Sobrevida del adenocarcinoma ductal de páncreas

El objetivo de este trabajo es analizar la presentación epidemiológica y la sobrevida de los pacientes con adenocarcinoma ductal de páncreas de acuerdo con su estadío clínico y al tipo de intervención realizada, en una cohorte de pacientes atendidos en una clínica en Lima, Perú. Estudio de cohortes retrospectivas que evaluó desde enero del 2015 a febrero del 2021 a pacientes con diagnóstico de adenocarcinoma ductal de páncreas considerando diversos factores epidemiológicos, radiológicos, estadiaje oncológico, haber recibido quimioterapia neoadyuvante o adyuvante, haber sido sometidos a cirugía y la sobrevida posterior a alguna de las intervenciones realizadas. De los 249 pacientes analizados, se encontró que 75 de ellos requerían cirugía resectiva. Entre los principales resultados obtenidos, se observó que aquellos con un nivel de CA 19-9 menor a 200 U/mL presentaban una media de sobrevida más alta en comparación con aquellos cuyo nivel de CA 19-9 era superior a 200 U/mL (HR: 1,96; IC95%: 0,18-0,53; p≤0,001). Asimismo, al comparar a los pacientes según su etapa, se encontró que aquellos con tumores resecables tenían una media de sobrevida de 37,72 meses, mientras que aquellos con tumores localmente avanzados tenían una media de sobrevida de 13,47 meses y aquellos con tumores metastásicos tenían una media de sobrevida de 7,69 meses (HR: 0,87; IC95%: 0,31-0,25; p≤0,001). Igualmente, se observó que recibir tratamiento neoadyuvante se asociaba con un mejor pronóstico de sobrevida para los pacientes (HR: 0,32; IC95%: 0,19-0,53; p≤0,001). Asimismo, se llevaron a cabo 5 pancreatectomías con resección metastásica en pacientes oligometastásicos tratados con quimioterapia de rescate, y se encontró que la media de sobrevida para estos pacientes fue de 22,51 meses. Conclusión: La cirugía resectiva en un estadío clínico temprano , presentar valores de CA 19-9 por debajo de 200 U/mL y haber recibido quimioterapia neoadyuvante se correlaciona estadísticamente con una mayor esperanza de sobrevida.

The objective of this study is to analyze the epidemiological presentation and survival of patients with pancreatic ductal adenocarcinoma according to their clinical stage and the type of intervention performed, in a cohort of patients treated at a clinic in Lima, Peru. A retrospective cohort study evaluated patients diagnosed with pancreatic ductal adenocarcinoma from January 2015 to February 2021, considering various epidemiological factors, radiological findings, oncological staging, receipt of neoadjuvant or adjuvant chemotherapy, undergoing surgery, and post-intervention survival. Out of the 249 patients analyzed, 75 of them required resective surgery. Among the main findings, it was observed that those with a CA 19-9 level below 200 U/mL had a higher median survival compared to those with a CA 19-9 level above 200 U/mL (HR: 1.96; 95% CI: 0.18-0.53; p≤0.001). Furthermore, when comparing patients according to their stage, those with resectable tumors had a median survival of 37.72 months, while those with locally advanced tumors had a median survival of 13.47 months, and those with metastatic tumors had a median survival of 7.69 months (HR: 0.87; 95% CI: 0.31-0.25; p≤0.001). Additionally, receiving neoadjuvant treatment was associated with a better prognosis of survival for patients (HR: 0.32; 95% CI: 0.19-0.53; p≤0.001). Furthermore, 5 pancreatectomies with metastatic resection were performed in oligometastatic patients treated with salvage chemotherapy, and the median survival for these patients was 22.51 months. Conclusion: Resective surgery at an early clinical stage, CA 19-9 levels below 200 U/mL, and receiving neoadjuvant chemotherapy are statistically correlated with a higher overall survival.

