Horacio J Asbun1, Kevin Conlon2, Laureano Fernandez-Cruz3, Helmut Friess4, Shailesh V Shrikhande5, Mustapha Adham6, Claudio Bassi7, Maximilian Bockhorn8, Markus Büchler9, Richard M Charnley10, Christos Dervenis11, Abe Fingerhutt12, Dirk J Gouma13, Werner Hartwig9, Clem Imrie14, Jakob R Izbicki8, Keith D Lillemoe15, Miroslav Milicevic16, Marco Montorsi17, John P Neoptolemos18, Aken A Sandberg19, Michael Sarr20, Charles Vollmer21, Charles J Yeo22, L William Traverso23. 1. Department of General Surgery, Mayo Clinic, Jacksonville, FL. Electronic address: Asbun.Horacio@mayo.edu. 2. Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland. 3. Department of Surgery, Clinic Hospital of Barcelona, University of Barcelona, Barcelona, Spain. 4. Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany. 5. Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India. 6. Department of HPB Surgery, Hopital Edouard Herriot, Lyon, France. 7. Department of Surgery and Oncology, Pancreas Institute, University of Verona, Verona, Italy. 8. Department of General-, Visceral- and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany. 9. Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany. 10. Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK. 11. Department of First Surgery, Agia Olga Hospital, Athens, Greece. 12. Department of Digestive Surgery, Centre Hospitalier Intercommunal, Poissy, France. 13. Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. 14. Acacdemic Unit of Surgery, Univesity of Glasgow, Glasgow, UK. 15. Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA. 16. First Surgical Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia. 17. Department of General Surgery, Instituto Clinico Humanitas IRCCS, University of Milan, Milan, Italy. 18. Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK. 19. Department of Surgery, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden. 20. Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN. 21. Department of Gastrointestinal Surgery, Penn Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA. 22. Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA. 23. St. Luke's Clinic - Center For Pancreatic and Liver Diseases, Boise, ID.
Abstract
BACKGROUND: Pancreatoduodenectomy (PD) provides the best chance for cure in the treatment of patients with localized pancreatic head cancer. In patients with a suspected, clinically resectable pancreatic head malignancy, the need for histologic confirmation before proceeding with PD has not historically been required, but remains controversial. METHODS: An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the literature and worked together to establish a consensus on when to perform a PD in the absence of positive histology. RESULTS: The incidence of benign disease after PD for a presumed malignancy is 5-13%. Diagnosis by endoscopic cholangiopancreatography brushings and percutaneous fine-needle aspiration are highly specific, but poorly sensitive. Aspiration biopsy guided by endoscopic ultrasonography (EUS) has greater sensitivity, but it is highly operator dependent and increases expense. The incidence of autoimmune pancreatitis (AIP) in the benign resected specimens is 30-43%. EUS-guided Trucut biopsy, serum levels of immunoglobulin G4, and HISORt (Histology, Imaging, Serology, Other organ involvement, and Response to therapy) are used for diagnosis. If AIP is suspected but not confirmed, the response to a short course of steroids is helpful for diagnosis. CONCLUSION: In the presence of a solid mass suspicious for malignancy, consensus was reached that biopsy proof is not required before proceeding with resection. Confirmation of malignancy, however, is mandatory for patients with borderline resectable disease to be treated with neoadjuvant therapy before exploration for resection. When a diagnosis of AIP is highly suspected, a biopsy is recommended, and a short course of steroid treatment should be considered if the biopsy does not reveal features suspicious for malignancy.
BACKGROUND: Pancreatoduodenectomy (PD) provides the best chance for cure in the treatment of patients with localized pancreatic head cancer. In patients with a suspected, clinically resectable pancreatic head malignancy, the need for histologic confirmation before proceeding with PD has not historically been required, but remains controversial. METHODS: An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the literature and worked together to establish a consensus on when to perform a PD in the absence of positive histology. RESULTS: The incidence of benign disease after PD for a presumed malignancy is 5-13%. Diagnosis by endoscopic cholangiopancreatography brushings and percutaneous fine-needle aspiration are highly specific, but poorly sensitive. Aspiration biopsy guided by endoscopic ultrasonography (EUS) has greater sensitivity, but it is highly operator dependent and increases expense. The incidence of autoimmune pancreatitis (AIP) in the benign resected specimens is 30-43%. EUS-guided Trucut biopsy, serum levels of immunoglobulin G4, and HISORt (Histology, Imaging, Serology, Other organ involvement, and Response to therapy) are used for diagnosis. If AIP is suspected but not confirmed, the response to a short course of steroids is helpful for diagnosis. CONCLUSION: In the presence of a solid mass suspicious for malignancy, consensus was reached that biopsy proof is not required before proceeding with resection. Confirmation of malignancy, however, is mandatory for patients with borderline resectable disease to be treated with neoadjuvant therapy before exploration for resection. When a diagnosis of AIP is highly suspected, a biopsy is recommended, and a short course of steroid treatment should be considered if the biopsy does not reveal features suspicious for malignancy.
Authors: J-Matthias Löhr; Ulrich Beuers; Miroslav Vujasinovic; Domenico Alvaro; Jens Brøndum Frøkjær; Frank Buttgereit; Gabriele Capurso; Emma L Culver; Enrique de-Madaria; Emanuel Della-Torre; Sönke Detlefsen; Enrique Dominguez-Muñoz; Piotr Czubkowski; Nils Ewald; Luca Frulloni; Natalya Gubergrits; Deniz Guney Duman; Thilo Hackert; Julio Iglesias-Garcia; Nikolaos Kartalis; Andrea Laghi; Frank Lammert; Fredrik Lindgren; Alexey Okhlobystin; Grzegorz Oracz; Andrea Parniczky; Raffaella Maria Pozzi Mucelli; Vinciane Rebours; Jonas Rosendahl; Nicolas Schleinitz; Alexander Schneider; Eric Fh van Bommel; Caroline Sophie Verbeke; Marie Pierre Vullierme; Heiko Witt Journal: United European Gastroenterol J Date: 2020-06-18 Impact factor: 4.623
Authors: Evan L Fogel; Safi Shahda; Kumar Sandrasegaran; John DeWitt; Jeffrey J Easler; David M Agarwal; Mackenzie Eagleson; Nicholas J Zyromski; Michael G House; Susannah Ellsworth; Ihab El Hajj; Bert H O'Neil; Attila Nakeeb; Stuart Sherman Journal: Am J Gastroenterol Date: 2017-01-31 Impact factor: 10.864
Authors: Ryan K Schmocker; David J Vanness; Caprice C Greenberg; Jeff A Havlena; Noelle K LoConte; Jennifer M Weiss; Heather B Neuman; Glen Leverson; Maureen A Smith; Emily R Winslow Journal: HPB (Oxford) Date: 2017-02-23 Impact factor: 3.647