Pancreaticoduodenectomy without Preoperative Radiological and Histological Diagnosis Diagnostic strategy/management

Introduction: Controversy exits about the diagnostic strategy/management of patients with clinical suspicion of a periampullary tumour but without a 'visible mass' noticed on US/CT/MRCP. In these patients EUS/brush/biopsy might be helpful in deciding whether surgery is indicated. Objective: The present study evaluated the additional value of EUS/brush/biopsy in the diagnostic workup of patients with inconclusive radiological imaging. Pathology after resection was correlated with preoperative diagnostics. Methods: A consecutive cohort of 303 patients, suspected to have a periampullary malignancy, underwent pancreaticoduodenectomy from Jan 2000-Oct 2005. Patients were classified by results of preoperative diagnostic workup: (A) visible mass on US/CT/MRCP, (B) no visible mass, conclusive additional EUS/brush/biopsy, (C) no mass, inconclusive results of additional diagnostic workup. Pathological findings after resection were correlated with preoperative diagnostic results. Results: A visible mass was found in 231 patients (group A: 76%). Of the 72 patients without a visible mass in 62 (86%) EUS/brush/biopsy had led to a preoperative diagnosis (group B: 21%). Remaining 10 patients had inconclusive results of additional diagnostic workup or no further diagnostics performed (group C: 3%). Pathological findings after resection were, overall & each group separately (A/B/C): (pre)malignancy 85% (85/87/60), benign cystic 5% (7/0/0), focal pancreatitis 10% (8/11/30), no tumour 1% (-/2/10). Conclusions: In patients clinically suspected to have a periampullary tumour, 76% has a visible mass of which 85% had a (pre)malignancy at pathology. Additional diagnostic workup (EUS/brush/biopsy) leads in 86% of the cases of the remaining group to a preoperative diagnosis. In the small subgroup without conclusive preoperative diagnostics, 60% has a (pre)malignancy after resection.