Carcinoma coloide pancreático y tumor del estroma gastrointestinal del estómago sincrónicos: reporte de caso y revisión de la literatura / Colloid Carcinoma of the pancreas and synchronous gastrointestinal stromal tumour of stomach. A case report and review of the literature

El carcinoma coloide (CC) es una variante histológica inusual del adenocarcinoma ductal del páncreas, el cual se caracteriza por la presencia de grandes lagos de mucina extracelular que contiene células neoplásicas y está asociado a una mejor sobrevida a los cinco años, comparada con los adenocarcinomas ductales (DAC) tubulares o no tipo especial (NOS).Presentamos el caso de una paciente mujer de 74 años con una lesión multiquística de tabiques finos en cola de páncreas con diagnóstico clínico radiológico sugestivo de cistoadenoma seroso vs. neoplasia mucinosa. En el acto operatorio se evidenció una lesión de 10 x 6 cm, que infiltraba hilio esplénico y mesocolon transverso. Por otro lado, se identificaron dos nódulos en la pared del fondo gástrico que también fue resecado en conjunto. El estudio anatomopatológico concluyó que la tumoración del páncreas correspondía a un CC asociado incidentalmente a un tumor del estroma gastrointestinal (GIST) de fondo gástrico.(AU)

Colloid carcinoma (CC) is a rare histological type of adenocarcinoma of the pancreatic duct and is characterized by the presence of large lakes of extracellular mucin containing neoplastic cells. Its 5 year prognosis is more favourable than that of ductal, tubular or not otherwise specified (NOS) adenocarcinomas.We present the case of a 74-year-old woman with a thin walled, multicystic lesion in the tail of the pancreas, radiologically suggestive of a serous cystadenoma as opposed to a mucinous neoplasm. Surgery revealed a 10 x 6 cm lesion invading the splenic hilum and transverse mesocolon. Two nodes on the wall of the gastric fundus were also removed. Histopathology showed the pancreatic tumour to be a colloid carcinoma with a synchronous gastrointestinal stromal tumour of the gastric fundus.(AU)

[Colloid Carcinoma of the pancreas and synchronous gastrointestinal stromal tumour of stomach. A case report and review of the literature]. / Carcinoma coloide pancreático y tumor del estroma gastrointestinal del estómago sincrónicos: reporte de caso y revisión de la literatura.

Colloid carcinoma (CC) is a rare histological type of adenocarcinoma of the pancreatic duct and is characterized by the presence of large lakes of extracellular mucin containing neoplastic cells. Its 5 year prognosis is more favourable than that of ductal, tubular or not otherwise specified (NOS) adenocarcinomas. We present the case of a 74-year-old woman with a thin walled, multicystic lesion in the tail of the pancreas, radiologically suggestive of a serous cystadenoma as opposed to a mucinous neoplasm. Surgery revealed a 10 x 6 cm lesion invading the splenic hilum and transverse mesocolon. Two nodes on the wall of the gastric fundus were also removed. Histopathology showed the pancreatic tumour to be a colloid carcinoma with a synchronous gastrointestinal stromal tumour of the gastric fundus.

Resección vascular mayor por adenocarcinoma pancreático ductal: reporte del primer caso registrado en Paraguay / Major vascular resection for pancreatic ductal adenocarcinoma: case report, of first case reported in Paraguay

El adenocarcinoma pancreático ductal (APD) es la cuarta causa de muerte por cáncer y se proyecta que para el 2030 ocupe el segundo lugar. El pronóstico es sombrío, siendo la sobrevida menor a 9% en 5 años. Se consideró durante mucho tiempo a la resección quirúrgica como el único tratamiento curativo, sin embargo, sólo el 15 a 20% de los pacientes pueden ser beneficiados con la misma. La clasificación pre terapéutica más utilizada es la del National Comprehensive Cáncer Network (NCCN), basada en la relación del tumor con estructuras vasculares, clasificándolos en tumores "resecables", de resección límite "Borderlines" y "localmente avanzados". Se presenta el primer caso registrado en Paraguay de APD con infiltración de la Vena Mesentérica Superior (VMS) tratado con duodenopancreatectomía cefálica (DPC) asociada a resección vascular mayor.

Pancreatic ductal adenocarcinoma (PDA) is the fourth leading cause of cancer death and is projected to rank second by 2030. The prognosis is bleak, with survival being less than 9% in 5 years. For a long time, surgical resection was considered the only curative treatment, however, only 15 to 20% of patients can benefit from it. The most widely used pre-therapeutic classification is that of the National Comprehensive Cancer Network (NCCN), based on the relationship of the tumor with vascular structures, classifying them into "resectable", "borderline" and "locally advanced" tumors. We present the first registered case in Paraguay of PDA with infiltration of the Superior Mesenteric Vein (SMV) treated with cephalic duodenopancreatectomy (CPD) associated with major vascular resection.

