposis colorectal cancer (HNPCC) mutation carriers with ≥1 affected FDR. Consensus was not reached for the age to initiate screening or stop surveillance. It was agreed that initial screening should include endoscopic ultrasonography (EUS) and/or MRI/magnetic resonance cholangiopancreatography not CT or endoscopic retrograde cholangiopancreatography. There was no consensus on the need for EUS fine-needle aspiration to evaluate cysts. There was disagreement on optimal screening modalities and intervals for follow-up imaging. When surgery is recommended it should be performed at a high-volume centre. There was great disagreement as to which screening abnormalities were of sufficient concern to for surgery to be recommended. Conclusions Screening is recommended for high-risk individuals, but more evidence is needed, particularly for how to manage patients with detected lesions. Screening and subsequent management should take place at high-volume centres with multidisciplinary teams, preferably within research protocols.
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            How good is endoscopic ultrasound-guided fine-needle aspiration in diagnosing the correct etiology for a solid pancreatic mass?: A meta-analysis and systematic review.

            Srinivas Puli, Matthew L. Bechtold, James L. Buxbaum … (2012)
            The objective of this study was to evaluate the accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in diagnosing the correct etiology for a solid pancreatic mass. Data extracted from EUS-FNA studies with a criterion standard (either confirmed by surgery or appropriate follow-up) were selected. Articles were searched in MEDLINE, CINAHL, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews. Pooling was conducted by both fixed- and random-effects models. Initial search identified 3610 reference articles, of these 360 relevant articles were selected and reviewed. Data were extracted from 41 studies (N = 4766) which met the inclusion criteria. Pooled sensitivity of EUS-FNA in diagnosing the correct etiology for solid pancreatic mass was 86.8% (95% confidence interval [CI], 85.5-87.9). Endoscopic ultrasound-guided FNA had a pooled specificity of 95.8% (95% CI, 94.6-96.7). Positive likelihood ratio of EUS was 15.2 (95% CI, 8.5-27.3), and the negative likelihood ratio was 0.17 (95% CI, 0.13-0.21). Endoscopic ultrasound-guided FNA is an excellent diagnostic tool to detect the correct etiology for solid pancreatic masses. When available, EUS-FNA should be strongly considered as the first diagnostic tool for sampling these lesions to optimize patient management.
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              Value of serum IgG4 in the diagnosis of autoimmune pancreatitis and in distinguishing it from pancreatic cancer.

              Amaar Ghazale, Suresh T Chari, Thomas C Smyrk … (2007)
              To determine the sensitivity and specificity of elevated serum IgG4 level for the diagnosis of autoimmune pancreatitis (AIP) and its ability to distinguish AIP from pancreatic cancer, its main differential diagnosis. We measured serum IgG4 levels (normal 8-140 mg/dL) in 510 patients including 45 with AIP, 135 with pancreatic cancer, 62 with no pancreatic disease, and 268 with other pancreatic diseases. Sensitivity, specificity, and positive predictive values for elevated serum IgG4 (>140 mg/dL) for diagnosis of AIP were 76%, 93%, and 36%, respectively, and 53%, 99%, and 75%, respectively, for IgG4 of >280 mg/dL. Among subjects with elevated IgG4, non-AIP subjects (N = 32) differed from AIP subjects (N = 34) in that they were more likely to be female (45%vs 9%, P 280 mg/dL (13%vs 71%, P 280 mg/dL compared with 53% of AIP. Compared with AIP, pancreatic cancer patients were more likely to have CA19-9 levels of >100 U/mL (71%vs 9%, P < 0.001). Elevated serum IgG4 levels are characteristic of AIP. However, mild (<2-fold) elevations in serum IgG4 are seen in up to 10% of subjects without AIP including pancreatic cancer and cannot be used alone to distinguish AIP from pancreatic cancer. Because AIP is uncommon, IgG4 elevations in patients with low pretest probability of having AIP are likely to represent false positives.
              Article 0 comments Cited 111 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Lulu Zhang
                Santosh Sanagapalli
                Alina Stoita
                Journal
                Journal ID (nlm-ta): World J Gastroenterol
                Journal ID (iso-abbrev): World J. Gastroenterol
                Journal ID (publisher-id): WJG
                Title: World Journal of Gastroenterology
                Publisher: Baishideng Publishing Group Inc
                ISSN (Print): 1007-9327
                ISSN (Electronic): 2219-2840
                Publication date (Print): 21 May 2018
                Publication date (Electronic): 21 May 2018
                Volume: 24
                Issue: 19
                Pages: 2047-2060
                Affiliations
                Department of Gastroenterology, St. Vincent’s Hospital Sydney, Darlinghurst 2010, NSW, Australia
                Department of Gastroenterology, St. Vincent’s Hospital Sydney, Darlinghurst 2010, NSW, Australia
                Department of Gastroenterology, St. Vincent’s Hospital Sydney, Darlinghurst 2010, NSW, Australia. astoita@ 123456stvincents.com.au
                Author notes

                Author contributions: Zhang L made substantial contribution to the collection and analysis of the data and drafted the initial manuscript; Sanagapalli S and Stoita A made substantial contributions to the analysis and interpretation of the data and Stoita A edited, made substantial contribution in writing and revised the final manuscript; all authors have given their final approval of the version published.

                Correspondence to: Alina Stoita, MBBS, FRACP, Doctor, Department of Gastroenterology St Vincent’s Hospital Sydney 390 Victoria Street, Darlinghurst 2010, NSW, Australia. astoita@ 123456stvincents.com.au

                Telephone: +61-283826622 Fax: +61-83826602

                Article
                Other ID: jWJG.v24.i19.pg2047
                DOI: 10.3748/wjg.v24.i19.2047
                PMC ID: 5960811
                PubMed ID: 29785074
                SO-VID: 3213dcc5-6ed1-4cfe-917a-2866f0236f9b
                Copyright © ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
                License:

                This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.

                History
                Date received : 28 March 2018
                Date revision received : 28 April 2018
                Date accepted : 11 May 2018
                Categories
                Subject: Review

                Keywords: pancreatic cancer,diagnosis,challenges,imaging,biomarkers,screening,endoscopic ultrasound,pitfalls
                Data availability:
                Keywords: pancreatic cancer, diagnosis, challenges, imaging, biomarkers, screening, endoscopic ultrasound, pitfalls

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