[Endoscopy in the diagnosis and staging of pancreatic cancer]. / L'endoscopia nella diagnosi e stadiazione del carcinoma pancreatico.

Pancreatic carcinoma is the fourth cause of death for cancer in the USA, carrying a dismal prognosis and poor overall survival. Unfortunately, resection for cure is feasible in a limited number of patients, thus confirming the need for an early diagnosis and accurate preoperative staging to select patients potentially resectable from those candidates to palliative treatment. Among imaging modalities, endoscopic procedures (endoscopic retrograde cholangiopancreatography, laparoscopy and endoscopic ultrasonography) play a key role in the diagnosis and staging of pancreatic tumors. Endoscopic retrograde cholangiopancreatography (ERCP) allows direct visualization of the main pancreatic duct and its side branches with their morphologic alterations, which are present in most cases of pancreatic cancer. The method is very sensitive in experienced hands, with diagnostic accuracy over 95%. The most common finding in pancreatic cancer is the stricture of the pancreatic duct, the bile duct, or both. Moreover, ductal brush cytology and K-ras mutation analysis can be performed during ERCP, possibly improving the diagnostic accuracy of the technique. Diagnostic laparoscopy provides detection of small (< 1 cm) liver metastases and peritoneal implants of tumor which cannot be visualized by any other imaging modality, with the possibility to biopsy under direct vision suspicious areas or to perform peritoneal lavage. The adjunct of laparoscopic ultrasound improves the staging capabilities of the technique for pancreatic cancer (retroperitoneal spread, vascular invasion). Endoscopic ultrasonography (EUS) is able to produce great detail of the pancreatic parenchyma and regional lymph nodes. It is especially sensitive in the detection of small pancreatic masses which cannot be imaged with other modalities. EUS has the additional advantage of directing transduodenal fine-needle aspiration biopsies. Presently it is the most sensitive technique for the diagnosis and locoregional staging of pancreatic cancer, but limits have been identified in the lack of specificity (differentiation between malignant tumor and focal pancreatitis) and its operator-dependency. Reported is our experience with EUS in the diagnosis and staging of pancreatic cancer. Over a seven-year period 43 patients with pancreatic tumors were staged with EUS preoperatively. Twenty-two patients were submitted to surgery at our Institution and EUS findings were compared with results of pathology or surgical exploration. EUS provided sensitivity of 100% for the diagnosis of pancreatic cancer, while its accuracy for staging tumor infiltration, lymph node involvement and vascular invasion was 86.4%, 69.2% and 77.8%, respectively. Despite improvements in the noninvasive imaging modalities, endoscopic techniques are likely to remain established methods for the diagnosis and staging of pancreatic cancer. EUS with fine-needle aspiration biopsy is probably the most promising, followed by laparoscopy (and laparoscopic ultrasound) which is essential to rule out small peritoneal implants and liver metastasis.

[Role of endoscopy in the palliative therapy of pancreatic cancer]. / Ruolo dell'endoscopia nella palliazione del carcinoma pancreatico.

The incidence of pancreatic cancer continues to increase and, although improving of diagnostic techniques, the prognosis is very poor with 5-year survival less than 5% and high mortality cancer rate. Neural and lymphatic micrometastases appear in early stages and curative resection is possible in few selected cases; in these patients there is a high local recurrence rate and a low median survival. Most patients with pancreatic cancer need palliative care of the obstructive jaundice (90%), duodenal stenosis and abdominal pain; endoscopic procedures have an important role in the treatment of these patients. Endoscopic placement of plastic biliary stents is a safe and efficient technique to perform a biliary drainage with a short hospital stay. The use of metal stent, instead of plastic prosthesis, improve median patency of the prosthesis with a low incidence of cholangitis, but they should be used only in patients with a life expectancy of more than six months, because of their high costs. Laparoscopic gastro-entero-anastomosis is a valid alternative to laparotomic procedure in the treatment of the duodenal stenosis, with a shorter hospital stay and a lower morbidity rate. The endoscopic treatment of abdominal pain with pancreatic endoprosthesis placement or with endosonography-guided celiac plexus neurolysis is an alternative approach to radiotherapy and analgesic drugs.

Management of malignant mucinous adenomas.

BACKGROUND: Malignant polyps are defined as adenoma with cancerous tissue penetrating into or through the muscolaris mucosae in the submucosa, and endoscopic removal is the most common treatment for such polyps. In the presence of malignant mucinous adenoma, defined as a malignant adenoma in which a significant amount of mucus is present in the stroma, the therapeutic approach is controversial and authors have performed surgical resection in all cases. The purpose of the study was to demonstrate that malignant mucinous adenoma is not a condition suggesting by itself a bowel resection. METHODS: Ten patients with malignant mucinous adenoma were enrolled in the study: endoscopic treatment alone was performed in 4 cases, and polypectomy was followed by surgical resection in 6 cases. RESULTS: At a median follow-up of 74.2 months no distant metastases had occurred in any of the patients treated with endoscopic polypectomy alone; during the follow-up, 1 patient had a local recurrence and surgical resection was performed. Only one case of residual disease was found at histology among the patients in which endoscopic polypectomy was followed by surgical resection. No complications occurred after endoscopic treatment in any case. CONCLUSIONS: In the absence of unfavorable histologic parameters, malignant mucinous adenomas should be managed with the same criteria of other malignant adenomas, and endoscopic polypectomy is considered as a safe and effective treatment when radicality criteria are fulfilled.

Endoscopic treatment of carpet-like adenomas of the rectum.

BACKGROUND: Transanal microsurgery, endoscopic laser photocoagulation and snare resection have all been used to treat large sessile adenomas of the rectum alternatively to a surgical approach. However, such modalities are often defective due to the carpet-like shape and the frequently large extension of the lesions. METHODS: Ten patients with carpet-like adenoma were submitted to transanal endoscopic resection by urological resectoscope. RESULTS: Complete eradication was obtained in all lesions. The mean number of treatment sessions was 3 (range, 1-5). The mean time between the first treatment and the complete eradication was 6 months (range, 1-18). The only complications were an intraoperative and an early postoperative bleeding. There was no early or late mortality related to the procedure. CONCLUSIONS: Transanal endoscopic resection by urological resectoscope appears to be a suitable therapeutic approach for sessile and carpet-like adenomas of the rectum or for pTI cancer in patients who refuse major surgery.