Difficult pancreatic mass FNA: tips for success

Pancreatic cancer is now the fourth leading cause of cancer-related deaths in the United States, and its incidence appears to be increasing. Cancer of the pancreas develops in approximately 30,000 people in the United States annually. The disease is associated with a high mortality rate and a median survival of approximately 4 months in untreated patients. Data from the National Cancer Database show the 5-year survival after surgery (pancreaticoduodenectomy) to be 3%.1 However, if surgery achieves clear margins and negative lymph nodes, the 5-year survival approaches 25%. Unfortunately, most patients diagnosed with pancreatic cancer display clinical symptoms at an advanced stage of the disease when surgical cure is no longer possible. When unresectable, chemotherapy, radiation therapy, and a combination of the two may improve overall survival and quality of life. EUS was developed in the early 1980s to overcome limitations to transabdominal US imaging of the pancreas caused by intervening gas, bone, and fat. The ability to position the transducer in direct proximity to the pancreas by means of the stomach and duodenum, combined with the use of high-frequency transducers, produces detailed high-resolution images of the pancreas that far surpasses that of CT or magnetic resonance imaging (MRI). A logical progression of diagnostic EUS was fine-needle aspiration (FNA). The echoendoscope itself serves as the vehicle to deliver the needle to the target site of puncture. The FNA needle is passed through the instrumentation channel of the echoendoscope and into the pancreatic target lesion under endosonographic guidance. With the availability of EUS and EUS-guided FNA procedures in major medical centers around the world, earlier diagnosis and more accurate staging have improved the management of pancreatic cancer. This article will review EUS-guided FNA of the pancreas and tips to achieve successful results.