S3-Guideline “Exocrine Pancreatic Carcinoma” 20071 ... - DGVS

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458 Leitlinie of these results is not known. Therefore, this type of monitoring should only be done under study conditions [86 – 88, 104]. Chronic pancreatitis Patients with many years of chronic pancreatitis have an increased risk of developing pancreatic carcinoma. Evidence level 2b, strong consensus Comments The data on the relative risk are heterogeneous and vary from 2.3 to 18.5. The cumulative incidence is reported to be 1.1% after 5 years, 1.8% after 10 years, and 4% after 20 years [105 – 109]. Type 2 diabetes mellitus Patients with type 2 diabetes mellitus have an increased risk for pancreatic carcinoma. Evidence level 2b, consensus Comments About 1% of diabetics age 50 years and younger develop pancreatic carcinoma in the following 3 years. That is equal to an about 8-fold higher risk [110]. Further studies show a risk that is lower [50, 111 – 118]. It must be taken into account that diabetes can be caused by pancreatic carcinoma [119, 120]. Recommendation on genetic consultation The genetic consultation of patients with genetic syndromes and their relatives is performed according to the directives of the German Medical Association. Recommendation grade: A, consensus Topic 2: Diagnostics ! Diagnostics in case of newly occurring symptoms Recommendation Newly occurring pain in the epigastric region and back should result in tests for diagnosing pancreatic carcinoma. Recommendation grade: C, evidence level 3, strong consensus Comments In general, newly occurring pain in the epigastric region or back which could be caused by pancreatitis or pancreatic carcinoma mandate further diagnostics. No literature is available that states for which symptoms alone or in combination and from which age pancreatic carcinoma should be considered. The diagnostics alone or in combination that are necessary to exclude pancreatic tumors have also not been reported. Newly occurring back pain alone which cannot be explained by alterations of the musculoskeletal system should not result in testing for pancreatic carcinoma. l " Table 8 suggests an age and suspicion level adapted procedure which is based on expert opinion. Recommendation A newly occurring or manifest type 2 diabetes mellitus with no further pancreatic carcinoma symptoms should not lead to pancreatic carcinoma diagnostic testing. Recommendation grade: B, evidence level 2b, consensus Adler G et al. S3-Guideline “Exocrine Pancreatic… Z Gastroenterol 2008; 46: 449–482 Table 8 Diagnostic procedures adapted to age and suspicion level for newly occurring pain of the epigastric region and back suspicion level age (years) symptoms procedure low < 50 just pain1 sonography in case of persisting symptoms intermediate 50 justpain1 sonography, if necessary CT pain plus2 sonography, if necessary CT high > 50 pain plus sonography, if necessary CT/ endosonography 1 Newly occurring pain that radiates localized/belt-like to the back and that is perceivable during the night should be clarified further regardless of age. If the suspicion level is high or if the ultrasound is negative, complementary CT, or endosonography should be implemented. 2 Pain plus other symptoms (inappetence, weight loss, weakness). Comment According to current studies, there is only a moderate connection between type 2 diabetes and pancreatic carcinoma [110, 112, 115]. This and the few possibilities for early pancreatic carcinoma diagnosis currently available, make diagnostic testing for pancreatic cancer not useful for type 2 diabetes mellitus patients without further symptoms. Recommendation Newly occurring painless jaundice should result in diagnostic testing for pancreatic carcinoma. Recommendation grade: B, evidence level 2b, strong consensus Comment Pancreatic and bile duct carcinoma are the most frequent cause (20%) for newly occurring jaundice in patients over 60 years of age [121 –123]. Recommendation In certain cases (patients > 50 years with primary “idiopathic” pancreatitis), acute pancreatitis of unknown etiology should result in additional procedures for the diagnosis of pancreatic carcinoma. Recommendation grade: C, evidence level 4, consensus Comments The pancreatic carcinoma incidence seems to be higher in patients with acute pancreatitis and even more so in patients with an acute episode of chronic pancreatitis. However, they do not exceed 1 – 2% of all pancreatic carcinoma cases or a maximum of 5% of idiopathic forms. There are only few systematic studies on this topic, especially on the idiopathic forms. Data using endosonography in this context are well documented. Thus, the primary recommendation is endoscopic ultrasound, which should be done during the symptom-free interval following acute pancreatitis. MD-CT examinations are an alternative. If the endoscopic ultrasound is negative, a clarification of the ducts should be considered. However, only data on ERCP are available, which has the risk of post-ERCP-pancreatitis. By analogy, MRCP is recommended [124, 125]. In general, CA 19–9-assessment should not be done to diagnose pancreatic carcinoma. Algorithms or diagnostic procedures are also not recommended to clarify an increased CA 19–9-value. Downloaded by: Thieme Verlagsgruppe. Copyrighted material.
