Approximately 30,000 new cases of pancreatic cancer and 7,000 biliary tract cancers are diagnosed annually in the United States. Few of these patients will survive 5 years, and most will succumb in less than 2 years. CT scanning is the principal means for initial diagnosis and staging of these neoplasms. The detection and staging of pancreatic and biliary tract cancers are best accomplished with contrast-enhanced CT scanning, MRCP, or EUS, but not ERCP. These modalities are relatively new and are based on technology that will continue to evolve, but it is clear that state-of-the-art, less invasive imaging is preferable to ERCP for diagnosis and staging in the overwhelming majority of cases.
ERCP is used for diagnosis and palliation in patients known or suspected to have pancreatic or biliary malignancies. However, there is very sparse information on the frequency with which ERCP is used for specific cancer types and stages or its influence on clinical management and outcomes. ERCP may be very beneficial in some cases and much less so in others. The selection of patients and timing in the course of disease where ERCP is used are critically important in maximizing the benefits.
ERCP is unnecessary for the diagnosis of cancer in a patient presenting with a localized pancreatic mass initially seen on a CT scan, if the patient is a candidate for surgery. Preoperative stenting and staging by ERCP in such cases confers no measurable advantage and is not supported by evidence from clinical trials. Preoperative ERCP may complicate or preclude surgical intervention. Contrast-enhanced CT or MRI scanning performed with a pancreaticobiliary protocol is usually sufficient for staging prior to surgical intervention. Preoperative CT angiography (CTA), MR angiography (MRA) and/or MRCP or EUS may be used if indicated.
Unfortunately, most cases of pancreatic cancer are not detected at a curable stage, so only palliation may be offered. Tissue diagnosis is required before chemotherapy and/or radiation therapy. EUS, percutaneous CT- or ultrasound-guided biopsy, and ERCP can provide the necessary tissue. ERCP tissue diagnosis may be achieved using needle aspiration, brush cytology, and forceps biopsy. Individually the diagnostic yield from these techniques is low, but their combination somewhat improves the ability to establish a tissue diagnosis. ERCP is not always successful in making a diagnosis by tissue sampling but offers the potential advantage of biliary tract decompression with a metal or plastic stent placement.
ERCP is the best available means for direct visualization to diagnose and biopsy ampullary malignancies. ERCP is useful for palliation in patients with biliary tract cancers. The role of ERCP in cholangiocarcinoma is parallel to that for pancreatic cancer. However, it may be useful for the diagnosis of biliary tract cancers, for example, in patients with underlying sclerosing cholangitis. In addition, it may be helpful in determining the extent of the cancer.
Palliative intervention for obstructive jaundice in pancreatic and biliary cancer may involve ERCP with stenting or surgery. The available evidence does not indicate a major advantage to either alternative, so the choice may be made depending on clinical availability and patient or practitioner preference. The technical skills to perform ERCP are widely available, and this modality may be preferable to surgery in some cases due to lower overall resource utilization and shorter hospitalization. If ERCP and stenting are used, metal stents remain patent longer than plastic. Metal stents may be preferred in patients who are expected to survive longer than 6 months.
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