Who is at Risk? |
History & Physical Examination
Family History |
Imaging modalities of the pancreas include endoscopic ultrasound (EUS), endoscopic
retrograde cholangiopancreatography (ERCP) and spiral CT. The first two tests appear
to be quite useful, while the latter appears to be ineffective for surveillance. The
endoscopic ultrasound findings can be subtle and require an experienced endoscopic
ultrasonographer to interpret. The same abnormal EUS findings that are present in
familial pancreatic cancer patients can also be seen in patients with chronic pancreatitis.
The next step in the work-up is to perform an ERCP (an examination of the pancreatic duct).
Because of the risk of inducing pancreatitis, ERCP should be reserved for those patients
who are symptomatic or have abnormal changes present at EUS. While some of the ERCP changes
seen in association with histologic dysplasia are similar to those seen with chronic pancreatitis
(main duct stricture), other features are often present that are unusual. These features include
focal side branch duct irregularities, small sacculations, and grape-like clusters of saccules.
It is essential to evaluate the endoscopic findings in the context of the patient’s symptoms
and familial history.
In cases where the EUS is abnormal and the ERCP is normal, we generally repeat the EUS every
6-12 months based on the degree of abnormality at EUS and whether the patient is symptomatic
or not. Patients who appear to be progressing symptomatically or on EUS (increase or extension
of echogenic foci or nodules, and/or development of discrete masses) would require another ERCP.
The last step in the work-up is a spiral CT scan. Our experience with other patients with pancreatic
precancer has indicated that the CT scan of pancreas is usually normal in appearance. The role of
pancreatic biopsy performed at CT, endoscopy, or EUS has not been studied.