Duodenopancreatectomía por adenocarcinoma ductal de páncreas en ancianos. ¿Podemos asumirla con seguridad? / Cephalic pancreaticoduodenectomy for ductal adenocarcinoma in the elderly. Can we do it safely?

Introducción: La cirugía y la quimioterapia han aumentado la supervivencia de los pacientes con neoplasias pancreáticas. La disminución de la morbimortalidad postoperatoria y el aumento de la esperanza de vida han ampliado las indicaciones de la duodenopancreatectomía cefálica (DPC), aunque sigue siendo controvertida en la población geriátrica. Métodos: Estudio observacional retrospectivo sobre una base de datos prospectiva, de pacientes con adenocarcinoma ductal de páncreas sometidos a una DPC entre 2007-2018. El objetivo principal fue analizar la morbimortalidad y supervivencia asociada a la DPC en pacientes≥75 años (ancianos). Resultados: Se incluyeron 79 pacientes, 21 de ellos mayores de 75 años (27%); dentro de este grupo el 23,9% tenían más de 80 años. El ASA de ambos grupos fue similar. Los pacientes≥75años requirieron más transfusiones. No se observaron diferencias en el tiempo operatorio, aunque en los ancianos se realizaron más resecciones vasculares (26 vs. 8,7%; p=0,037).La morbilidad fue mayor en los ancianos (61,9 vs. 46,6%), aunque sin diferencias. Los≥75años presentaron más complicaciones no quirúrgicas (33,3%; p=0,050) siendo la neumonía la más frecuente. La mortalidad postoperatoria fue superior en los≥75años (9 vs. 0%; p=0,017), constituyendo la resección venosa un factor de riesgo (p=0,01). La supervivencia global y la supervivencia libre de enfermedad no mostraron diferencias significativas en ambos grupos. Conclusiones: Los pacientes ancianos presentaron una mayor mortalidad postoperatoria y más complicaciones no quirúrgicas. La supervivencia no mostró diferencias, por lo que, con una adecuada selección de pacientes, la edad no debe constituirse por sí misma como una contraindicación para la DPC(AU).

Introduction: Surgery and chemotherapy have increased the survival of pancreatic cancer. The decrease in postoperative morbidity and mortality and increase in life expectancy, has expanded the indications por cephalic pancreaticoduodenectomy (PDC), although it remains controversial in the geriatric population. Methods: Retrospective study on a prospective database of patients with ductal adenocarcinoma of pancreas who underwent PDC between 2007-2018.The main objective was to analyse the morbidity-mortality and survival associated with PDC in patients≥75 years (elderly). Results: 79 patients were included, 21 of them older than 75 years (27%); within this group, 23.9% were over 80 years old. The ASA of both groups was similar. Patients≥75 years required more transfusions. No differences in operating time were observed, although more vascular resection were performed in the elderly (26 vs. 8.7%; P=.037). Morbidity was higher in the elderly (61.9 vs. 46.6%), although without differences. Patients aged≥75 years had more non-surgical complications (33.3%, P=.050), being pneumonia the most frequent. Postoperative mortality was higher in the≥75 years (9 vs. 0%; P=.017). The overall survival and disease-free survival did not show significant differences in both groups. Conclusions: Elderly patients had higher postoperative mortality and more non-surgical complications. Survival did not show differences, so with an adequate selection of patients, age should not be considered itself as a contraindication for PDC(AU).

Cephalic pancreaticoduodenectomy for ductal adenocarcinoma in the elderly. Can we do it safely?

INTRODUCTION: Surgery and chemotherapy have increased the survival of pancreatic cancer. The decrease in postoperative morbidity and mortality and increase in life expectancy, has expanded the indications por cephalic pancreaticoduodenectomy (PDC), although it remains controversial in the geriatric population. METHODS: Retrospective study on a prospective database of patients with ductal adenocarcinoma of pancreas who underwent PDC between 2007-2018. The main objective was to analyse the morbidity-mortality and survival associated with PDC in patients ≥75 years (elderly). RESULTS: 79 patients were included, 21 of them older than 75 years (27%); within this group, 23'9% were over 80 years old. The ASA of both groups was similar. Patients ≥75 years required more transfusions. No differences in operating time were observed, although more vascular resection were performed in the elderly (26 vs. 8.7%; P = .037). Morbidity was higher in the elderly (61.9% vs. 46.6%), although without differences. Patients aged ≥75 years had more non-surgical complications (33.3%, P = .050), being pneumonia the most frequent. Postoperative mortality was higher in the ≥75 years (9 vs. 0%; P = .017). The overall survival and disease-free survival did not show significant differences in both groups. CONCLUSIONS: Elderly patients had higher postoperative mortality and more non-surgical complications. Survival did not show differences, so with an adequate selection of patients, age should not be considered itself as a contraindication for PDC.

