Guidelines generally recommend the selective use of endoscopic ultrasound (EUS) as an adjunct to CT-scan in the assessment of pancreatic ductal adenocarcinoma (PDAC) resectability, without an established role in the detection of liver metastases or carcinomatosis. Our main objective was to evaluate the impact of EUS staging on the management of PDAC patients, since the majority of them underwent this procedure at our high volume center.

We used a prospectively maintained database of consecutive patients who underwent EUS staging for PDAC. We retrospectively analyzed the rate of intra-abdominal metastases suspected on pre-EUS CT-scan, pre-operative categorization of patients for resectable, borderline, or locally advanced tumor, EUS detection rate of intra-abdominal metastases, resection rate, and causes of non-resection.

From January 2010 to October 2014, 599 patients underwent EUS staging for suspected PDAC. Intra-abdominal metastases were not detected on initial CT-scan in 457 (76.3%) patients. Of these 457 patients, EUS detected and cytologically confirmed liver metastases in 6 (1.3%), and carcinomatosis was highly suspected in 8 (1.8%). Of the 188 patients with potentially resectable PDAC based on initial CT-scan, EUS detected liver metastases in 4 (2.1%) and carcinomatosis in 1 (0.5%). Of the 149 patients who underwent surgery with curative intent, resection was not performed due to local invasion in 17 (11.4%), liver metastases in 14 (9.4%), and carcinomatosis in 2 (1.3%). Portal venous reconstruction was done in 31 (29.0%) of the 107 pancreatectomies.

EUS staging prevented futile laparotomies in 2.6% of PDAC patients by the detection of early intra-abdominal metastases. Pre-operative EUS and CT-scan combined with a low threshold for portal venous resection may have accounted for the relatively low rate of pancreatectomies aborted for local invasion. Liver metastases were still found at time of surgery in 9.4% of patients, arguing for the development of more sensitive pre-operative staging tools.

Impact of endoscopic ultrasound staging on the management of patients with pancreatic adenocarcinoma