Most appropriate initial method of investigation for carcinoma head of pancreas
(A) EUS guided Transgastric biopsy [?]Endoscopic Ultrasonography (EUS):EUS can image the primary cancer and be a means of obtaining a FNA of pancreatic adenocarcinoma.When a mass cannot be visualized on CT scan, sonography through the wall of the stomach or duodenum can image tumors in the body or tail and head of the pancreas, respectively.Suspicious lesion by imaging should be treated with resection.In specific patients a tissue diagnosis may be needed, such as in patients entering a clinical trial, prior to neoadjuvant therapy, and prior to chemotherapy in advanced tumors (EUS can be highly accurate).EUS has a sensitivity for histologic diagnosis of 91% with a specificity of 100% with a pancreatic mass.Other Options[?]Multiphase Multidetector Helical Computerized Axial Tomography:Among diagnostic imaging techniques, abdominal CT scanning is the most common for confirming suspected pancreatic malignancy.Standard CT techniques are relatively insensitive for the assessment of resectability.Vascular involvement & liver metastases can be most optimally assessed with newer CT imaging techniques.Cornerstone of diagnostic evaluation of a pancreatic tumor is the multiphase CT scan, with i.v. contrast CT through pancreas during arterial, portal venous, & parenchymal phases of enhancement.[?]Magnetic Resonance Imaging:To date, MRI has not been widely used to assess pancreatic cancer.This method was initially limited by long scanning times and the resultant artifact caused by organ motion.Dynamic MRI, with i.v. contrast enhance have sensitivity & specificity comparable to those for helical CT.Some found MRI more accurate at predicting malignancy of the pancreatic duct due to findings of concurrent MRI cholangiopancreatography, but use of this imaging method for pancreatic cancer is currently not widespread.[?]Staging Laparoscopy:Laparoscopy & multiphase CT have evolved concurrently as methods to evaluate a pancreatic mass.Both have emerged as highly effective in evaluating the tumors, but CT as a noninvasive modality supplants the use of routine laparoscopy.Laparoscopy that precedes planned resection can accurately identify metastases that avoid detection by CT, and when combined with laparoscopic ultrasound, can delineate vascular invasion as well as metastases within the hepatic parenchyma.Currently, routine use of laparoscopy is not warranted.Few patients will have findings on laparoscopy that add to information found at CT scanning.The group at JHMI retrospectively reviewed 188 cases of patients studied preoperatively using CT and treated through a laparotomy.Preoperative laparoscopy would have benefited a maximum of 2.3% of patients with a pancreatic head tumor.Lesions in the body and tail were more likely to have misleading CT scans (35.3%).American Hepato-Pancreato-biliary Association recommends laparoscopy be limited to select patients with primary tumors greater than 3 cm in diameter, body or tail tumors, equivocal findings of metastasis on CT, & CA19-9 level greater than 100U/mL.Using these criteria, the subset of patients with advanced tumors not identified on CT scan can be accurately assessed by laparoscopy.
EUS guided Trans gastric biopsy
CT guided Biopsy
MRI guided biopsy
Laparoscopic Biopsy
Radiotherapy