Benign Histology After Pancreaticoduodenectomy for Suspected Malignancy. Lessons to be Learned – a Single Centre Experience (original) (raw)
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Surgery
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 prior to proceeding with PD has not historically been required, but still 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 pancreatoduodenectomy in the absence of positive histology. Results The incidence of benign disease after PD for a presumed malignancy is 5-13%. Diagnosis by ERCP brushings and percutaneous fine needle aspiration (FNA) 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 ...
Is Intraoperative Confirmation of Malignancy During Pancreaticoduodenectomy Mandatory?
Journal of Gastrointestinal Surgery, 2013
Introduction Differentiating between chronic pancreatitis and pancreatic adenocarcinoma can be difficult due to considerable overlap in disease presentation and radiological signs and the frequent co-existence of the two conditions. In this situation, surgeons may have to proceed to "blind" pancreaticoduodenectomy or attempt to confirm malignancy intraoperatively with frozen section (FS) histology. Methods This study attempted to ascertain the false-negative and false-positive rates of undertaking pancreaticoduodenectomies (PD) based on clinical suspicion (CS) or after intraoperative confirmation of malignancy using FS histology. Results Of patients, 13.6% (nine out of 66) underwent a benign PD in the CS group; 6.7% of patients had a missed malignancy in the FS group (n=62), but intraoperative histology prevented PD in 35% of patients with benign disease in the FS group. Specificity and sensitivity of intraoperative FS in detecting malignancy was 100% and 89.7%, respectively. Sensitivity of clinical assessment in detecting malignancy was 86.4%. Conclusions In experienced hands, intraoperative confirmation of malignancy is effective and will avoid resection in patients with benign disease. However, for many surgeons the chance of missing a small tumour with a false-negative biopsy will be unacceptable and they would prefer to undertake a "blind" resection and accept the mortality risk of pancreaticoduodenectomy for benign disease.
Pancreaticoduodenectomy for suspected periampullary cancers: the mimes of malignancy
Hpb, 2009
Background: Pancreaticoduodenectomies are often undertaken with suspicion of malignancy. We undertook this study to determine if and how unnecessary pancreaticoduodenectomies can be avoided.Methods: Data from patients undergoing pancreaticoduodenectomy were prospectively collected. Operative indications, including presenting symptoms and results with imaging, with or without biopsy, were reviewed.Results: From 1996 through to 2007, 551 patients underwent pancreaticoduodenectomy at our institution. Chronic pancreatitis was the operative indication in 3% of patients; premalignant/malignant lesions were present in 86% of patients. Eleven per cent of patients underwent ‘unnecessary’ pancreaticoduodenectomies with presumptive diagnoses of cancer but were without premalignant/malignant disease on final report by Pathology [pancreatitis in 63%, serous cystadenomas (<4 cm) in 14%]. Of the unnecessary resections, 20% had histories and imaging sufficient to diagnose pancreatitis, 18% had inaccurate preoperative brushings/biopsies ‘documenting’ cancer, 11% had clear misinterpretations of their imaging studies and 7% had inadequate preoperative evaluations. However, 45% had signs/symptoms of cancer with a pancreatic head mass/biliary stricture.Conclusion: Only a small minority of patients undergoing pancreaticoduodenectomy for suspicion of periampullary cancer do so unnecessarily. Preoperative review of biopsies, better considerations of pancreatitis and careful evaluation of imaging, particularly for cystic masses, will decrease unnecessary pancreaticoduodenectomies.
Evaluation of Safety of Pancreaticoduodenectomy for Patients with Benign Conditions
Clinical Hematology and Research, 2020
With the wide spread use of cross-sectional imaging examinations, more and more pancreatic benign tum or have been diagnosed. In patients with abdominal multi-slice spiral CT or MRI for reasons unrelated to pancreatic tumor, more than 2% of pancreatic tumor may be detected, which increases with age [1,2]. Benign pancreatic tumors are often difficult to diagnose and most are at risk of malignant transformation. Pancreaticoduodenectomy (PD) is the gold standard for benign and malignant tumors of the pancreatic head. PD is a multiple organ resection operation that requires removal of part of the stomach, extrahepatic bile ducts, and duodenum. However, one study found that 38% of patients suitable for resection of pancreatic cancer refused surgery [3]. Further
Diagnostic and therapeutic endoscopy, 2014
Despite using imaging studies, tissue sampling, and serologic tests about 5-10% of surgeries done for presumed pancreatic malignancies will have benign findings on final pathology. Endoscopic ultrasound (EUS) is used with increasing frequency to study pancreatic masses. The aim of this study is to examine the effect of EUS on prevalence of benign diseases undergoing Whipple over the last decade. Patients who underwent Whipple procedure for presumed malignancy at Emory University Hospital from 1998 to 2011 were selected. Demographic data, history of smoking and drinking, history of diabetes and pancreatitis, imaging data, pathology reports, and tumor markers were extracted. 878 patients were found. 95 (10.82%) patients had benign disease. Prevalence of benign finding had increased over the recent years despite using more EUS. Logistic regression models showed that abdominal pain (OR: 5.829, 95% CI 2.681-12.674, P ≤ 0.001) and alcohol abuse (OR: 3.221, CI 95%: 1.362-7.261, P: 0.002) w...
Hepatobiliary & Pancreatic Diseases International, 2017
BACKGROUND: The necessity to obtain a tissue diagnosis of cancer prior to pancreatic surgery still remains an open debate. In fact, a non-negligible percentage of patients undergoing pancreaticoduodenectomy (PD) for suspected cancer has a benign lesion at final histology. We describe an approach for patients with diagnostic uncertainty between cancer and chronic pancreatitis, with the aim of minimizing the incidence of PD for suspicious malignancy finally diagnosed as benign disease. METHODS: Eighty-eight patients (85.4%) with a clinicoradiological picture highly suggestive for malignancy received formal PD (group 1). Fifteen patients (14.6%) in whom preoperative diagnosis was uncertain between pancreatic cancer and chronic pancreatitis underwent pancreatic head excavation (PHEX) for intraoperative tissue diagnosis (group 2): those diagnosed as having cancer received PD, whereas those with chronic pancreatitis received pancreaticojejunostomy (PJ). RESULTS: No patient received PD for benign disease. All patients in group 1 had adenocarcinoma on final histology. Eight patients of group 2 (53.3%) received PD after intraoperative diagnosis of cancer, whereas 7 (46.7%) received PJ because no malignancy was found at introperative frozen sections. No signs of cancer were encountered in patients receiving PHEX and PJ after a median follow-up of 42 months. Overall survival did not differ between patients receiving PD for cancer in the group 1 and those receiving PD for cancer after PHEX in the group 2 (P=0.509). CONCLUSION: Although the described technique has been used in a very selected group of patients, our results suggest that PHEX for tissue diagnosis may reduce rates of unnecessary PD, when the preoperative diagnosis is uncertain between cancer and chronic pancreatitis.