Diagnosis and assessment of resectability for neoplasms of the pancreas and periampullary region

Abstract

Summary CT remains the initial study of choice for determining whether a patient has potentially resectable, locally advanced, or metastatic pancreatic cancer; such clinical staging is critical for accurate treatment planning. EUS has become the preferred method of tissue acquisition through the use of EUS-guided FNA biopsy. ERCP remains an important diagnostic tool, and endobiliary stenting is the preferred initial therapy for biliary obstruction. The extent to which laparoscopy should be used remains controversial. Laparoscopy is reasonable to consider before laparotomy (during the same anesthesia induction) in patients with biopsy-proven or suspected potentially resectable pancreatic cancer in whom a decision has been made to proceed with pancreatoduodenectomy. Pancreatoduodenectomy should be considered only in those patients whose tumors appear to be resectable based on high-quality CT and who have a good performance status. Furthermore, pancreatoduodenectomy should be part of a multimodality treatment program that includes preoperative or postoperative chemoradiation. Because of the modest survival rates associated with current treatments, the enrollment of all patients into clinical trials of new combinations of surgery, chemoradiation, and newly developed systemic drugs is strongly encouraged. Future progress in the treatment of pancreatic cancer will involve techniques for early diagnosis and effective systemic therapy. For now, the best results can be achieved by careful attention to patient selection, preoperative assessment of resectability, surgical technique, and postoperative care.