Although pancreatic carcinoma may also develop before the age of 50, the age dependent incidence curve does not show an increase until after the age of 50 [122]. Therefore, diagnostic testing should be done in patients age 50 years and older. Imaging techniques for primary diagnostics Recommendation Different procedures such as sonography, endosonography, multidetector-CT, MRT with MRCP or ERCP are suitable to confirm suspected tumors. Recommendation grade: B, evidence level 2, consensus Comments The abovementioned procedures are not always available. Therefore, they cannot be implemented in an algorithm defined for every situation. It was agreed that initially an ultrasound examination of the epigastric region should be done. This would allow a tentative diagnosis of pancreatic carcinoma and perhaps also diagnosis of metastases. The diagnosis of pancreatic carcinoma is also possible with all other procedures. However, ERCP alone is not sufficient to diagnose ductal pancreatic carcinoma, because it depicts only the ductal changes and not the lesion itself [126, 127]. Computed tomography (multi-detector-CT) should be done using a biphasic contrast medium protocol (pancreas parenchyma phase and portal venous phase). The section thickness should be £ 3 mm. The MRT/MRCP should be done with a field strength of at least 1.5 tesla and standard weighting (T1 and T2 including MRCP). The section thickness should be 5 – 7 mm. The endoscopic ultrasound may be done with a mechanical radial scanner as well as an electronic endosonography device. However, the published data are based on mechanical radial scanners. Although the electronic endosonography most likely has a better local resolution, it has not been investigated whether carcinomas can be identified with a higher sensitivity with this device. Recommendation Sonography of the epigastric region, endosonography, multi-detector-CT, as well as MRT in combination with MRCP are first choice diagnostic procedures to detect pancreatic carcinoma. Recommendation grade: B, evidence level 3, consensus Comments According to the literature multi-detector-CT and MRT in combination with MRCP are the most sensitive procedures for the detection of pancreatic carcinoma. If used by specialists, endosonography may partly be even more sensitive. A clear recommendation for or against one of these procedures cannot be given. The procedure for which there is the most expertise in the facility should be used. Different complementary procedures may also have to be implemented. Cytologic and laboratory diagnostics Recommendation If pancreatic carcinoma is suspected, brush cytology from the bile ducts is not sensitive enough. It is also not recommended to use brush cytology from the pancreas duct to detect pancreatic carcinoma. Therefore, an ERCP for tissue diagnostics is not indicated. Recommendation grade: D, evidence level 5, consensus Leitlinie 459 Comments The literature does not allow for an adequate statement on the abovementioned question. Brush techniques in pancreas as well as in the bile duct system are risky and not useful. Laboratory tests Recommendation If there is a pancreatic lesion, CA 19–9-testing should be done. Recommendation grade: C, evidence level 2a, majority approval Comments CA 19–9 laboratory tests may be used in individual cases for differential diagnostics. Potential resectability detected with imaging techniques and a very high preoperative CA 19–9-value may make staging laparoscopy necessary. In such cases the tumor load is often greater than expected from the imaging technique e. g. a disseminated tumor. However, so far there are no cost-benefit analyses which support the use of this test [128– 131]. Tissue diagnostics: procedure in case of pancreatic lesion Recommendations Initially a resection should be done if there is a potentially resectable lesion in the pancreas that may be a tumor. An endosonographic guided biopsy may be done if differential diagnostic indications are present that would change the procedure e. g. if metastases are suspected because of an earlier malignancy. Recommendation grade: B, evidence level 2, consensus Comments The endosonographically guided fine needle puncture is sensitive and highly specific for histologic or cytologic diagnosis of pancreatic carcinoma [132–134]. However, in most cases it is unnecessary, because if resectable, lesions of unclear dignity should also be operated on. Therefore, for a potentially resectable lesion, a preoperative biopsy to confirm the diagnosis of pancreatic cancer is not necessary. Recommendation If nonetheless a biopsy is done for differential diagnostics, biopsies should be preferably taken from those lesions that have the lowest risk of complications. Recommendation grade: D, evidence level 5, consensus Recommendation A biopsy to confirm a diagnosis is mandatory before specific palliative therapy is initiated independently of whether the pancreatic tumor is locally advanced, inoperable, or metastatic. Recommendation grade: B, evidence level 2a, strong consensus Comment The diagnosis must be cytologically or histologically confirmed before palliative chemotherapy is started to exclude false treatment due to other differential diagnoses [135]. Recommendation The lesion that is easiest to reach and that has the lowest risk is biopsied independently of whether it is the primary tumor or a metastasis. Recommendation grade: D, evidence level 5, strong consensus Adler G et al. S3-Guideline “Exocrine Pancreatic… Z Gastroenterol 2008; 46: 449–482 Downloaded by: Thieme Verlagsgruppe. Copyrighted material.
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