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EUS in Solid Pancreatic lesions Ahmed Alwassief, MD Alazhar university , CairoEUS for Detection of Pancreatic CancerPanc CA: 4th leading cause of Ca death in men and womenOverall 5-yr survival = 4%Survival is inversely proportionate to tumor sizeSmall tumors, LN (-), Vascular Invasion (-) = 25% 5-yr survivalEUS superior to CT/MR for lesions < 2-cmAccurate detection of small lesions impacts timing and type of therapyApproximately 85% of patients With pancreatic cancer have Stage IV disease at the time of initial presentation

2Differential Diagnosis of Pancreatic massPancreatic adenocarcinomaNeuroendocrine tumoutssquamous-cell carcinoma,acinar-cell carcinoma & solid pseudopapillary tumors.METS like Renal-cell carcinoma, melanoma, GIST, as well as primary cancers of the breast, ovary, thyroid, lung, prostate and colon.Focal pancreatitis/ AutoimmuneLymphoma6% of patients undergoing pancreaticoduodenoectomy have a benign process. Another 6% of patient may have an unusual histology .Value of EUS in Solid pancreatic lesionsPublished literature supports the superiority of EUS compared with cross-sectional imaging for tumor detection, mainly for the detection of tumors smaller than 2-3 cm Although the sensitivity for tumor detection is high it is also important to note that it has a very high negative predictive value (NPV. This has important implications because it means that EUS can reliably exclude pancreatic cancer, especially in the setting of a low or indeterminate pretest probability0% of Patients underwent EUS developed cancer during a follow-up period of 24 months. Therefore a normal pancreas by EUS examination essentially rules out pancreatic cancer

EUS proved to be the most sensitive tool in the evaluation of pancreatic diseases, among them solid pancreatic lesions. However, its ability to determine whether a lesion is malignant or not is difficult to establish based only in the endosonographic image. EUS-guided fine needle aspiration (EUS-FNA) allows obtaining a cytological and/or histological sample from pancreatic lesions, with a high overall accuracy and low complication rates the indications for tissue diagnosis of pancreatic lesions suspected to be malignant is still controversialSigns of Malignancy by EUSPeriductal hypoechoic sign (defined as patchy hypoechoic areas adjacent to a dilated pancreatic duct) had a sensitivity of 74%, a specificity of 86%, and an accuracy of 80% for the diagnosis of pancreatic malignancy.Pancreatic duct diameter or dilation of both bile and pancreatic ducts were not predictive of malignancy in this study.Diameter to pancreatic gland width ratio greater or equal to 0.34 at the level of the portosplenic confluence had a PPV, NPV, sensitivity, specificity, and accuracy of 87%, 99%, 94%, 97%, and 97%, respectivelyLimitations of EUSEUS may fail to identify true pancreatic masses in patients with Chronic pancreatitis, a diffusely infiltrating carcinoma,Prominent ventral/dorsal split, or Recent episode ( 4 markers to box-in the lesion is idealTherapeutic EndoscopicInterventionsFiducial Placement Safety/EfficacyPrior studies reported technical failure with 19 gauge delivery system in the pancreatic head and/or altered anatomyNewer trials report 88-97% success with only minor complicationsEquipment malfunctionPain (Pancreatitis)Bleeding/InfectionMigration

Celiac Plexus Neurolysis (CPN)Bupivacaine and absolute alcohol74-88% effectiveHead lesions may respond more favorablySingle/Multiple Sites +/- Fenestrated needlesSide Effects:Bleeding/InfectionDiarrheaPainHypotensionParalysis

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