Prevalencia de diabetes mellitus y glucemia en ayuno alterada al momento del diagnóstico de cáncer de páncreas, en un grupo de pacientes asistidos en un centro de referencia gastroenterológico en Argentina / Prevalence of diabetes mellitus and altered fasting blood glucose at the time of pancreatic cancer diagnosis, in a group of patients assisted in a gastroenterological referral center in Argentina

Introducción: la diabetes mellitus (DM) se considera un factor de riesgo para el desarrollo de adenocarcinoma ductal de páncreas (ACDP). Objetivos: describir la prevalencia de DM y glucemia en ayuno alterada (GAA) al diagnóstico de ACDP en pacientes asistidos en un centro de referencia gastroenterológico; analizar las diferencias en las características personales y nutricionales en pacientes con ACDP y DM, ACDP y GAA, y ACDP sin DM ni GAA; establecer el tiempo transcurrido desde el diagnóstico de DM hasta diagnosticar ACDP. Materiales y métodos: de octubre de 2019 a marzo de 2020 se revisaron 465 historias clínicas de las Secciones Oncología y Nutrición de pacientes >18 años con diagnóstico de ACDP. Resultados: se registraron 171 historias clínicas (36,7%) con ACDP y DM, y 294 (63,2%) con ACDP sin DM. En el 45,1% de las primeras, el intervalo entre el diagnóstico de DM y el de ACDP fue <1 año, y en el 17,65%, 15,69% y 21,57% los lapsos correspondieron a 1 y 5 años, entre 5 y 10 años y >10 años respectivamente. Conclusiones: la prevalencia de DM en ACDP fue superior a la registrada en la población general (37% vs 12,7%), siendo del 45,10% cuando se presentó dentro del primer año del diagnóstico oncológico. Nuestros resultados concuerdan con la bibliografía internacional que relaciona la DM de reciente diagnóstico como factor asociado a la presencia de ACDP por factores de riesgo compartidos, variables fisiopatológicas de la DM o a consecuencia de la terapéutica farmacológica de la misma.

Introduction: diabetes mellitus (DM) is considered to be a risk factor for the development of pancreatic ductal adenocarcinoma (PDAC). Objectives: describe the prevalence of DM and of impaired fasting glucose (IFG) at the diagnosis of PDAC, among patients assisted in a gastroenterological reference center. Analyze differences in personal and nutritional characteristics in patients with both PDAC and DM; with both PDAC and IFG; and with PDAC but neither DM nor IFG. Determine the time lapse between the diagnosis of DM and the diagnosis of PDAC. Materials and methods: between October 2019 and March 2020, we analyzed 465 clinical records of PDAC-diagnosed patients over 18 years, from Oncology and Nutrition Sections. Results: 171 clinical records (36.7%) showed both PDAC and DM; 294 clinical records (63.2%) showed PDAC but not DM. In 45.1% of the former, the interval between the diagnosis of DM and that of PDAC was <1 year, and in 17.65%, 15.69% and 21.57%, the lapses corresponded to 1 and 5 years, between 5 and 10 years y >10 years, respectively. Conclusions: the prevalence of DM in PDAC patients (37%) is higher than that registered in the overall population (12.7%), reaching a 45.10% when detected during the first year of oncological diagnosis. Our results match the international literature relating recently-diagnosed DM with the presence of PDAC, as effect of shared risk factors between both diseases, or DM pathophysiology factors, or DM pharmacological therapeutic

Cephalic pancreaticoduodenectomy for ductal adenocarcinoma in the elderly. Can we do it safely? / Duodenopancreatectomía por adenocarcinoma ductal de páncreas en ancianos. ¿Podemos asumirla con seguridad?

