The role of preoperative biopsy in pancreatic cancer

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Abstract
The inaccessible position of the pancreas and the difficulty in distinguishing inflammatory changes from malignancy make it difficult to establish a preoperative diagnosis of pancreatic cancer. Previously the high mortality rate associated with pancreato‐duodenectomy meant that surgeons were reluctant to proceed to operation without such a diagnosis. Obtaining histological confirmation of cancer before operation became an important issue in management algorithms. However, advances in imaging techniques have greatly improved the capability of radiology to diagnose pancreatic cancer. This development coupled with the fact that pancreato‐duodenectomy can be performed with a low mortality rate, albeit with an appreciable morbidity rate, has resulted in less emphasis being placed on the establishment of a preoperative diagnosis [ 1 x 1 Sohn, T.A., Yeo, C.J., and Cameron, J.L. Should pancreaticoduodenectomy be performed in octogenarians?. J Gastrointest Surg. 1998; 2: 207–216 Crossref | PubMed | Scopus (159) | Google Scholar See all References , 2 x 2 Yeo, C.J. Pancreatic cancer: 1998 update. J Am Coll Surg. 1998; 187: 429–442 PubMed | Google Scholar See all References , 3 x 3 Stephens, J., Kuhn, J., and O'Brien, J. Surgical morbidity, mortality, and long‐term survival in patients with peripancreatic cancer following pancreaticoduodenectomy. Am J Surg. 1997; 174: 600–603 Abstract | Full Text PDF | PubMed | Scopus (43) | Google Scholar See all References , 4 x 4 Yeo, C.J., Cameron, J.L., and Sohn, T.A. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg. 1997; 226: 248–257 Crossref | PubMed | Scopus (1510) | Google Scholar See all References ]. Certain considerations make a preoperative tissue diagnosis necessary. These include the use of neo‐adjuvant therapy, and situations of diagnostic doubt involving benign strictures or focal areas of pancreatitis, in which either no operation or a different operation would be performed. When non‐operative palliation is being considered, a tissue diagnosis is necessary for counselling. In specific instances, a favourable histology report may prompt an operation that would not have been considered in the setting of pancreatic adenocarcinoma. In a small but important subset of patients, treatable conditions such as lymphoma or tuberculosis may be distinguished from adenocarcinoma by preoperative biopsy [ 5 x 5 Singh, B., Moodley, J., Batitang, S., and Chetty, R. Isolated pancreatic tuberculosis and obstructive jaundice. S Afr Med J. 2002; 92: 357–359 PubMed | Google Scholar See all References 5 , 6 x 6 Kouraklis, G., Glinavou, A., Karayiannakis, A., and Karatzas, G. Primary tuberculosis of the pancreas mimicking a pancreatic tumor. Int J Pancreatol. 2001; 29: 151–153 Crossref | PubMed | Google Scholar See all References 6 ]. A variety of techniques can be used to obtain tissue and cellular material for diagnosis.

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