1. Pancreatic endoscopy : ROLE Of Endo TOF PET US Pr. René LAUGIER La Timone Hospital,Marseille MEDAMI Alghero, 4 th September 2014

2. Why pancreas is difficult to examine ? Retroperitoneal organ, Deep and hiden Not directly accessible to endoscopy

3. Organization of a pancreatic gland

4. Epidemiological data 3500 new cases/year in France Enhancing incidence 6th in frequency 2 nd digestive cancer in mortality, Poor prognosis Lack of improvement in the early diagnosis Warshaw N Engl J Me 1992; Faivre GCB 1997; Di Magno Gastroenterology 1999 Why pancreatic cancer is a big problem ?

5. Early clinical symptoms do not exist : Signs often only appear when neighbouring organs are involved : too late Pain : very evocative (solar type) but very late Jaundice : non specific and often late Biology : CA 19-9 non specific, only for surveillance after treatment What are the clinical symptoms ?

6. How to examine a pancreas ? Ultrasonography Low sensibility, only when tumor exceed 15 to 20 mm

7. C T Invasion S M A Invasion How to examine a pancreas ? CT Scan: confirmation and staging of an already diagnosed lesion or incidental abnomal lesion Precision : 83-93 % Good for resectability evaluation

8. CT Scan: good for operability Lymph nodes: 54-77 % lack of criteria for malignancy Hepatic Metastasis : sensibility: 75 % problem with peripheric small 2-10 mm, lesions Peritoneal carcinomatosis, detected in 6 to 7 % of « resectable » patients

9. How to examine a pancreas ? Endosonography: E U S

10. How to examine a pancreas ? Endosonography: radial probe 7. MHz12 MHz

11. How to examine a pancreas ? Endosonography: linear probe

12. Endosonography: the linear probe allows a direct cytology guidance and puncture

13. Endosonography: the linear probe allows a direct cytology guidance or puncture of cystic lesions

14. Endosonography: allows also direct injection of contrast material in a dilated duct

15. Positron Emission Tomography: staging of primitive pancreatic lesion and liver metastasis TEP = staging > diagnosis or incidental lesion

16. Positron Emission Tomography: surveillance after surgery (pancreatico-duodenectomy)

17. : no longer for diagnosis but only for palliative treatment E R C P

18. Pancreatoscopy

19. Is a pancreatic cancer screening possible ? Not in the whole population, BUT some sub populations are of interest for the GE because they are pre-malignant * Chronic pancreatitis patients, at a late stage (patients with a stricture of MPD ) * IPMN: mixt and branch duct types * Chronic Hereditary Pancreatitis * Mucinous neoplasms * Endocrine tumors

20. Chronic pancreatitis patients, at a late stage Relevance of a stricture ?? Endoscopic treatment or surgery ??

21. * IPMN Transformation of the cubic type epithelium of the ducts into a mucinous type with a risk of dysplasia Acute bouts of pancreatitis and duct dilation Mucus secretion Risk of degeneration into a cancer Main duct++, branch duct and mixt types: surveillance

22. * IPMN mixt and branch duct types

24. * IPMN mixt and branch duct forms: MRI and EUS +++ No cancer ? Surveillance ? or surgery ?

25. * IPMN mixt and branch duct forms: MRI and EUS +++ Nodule or mucus ??

26. * IPMN : later with carcinoma No surgery, palliative treatment with ERCP

27. Chronic Hereditary Pancreatitis Dominant autosomic mutation Symptoms of CP, but very high risk of cancer > 50 Years: - What nature for this stricture ??? EUS, MRI, PET scan

28. Mucinous cyst adenoma

30. Endocrine tumors: various symptoms related to their secretion Problem of localisation: EUS, PET Possible benignancy for a long time Confirmation and staging if malignancy Octreoscan

31. CONCLUSION Pancreas is a difficult organ Symptoms are late for adeno-carcinoma Surveillance of pancreatic patients is difficult despite immense improvements of technology TEPscan, MRI and EUS have followed a very rapid development EndoTOF PET-US may help us to solve difficult problems of therapeutic indications: surveillance or surgery ? Any indication of PET scan during surveillance may become an EndoTOF PET-US indication