Endoscopic approach in the diagnosis of high‐grade pancreatic intraepithelial neoplasia

Abstract

Early diagnosis of pancreatic ductal adenocarcinoma (PDAC) is essential for improving prognosis; however, diagnosing PDAC at an early stage is challenging. In patients with localized high‐grade pancreatic intraepithelial neoplasia (HG‐PanIN), whose tumorous lesion is undetectable on cross‐sectional images such as computed tomography or magnetic resonance image, long‐term survival is expected. Pancreatic cystic lesions or main pancreatic duct (MPD) dilatation are important indirect findings for the initial diagnosis of HG‐PanIN. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) should play important roles in detecting abnormal image findings, such as local irregular MPD stenosis, caliber MPD changes, small cystic lesions, or branch duct dilatation. Additionally, EUS could detect hypoechoic areas around the MPD stenosis in some patients with HG‐PanIN. Subsequently, endoscopic retrograde cholangiopancreatography (ERCP) and its associated pancreatic juice cytology, including serial pancreatic juice aspiration cytologic examination (SPACE) after placement of an endoscopic nasopancreatic drainage (ENPD) tube, may have high diagnostic accuracy for confirming the malignancy in HG‐PanIN. Although ERCP and its associated pancreatic cytology, including SPACE, may be associated with post‐ERCP pancreatitis (PEP), a recent randomized trial suggested that a 4‐Fr ENPD tube may reduce the incidence of PEP. In the future, further prospective multicenter studies are required to establish a standard method of SPACE. Additionally, further studies for novel biomarkers could help to establish evolutionary methods with duodenal fluid and pancreatic juice for the early and accurate diagnosis of early‐stage PDAC.

Clinical application of pancreatic juice‐derived small extracellular vesicles of pancreatic ductal adenocarcinoma

“…Recently, some retrospective cohort studies suggested distinctive imaging features that can be used to suspect small PDAC including HG-PanIN, including: focal pancreatic parenchyma atrophy, stenosis of the pancreatic duct and main pancreatic duct dilation. 12,61 Especially for patients without a pancreatic mass, repeated PJC using ENPD is a feasible method that is important for the diagnosis of early-stage PDAC including HG-PanIN. 3,11,12…”

Artificial Intelligence-Driven Diagnosis of Pancreatic Cancer

“…Early detection of pancreatic cancer is essential to provide the affected individual with a fair chance of survival beyond five years. However, most imaging techniques, including MRI, fail to identify conclusively subtle changes observed in the pre-malignant stages, such as the pancreatic intraepithelial neoplasia, which is commonly associated with the tumorigenesis of PDAC [ 72 ]. Even an individual with stage I (localized) pancreatic cancer has only a 39% survival rate over a five-year period [ 73 ].…”

Diagnostic yield of liquid‐based cytology in serial pancreatic juice aspiration cytological examination

“… 5 , 6 Although carcinoma in situ (CIS) of the pancreas without mass formation occurs, its diagnosis by EUS‐FNA is not possible; instead, conventional diagnostic endoscopic retrograde cholangiopancreatography (ERCP) is required. 7 , 8 The efficacy of serial pancreatic juice aspiration cytological examination (SPACE) via an endoscopic naso‐pancreatic drainage (ENPD) tube has also been reported, 8 but it is sometimes difficult to collect an adequate volume for analysis. The diagnostic performance of ERCP‐based tissue sampling may be inferior to that of EUS‐FNA, 9 and the incidence of post‐ERCP pancreatitis (PEP) cannot be negligible.…”