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LETTER TO EDITOR
Ahead of print publication  

Routine EUS-guided tissue acquisition in patients with resectable solid pancreatic masses – Pros and cons reassessment in 2020


1 Gastroenterology Unit, Hospital of Imola, University of Bologna, Italy
2 Medical Oncology Department, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy

Date of Submission21-Apr-2020
Date of Acceptance11-Jun-2020
Date of Web Publication09-Sep-2020

Correspondence Address:
Andrea Lisotti,
Gastroenterology Unit, Hospital of Imola, Via Montericco 4, 40026 Imola, Bologna; Department of Medical and Surgical Science, University of Bologna, Bologna
Italy
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/eus.eus_48_20

PMID: 32913148



How to cite this URL:
Lisotti A, Brighi N, Marocchi G, Fusaroli P. Routine EUS-guided tissue acquisition in patients with resectable solid pancreatic masses – Pros and cons reassessment in 2020. Endosc Ultrasound [Epub ahead of print] [cited 2020 Nov 29]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=294597



Dear Editor,

We have read with great interest Dr. Larghi et al.'s manuscript, in which the authors brilliantly summarize the preoperative management of resectable solid pancreatic masses (SPMs).[1] The authors emphasized the role of EUS-guided tissue acquisition (EUS-TA), based on several recent advances in the field of surgery, oncology, molecular biology, and gastrointestinal endoscopy. However, to date, the clinical practice has not substantially changed accordingly. As shown in [Table 1], oncological and endoscopic guidelines do not reach any agreement on the recommendations regarding the role of EUS-TA for resectable SPMs before surgery.
Table 1: Guidelines recommendations on the management of resectable solid pancreatic masses

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Recently, interesting results have been achieved by neoadjuvant chemotherapy trials.[2] Therefore, international guidelines agree on considering the option of preoperatory chemotherapy even in patients with resectable pancreatic ductal adenocarcinoma (PDAC), even if resectable [Table 1].

However, if a pathological diagnosis is mandatory before starting any chemotherapy treatment, we need to discuss whether giving indication for the resection of SPMs without a pathological diagnosis could be considered the best strategy. In fact, upfront surgery with no pathological confirmation may lead to a not negligible risk (5%–13%) of only benign disease on surgical specimen.[1] Moreover, immediate surgery could be detrimental even for those patients with an underlying PDAC who would have benefitted from neoadjuvant treatment.

On these bases, if a “perfect” diagnostic procedure would be available in this setting, there would be a strong agreement on including EUS-TA in the diagnostic paradigm. Thus, EUS-TA should be reconsidered to evaluate if its limits still overcome the above-mentioned advantages. Several high-quality studies have shown that preoperative EUS-TA was not associated with an increased rate of peritoneal recurrence or mortality due to needle tract seeding.[3] Once the potential risk related to adverse events has been ruled out, only considerations about EUS-TA diagnostic yield could justify the lack in guidelines agreement.

As Larghi et al. correctly addressed, EUS-TA in SPMs shows excellent specificity with suboptimal sensitivity.[1] The not-negligible rate of false-negative results and the low-negative predictive value in this setting do not guarantee a definitive diagnosis of a benign condition after negative or nondiagnostic results. To date, this issue represents the greatest limit in the preoperative management of resectable SPMs, and even the subsequent management of nondiagnostic or inconclusive results represents a gray area. Indeed, there is no concordance on how to follow-up or which further diagnostic procedure should be performed.

We recently assessed the pooled diagnostic accuracy of repeated EUS-TA of SPMs after nondiagnostic or inconclusive results. We identified 12 studies and observed that when repeated EUS-FNA was performed with rapid on-site evaluation, eight out of ten cases were correctly diagnosed (sensitivity 83% and specificity 98%).[4] Unfortunately, no data on repeated EUS-FNB are available yet, but we may speculate that the good EUS-FNB performance could be replied in this setting.[5]

In conclusion, we think that recent knowledge and technical advances should be considered satisfactory to include EUS-TA in the diagnostic algorithm of resectable SPMs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Larghi A, Rimbaş M, Rizzatti G, et al. Resectable pancreatic solid lesions: Time to move from surgical diagnosis? Endosc Ultrasound 2020;9:76-82.  Back to cited text no. 1
    
2.
Reni M, Balzano G, Zanon S, et al. Safety and efficacy of preoperative or postoperative chemotherapy for resectable pancreatic adenocarcinoma (PACT-15): A randomised, open-label, phase 2-3 trial. Lancet Gastroenterol Hepatol 2018;3:413-23.  Back to cited text no. 2
    
3.
Kim SH, Woo YS, Lee KH, et al. Preoperative EUS-guided FNA: Effects on peritoneal recurrence and survival in patients with pancreatic cancer. Gastrointest Endosc 2018;88:926-34.  Back to cited text no. 3
    
4.
Lisotti A, Frazzoni L, Fuccio L, et al. Repeat EUS-FNA of pancreatic masses after nondiagnostic or inconclusive results: Systematic review and meta-analysis. Gastrointest Endosc 2020;91:1234-41.  Back to cited text no. 4
    
5.
Grassia R, Imperatore N, Capone P, et al. EUS-guided tissue acquisition in chronic pancreatitis: Differential diagnosis between pancreatic cancer and pseudotumoral masses using EUS-FNA or core biopsy. Endosc Ultrasound 2020;9:122-9.  Back to cited text no. 5
    



 
 
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