INTRODUCTION: Surgery and chemotherapy have increased the survival of pancreatic cancer. The decrease in postoperative morbidity and mortality and increase in life expectancy, has expanded the indications por cephalic pancreaticoduodenectomy (PDC), although it remains controversial in the geriatric population. METHODS: Retrospective study on a prospective database of patients with ductal adenocarcinoma of pancreas who underwent PDC between 2007-2018.The main objective was to analyse the morbidity-mortality and survival associated with PDC in patients≥75 years (elderly). RESULTS: 79 patients were included, 21 of them older than 75 years (27%); within this group, 23.9% were over 80 years old. The ASA of both groups was similar. Patients≥75 years required more transfusions. No differences in operating time were observed, although more vascular resection were performed in the elderly (26 vs. 8.7%; P=.037). Morbidity was higher in the elderly (61.9 vs. 46.6%), although without differences. Patients aged≥75 years had more non-surgical complications (33.3%, P=.050), being pneumonia the most frequent. Postoperative mortality was higher in the≥75 years (9 vs. 0%; P=.017). The overall survival and disease-free survival did not show significant differences in both groups. CONCLUSIONS: Elderly patients had higher postoperative mortality and more non-surgical complications. Survival did not show differences, so with an adequate selection of patients, age should not be considered itself as a contraindication for PDC.

Invasive ductal adenocarcinoma arising from heterotopic pancreas in the jejunum: Case report and literature review.

Although the presence of pancreatic tissue outside of the usual anatomical location of the pancreas is not an uncommon incidental finding, the risk of malignancy is extremely low. We report a case of ductal adenocarcinoma arising within a focus of heterotopic pancreas, occurring in the jejunum of an 81 year old woman. The patient presented with a history of progressive gastrointestinal occlusive symptoms. Computerized tomography showed a mass in the jejunum, which was surgically removed. Histopathology revealed an invasive pancreatic ductal adenocarcinoma from pancreatic tissue with no connection with the original gland (Heinrich type II). At the 12-month follow-up, there were no signs of recurrence. Despite the low risk of malignancy in heterotopic pancreas, adenocarcinoma is the most frequent histological type, and the prognosis is still not clear. Lesions incidentally detected during surgery and in symptomatic patients need to be removed by conservative procedures in order to exclude malignant disease.

Cáncer de páncreas: alteraciones genéticas, cambios morfológicos y sus implicaciones terapéuticas / Pancreas cancer: genetic alterations, morphological changes and its therapeutic implications

Resumen El cáncer de páncreas es una enfermedad mortal, principalmente porque se descubre muy tarde y es muy resistente a la quimioterapia y radioterapia. El tipo más común de cáncer de páncreas (más del 90%) se desarrolla a partir de las células exocrinas del páncreas y se denomina adenocarcinoma ductal pancreático (ACDP). Se han reconocido tres lesiones precursoras de cáncer de páncreas ductal: neoplasia intraepitelial pancreática (PanIN), neoplasia papilar-mucinosa intraductal (NPMI) y neoplasia quística mucinosa (NCM). Uno de los primeros eventos genéticos implicados en la patogénesis de ACDP es una mutación en el punto de activación en el oncogén KRAS, una mutación conductora oncogénica que se encuentra en más del 90% de todos los cánceres de páncreas. Además, se ha informado que hasta un 10% de los cánceres de páncreas están asociados con el historial familiar. Aunque la causa es multifactorial, el tabaquismo y la historia familiar son dominantes. Existe heterogeneidad morfológica en muchos cánceres humanos, pero parece ser un hallazgo particularmente común en ACDP. La cirugía solo es posible en 15-20% de los casos: tumores confinados al páncreas con posible afectación ganglionar local no muy extensa y que no produce afectación vascular o está limitada.

Abstract Pancreatic cancer is a deadly disease, mainly because it is generally discovered very late and it is very resistant to chemotherapy and radiation therapy. The most common type of pancreatic cancer (over 90%) develops from the exocrine cells of the pancreas and is named pancreatic ductal adenocarcinoma (PDAC). Three precursor lesions of ductal pancreatic cancer have been recognized: pancreatic intraepithelial neoplasia (PanIN), intraductal papillary-mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN). One of the earliest genetic events involved in PDAC pathogenesis is an activating point mutation in the KRAS oncogene, an oncogenic driver mutation found in more than 90% of all pancreatic cancer. In addition, it has been reported that up to 10% of pancreatic cancer is associated with family history. Although the cause is multifactorial, cigarette smoking and family history are dominant. Morphological heterogeneity exists in many human cancers, but seems to be a particularly common finding in PDAC. Surgery is only possible in 15-20% of cases: tumors confined to the pancreas with possible local nodal involvement not very extensive and that do not produce vascular involvement or is limited.

