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Suspected pancreatic cancer presenting as pain or weight loss: Analysis of diagnostic strategies

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Abstract

Comprehensive strategies for the diagnosis of pancreatic cancer were evaluated with decision analysis for accuracy, cost, and invasiveness. An optimal strategy began with ultrasonography followed by a combination of computerized tomography, needle aspiration biopsy, endoscopic retrograde cholangiopancreatography, and laparotomy. The refined strategy established or excluded the diagnosis of pancreatic cancer with sufficient reliability for clinical decisions. This strategy had an overall sensitivity of 92% and specificity was greater than 99%. The number of invasive tests increased with the prevalence of disease in the population, but the frequency of diagnostic laparotomy was only 1–9%. The comprehensive strategy could not be significantly improved without marked increases in the utilization of invasive technology.

Résumé

Les différentes méthodes de diagnostic du cancer du pancréas ont été étudiées aussi bien sur le plan de la précision que sur celui de leur coût et de leur caractère invasif. La stratégie la meilleure à observer consiste après ultrasonographie initiale à employer une combinaison des différentes méthodes suivantes: tomodensitométrie, biopsie aspiration à l'aiguille, cathétérisme rétrograde biliopancréatique et laparotomie exploratrice. Elle permet d'affirmer ou d'exclure le diagnostic présumé de cancer avec assez de précision pour que des décisions cliniques soient prises. Cette stratégie exploratrice présente une sensibilité de 92% et une spécificité supérieure à 99%. Le nombre des méthodes à employer est d'autant plus grand que les risques de cancer du pancréas sont plus élevés pour une population donnée, le taux de la laparotomie exploratrice étant finalement de 1–9%.

Il ne paraît pas possible d'aller au-delà des possibilités offertes par cette ligne de conduite à moins d'avoir recours à des méthodes plus invasives.

Resumen

Diversas estrategias comprensivas para el diagnóstico de cancer pancreático fueron evaluadas por medio del análisis de decisión para definir su sensibilidad, especificidad, costo y riesgo. La estrategia óptima se inicia con la ultrasonografía, seguida de una combinación de tomografía computadorizada, aspiración-biopsia con aguja, colangiopancreatografía retrógrada endoscópica y laparotomía. La estrategia refinada establece o excluye el diagnóstico de cáncer pancreático con suficiente confiabilidad para la toma de decisiones clínicas. Esta estrategia presenté una sensibilidad global de 92% y la especificidad fué de más de 99%. El número de pruebas invasivas aumentó con la preponderancia de la enfermedad en la población, pero la frecuencia de la laparotomía de diagnóstico fué de solo 1 a 9%. La estrategia comprensiva no pudo ser mejorada en una forma significativa sin un aumento marcado en la utilización de tecnologías invasivas.

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Authors and Affiliations

  1. Medical Service (Medical Practice Evaluation Unit, Primary Care Program, and Gastrointestinal Unit) and Surgical Service, Massachusetts General Hospital, Boston, USA

    Marc D. Silverstein M.D., James M. Richter M.D., Daniel K. Podolsky M.D. & Andrew L. Warshaw M.D.

  2. Departments of Medicine and Surgery, Harvard Medical School, Boston, Massachusetts, USA

    Marc D. Silverstein M.D., James M. Richter M.D., Daniel K. Podolsky M.D. & Andrew L. Warshaw M.D.

Authors
  1. Marc D. Silverstein M.D.
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  2. James M. Richter M.D.
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  3. Daniel K. Podolsky M.D.
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  4. Andrew L. Warshaw M.D.
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Additional information

Dr. Silverstein was supported as a Henry J. Kaiser Fellow in General Internal Medicine and is now with the Department of Medicine, University of Chicago, Illinois, U.S.A.

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Silverstein, M.D., Richter, J.M., Podolsky, D.K. et al. Suspected pancreatic cancer presenting as pain or weight loss: Analysis of diagnostic strategies. World J. Surg. 8, 839–845 (1984). https://doi.org/10.1007/BF01656023

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