- should it be used to characterise all cysts are just those greater then a certain diameter?
- what is its application in surveillance?
- should FNAC be routinely undertaken for all cysts?
- Can characterisation be reliably made by cross-sectional imaging hence reserving EUS for more suspicious lesions?
A1. Depends on history. If there is history of acute pancreatitis, I may be initially avoided as opposed to asymptomatic cysts incidentally detected OR ASSOCIATED WITH JAUNDICE, WEIGHT LOSS OR ABDOMINAL PAIN where diameter is no criteria. It can be used to study cyst fluid amylase, CA 19-9, Kras mutation etc. for helping diagnosis. EUS can often diagnose subtle changes of chronic pancreatitis not otherwise diagnosable on radiology and other obscure biliary pathology. It can also help therapeutic drainage.
A2. Any suspicious cysts may need EUS for surveillance regarding increase in size, change of appearance etc.
A3. Again depends on history As discussed in A1.
A4. Very good quality CT SCAN OR MRI SCAN DONE BY RADIOLOGIST EXPERIENCED IN THIS may help but still cannot replace information given by EUS like local lymph node involvement, subtle lower biliary pathology
EUS with FNA is the best tool for a positive diagnosis of pancreatic cyst. It can differentiate benign lesions (pseudocysts, serous cystadenomas) from potentially malignant (mucinous cystadenomas, IPMN) or malignant (mucinous cystadenocarcinomas) with a high degree of accuracy based on image characteristics, biochemical fluid analysis and fluid cytology.
When cysts are small, with no mural nodules and sugestive for branched duct IPMN, FNA is not mandatory. The same can be said for a typical "honeycomb" serous cystadenoma, FNA may not be mandatory.
EUS can also be used for surveillance of branched duct small size IPMNs.
As CT scan or MRI have lesser accuracies than EUS and as EUS allows FNA, I would suggest EUS in all cases to establish an accurate diagnosis.
EUS is probably the method with least harm even if applied routinely to closely monitor newly diagnosed lesions in terms of growth. Smaller lesions (few mm) are sometimes better detected than with CT and MRI, but this needs routine skills. Fine needle aspiration may be used, but from the first FNA on additional small lesions may be present (iatrogenic). A negative FNA may be a "miss" and does help at all. Laparoscopic examination of the retroperitoneum and pancreatic surface may be the next step. Excisional biopsy is the only safe road to histological proof / exclusion of neoplasia, as EUS only gives indirect hints of tumour presence or spread.
Please go through the following article
What are the current and potential future roles for endoscopic ultrasound in the treatment of pancreatic cancer? January 2016 DOI: 10.4253/wjge.v8.i7.319
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