1. Simposio: “Pancreatic Cancer: Surgical Treatment, 2013” Roma, 26 marzo 2013

2. Suspected pancreatic cancer Resectable Surgery Metastatic EUS+FNA CH-xRT pall Locally advanced EUS+FNA CH-xRT Borderline resectable EUS +/- FNA; MR; Laparoscopy neo-adjuvant CH-xRT 15% 35% 50% Helical CT

3. For patients expected to undergo surgery with radical intent, a previous biopsy is not necessary, and even preoperative percutaneous sampling should be avoided. Biopsy proof of malignancy is not required before surgical resection and a non-diagnostic biopsy should not delay surgical resection when the clinical suspicion for pancreatic cancer is high However, a preoperative diagnostic biopsy may not be needed in a fit patient with a potentially resectable pancreatic lesion that is highly suspected of malignancy.

4. Autore, rivistaAnnoN° blind DCP N° casi benigni % benignità Thompson, Am J Surg Path1994201155% Smith, Br J Surg1994603284.6% Van Gulik, Gastroint Endosc1997220146% Bottger, World J Surg1999186136.9% Weber, J Gastroint Surg2003128715912% Abraham, Am J Surg Path2003435409.2% Camp, Am Surg2004681420.3% Sasson, Am J Surg20061321712.9% Tessler, Am J Surg2006712231.1% Kennedy, Am Surg20061622113.0% Tien Y-W, J Gastroint Surg2009641015.6% TOTALE324834910.7% Camp ER et al., American Surgeon 2004 Sasson AR et al., American Journal of Surgery 2006

5. ProceduraMortalitàMorbilitàInsufficienza eso-endocrina postop. DCP< 5%30-40%40% Pancreatectomia distale < 1%30%25% Resezioni atipiche< 1%30-40%10% Pancreatectomia totale < 1%20%100%

6. Avoid transperitoneal biopsy in patients with potentially resectable tumours If EUS is being done, try and obtain tissue diagnosis Try to obtain histological confirmation of cancer in all patients being referred for chemotherapy and/or radiotherapy, and preferably in patients being referred for palliative care Many surgeons are reluctant to proceed with pancreaticoduodenectomy in the absence of cytologic or histologic confirmation of disease. For those surgeons, EUS-guided or CT-guided FNA is a reasonable alternative. Attempts should be made to obtain a tissue diagnosis during the course of investigative endoscopic procedures. Failure to obtain histological confirmation of a suspected diagnosis of malignancy does not exclude the presence of a tumour, and should not delay appropriate surgical treatment.

7. Giorno 0 1° tentativo Giorno 7 2° tentativo Giorno 14 3° tentativo attesa per l’E.I. programmazione del 2° tentativo attesa per l’E.I. programmazione del 3° tentativo attesa per l’E.I. Giorno 21 Giorno 0 diagnosi istologica Giorno 5 preospedalizzazione Giorno 10-15 intervento chirurgico

8. 1. CPRE  brushing  biopsia 2. EUS  EUS-FNA 3. Biopsia percutanea  ECO/TC-guidata

9. Median (range) No. of patients Sensitivity %Specificity %NPV %Accuracy % Percutaneous CT-US 83 (41-510)87 (45-100)100 (91-100)58 (23-100)84 (61-98) EUS81 (41-611)83 (54-95)100 (71-100)72 (16-92)88 (65-96)

10. Tir 1. NON DIAGNOSTICO Tir 2. NEGATIVO PER CELLULE MALIGNE Tir 3. INCONCLUSIVO/INDETERMINATO (Proliferazione Follicolare) Tir 4. SOSPETTO DI MALIGNITA’ Tir 5. POSITIVO PER CELLULE MALIGNE CITOLOGIA TIROIDEA Panc 1. NON DIAGNOSTICO Panc 2. NEGATIVO PER CELLULE MALIGNE Panc 3. INCONCLUSIVO/INDETERMINATO (atipie epiteliali lievi-moderate) Panc 4. SOSPETTO DI MALIGNITA’ Panc 5. POSITIVO PER CELLULE MALIGNE CITOLOGIA PANCREATICA

11. CLASSI DIAGNOSTICHE N%° PANC1913.2% PANC2710.2% PANC357.3% PANC4811.7% PANC53957.3% TOTALE68 69% 23.4%

12. Quadro atipico/inconclusivo (Panc3) Tada M. et al., Am J Gastr 2002 VALUTAZIONE DEL K-RAS SENSIBILITA’: 80% SPECIFICITA’: 100% K-RAS: negativo RISULTATO NEGATIVO PER NEOPLASIA

15. Tipo lesione Con verifica Senza verificaCi 95% p Solida86.3%76.9% +4.4% +14% 0.0002 Cistica52.2%34.7% +6.7% +28% 0.0015

16. IPMN centraliIPMN misti IPMN periferici

17. IPMN centrale/misto senza sintomi/noduli e con Wirsung < 1 cm – Pz anziano EUS + FNA Nodulo murale, ispessimento parietale, citologia positiva per cellule atipiche/maligne CHIRURGIA Esame ″negativo″ o “non diagnostico” FOLLOW-UP stretto

18. Resezione chirurgica se (high-risk stigmata): Sintomi maggiori (ittero) Noduli parietali vascolarizzati Citologia positiva per cellule maligne/atipiche (Diametro > 3 cm, rapida crescita)