EUS-FNA During Initial ERCP for Obstructive Jaundice From Pancreatic Head Adenocarcinoma Results in Fewer Subsequent Invasive Procedures

Abstract

Introduction: Patients with pancreatic masses presenting with obstructive jaundice often need both tissue diagnosis and biliary decompression prior to initiation of treatment. Where available, EUS-FNA for tissue diagnosis is often performed during the same session as the initial ERCP with stenting. The aim of this study is to determine whether performing EUS-FNA with the initial ERCP leads to patients undergoing fewer diagnostic and therapeutic invasive procedures. Methods: Patients with pancreatic head adenocarcinoma presenting with jaundice referred to a comprehensive cancer hospital between Feb 2005 and Sep 2013 were identified by chart review. Patients were classified into two groups based on initial endoscopic procedure; 1) combined EUS-FNA plus ERCP with biliary stenting (combined group) or 2) ERCP with brushings and biliary stenting (ERCP group). The primary outcome was the number of subsequent invasive procedures for tissue diagnosis and biliary decompression patients needed to have prior to initiation of cancer treatment. Statistical analyses were done using Fisher’s exact test to compare categorical variables and Wilcoxon rank sum test to compare numeric variables. All associations were considered statistically significant at an alpha error <0.05 (P value 0.05). Results: Overall, 161 patients met study criteria (combined = 57, ERCP = 104). Cytology was diagnostic for adenocarcinoma in 82.5% of the combined group vs. 19.8% in the ERCP group (p<0.0001). The combined group required fewer subsequent diagnostic interventions (10 vs. 100, p<0.001). Biliary cannulation rates were similar in both groups (82.1% vs. 71.2%, p=0.18). Due to information gained from rapid on-site cytologic evaluation of FNA specimens and EUS staging, more patients in the combined group received metal biliary stents than in the ERCP group (74.5% vs. 40.5%, p=0.004). The combined group required fewer subsequent biliary drainage procedures (19 vs. 47, p=0.03). Complications were similar in both groups (6 vs. 9, p=0.18). The type of initial cancer therapy was not statistically different between the two groups. Median time to treatment (in days) between the two groups was 28 vs. 49 for chemotherapy (p<0.001), 25 vs. 34 for surgery (p=0.917) and 7 vs. 31 for hospice referral (p=0.002). Conclusion: Pancreatic cancer patients presenting with obstructive jaundice who undergo EUS-FNA with the initial ERCP are subjected to fewer subsequent invasive diagnostic and therapeutic procedures resulting in sooner initiation of cancer treatment. Further studies are needed to determine if this expedited treatment influences survival.