Adenocarcinoma de pâncreas / Pancreatic adenocarcinoma

Introdução: Este artigo revisa o conhecimento atual do adenocarcinoma pancreático, dissertando sobre a definição, a sintomatologia e os processos diagnóstico, terapêutico e prognóstico. Métodos: Revisão bibliográfica de artigos científicos, selecionados nas bases Medline e PubMed entre março e maio de 2018, e em sites epidemiológicos sobre neoplasias pancreáticas. Resultados: A doença maligna do pâncreas é uma das neoplasias mais letais na atualidade, uma vez que sua detecção normalmente ocorre em estágios avançados da doença, impossibilitando a ressecção cirúrgica, que é a única opção potencialmente curativa disponível. A maior parte dos casos, entretanto, não é candidata a cirurgia por presença de metástases à distância ou por comprometimento vascular local, notadamente dos vasos mesentéricos. Conclusão: O adenocarcinoma ductal pancreático é uma patologia incomum, mas que merece atenção por sua alta agressividade e prognóstico reservado, com baixos índices de cura e de sobrevida, situação que se mantém inalterada ao longo das últimas décadas.

Introduction: This article reviews the current knowledge about pancreatic adenocarcinoma, discussing definition, symptomatology and diagnostic, as well as therapeutic and prognostic processes. Methods: Bibliographic review of scientific articles, selected from Medline and PubMed databases between March and May 2018, and in epidemiological sites on pancreatic neoplasms. Results: Malignant disease of the pancreas is one of the most lethal neoplasms today, since its detection usually occurs in advanced stages of the disease, making surgical resection impossible, which is the only potentially curative option available. Most cases, however, are not candidates for surgery due to presence of distant metastases or local vascular impairment, notably mesenteric vessels. Conclusion: Pancreatic ductal adenocarcinoma is an uncommon pathology, but it deserves attention because of its high aggressiveness and reserved prognosis, with low rates of cure and survival, a situation that has remained unchanged over the last decades.

Utility of 18 fludeoxyglucose in preoperative positon-emission tomography-computed tomography (PET-CT) in the early diagnosis of exocrine pancreatic cancer: A study of 139 resected cases. / Utilidad de la 18-fluorodeoxiglucosa en la tomografía por emisión de positrones-tomografía computarizada (PET-TC) preoperatoria en el diagnóstico precoz del cáncer de páncreas exocrino: estudio en 139 casos resecados.

INTRODUCTION: In pancreatic ductal adenocarcinoma (PDA), surgical resection is the only curative treatment, but due to its late clinical presentation only 15-25% patients are candidates for curative resection. The aim of this prospective, single-center study is to determine the diagnostic utility of preoperative PET-CT for early detection of PDA and early panIN lesions. METHODS: We studied the histopathological features of PDA and different panIN lesions in 139 surgical samples from patients undergoing pancreatic resection (from 2010-2014), comparing these results with preoperative PET-CT and MDCT study. For tumor diagnosis in PET-CT maximum standard SUV 2.5 was used. Pancreatic baseline SUVmax is the maximum uptake of the radiotracer 18-2FDG on the ROI curve determined for the area of the normal pancreas after pathological reassessment with areas not affected by tumours or preneoplastic lesions. Tumour Uptake Index is the ratio between the tumour SUVmax and pancreatic baseline SUVmax. RESULTS: Using an standard maximum SUV value of 2.5, PET-CT sensitivity was 77.7% (108 of the 139 cases) against 75.5% (105 of the 139 cases) of MDCT. But when we combined this value with maximum SUV of normal pancreatic tissue from each patient, PET-CT sensitivity improved its value to 94.9%. CONCLUSION: A combination of studies of PET-CT in tumor and non-tumor tissue of each patient might be a very useful diagnostic tool not only for preoperative diagnosis of PDA, but also for early panIN lesions.