Diagnostic and Therapeutic Endoscopy in Pancreatic Cancer

  • Folasade P. May
  • Field F. Willingham
  • David L. Carr-Locke
Reference work entry


While endoscopic ultrasound is the most sensitive procedure for the diagnosis of pancreatic cancer, endoscopic retrograde cholangiopancreatography (ERCP) is a safe and effective approach to the diagnosis, treatment, and palliation of biliary and pancreatic disorders [1]. Most patients with pancreatic cancer will have multiple contacts with the therapeutic endoscopy service over the course of their disease. ERCP is commonly employed to examine the biliary tree and pancreatic duct, to confirm the presence of obstructive lesions, and to define the location of benign and malignant strictures. The procedure allows for tissue diagnosis in some settings via sampling of ductal strictures. There is a major role for ERCP in the palliation of pancreatic cancer where stent placement can relieve obstructive jaundice and enteral stenosis. This chapter addresses the use of ERCP in pancreatic adenocarcinoma with respect to cancer diagnosis, therapy, and palliation.


Pancreatic Cancer Pancreatic Duct Stent Placement Metallic Stents Gastric Outlet Obstruction 
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  1. 1.
    Thomopoulos KC, Vagenas K, Assimakopoulos SF, et al.: Endoscopic retrogade cholangiopancreatography is safe and effective method for diagnosis and treatment of biliary and pancreatic disorders in octogenarians. Acta Gastroenterol Belg 2007;70:199–202.PubMedGoogle Scholar
  2. 2.
    Barkin JS, Goldstein JA: Diagnostic approach to pancreatic cancer. Gastroenterol Clin North Am 1999;28:709–722, xi.CrossRefPubMedGoogle Scholar
  3. 3.
    Hawes RH: Diagnostic and therapeutic uses of ERCP in pancreatic and biliary tract malignancies. Gastrointest Endosc 2002;56:S201–S205.CrossRefPubMedGoogle Scholar
  4. 4.
    Jakobs R, Riemann JF: The role of endoscopy in acute recurrent and chronic pancreatitis and pancreatic cancer. Gastroenterol Clin North Am 1999;28:783–800, xii.CrossRefPubMedGoogle Scholar
  5. 5.
    Gilinsky NH, Bornman PC, Girdwood AH, Marks IN: Diagnostic yield of endoscopic retrograde cholangiopancreatography in carcinoma of the pancreas. Br J Surg 1986;73:539–543.CrossRefPubMedGoogle Scholar
  6. 6.
    Menges M, Lerch MM, Zeitz M: The double duct sign in patients with malignant and benign pancreatic lesions. Gastrointest Endosc 2000;52:74–77.CrossRefPubMedGoogle Scholar
  7. 7.
    Kalady MF, Peterson B, Baillie J, et al.: Pancreatic duct strictures: identifying risk of malignancy. Ann Surg Oncol 2004;11:581–588.CrossRefPubMedGoogle Scholar
  8. 8.
    Shah SA, Movson J, Ransil BJ, Waxman I: Pancreatic duct stricture length at ERCP predicts tumor size and pathological stage of pancreatic cancer. Am J Gastroenterol 1997;92:964–967.PubMedGoogle Scholar
  9. 9.
    Freeny PC, Bilbao MK, Katon RM: “Blind” evaluation of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of pancreatic carcinoma: the “double duct” and other signs. Radiology 1976;119:271–274.PubMedGoogle Scholar
  10. 10.
    Ralls PW, Halls J, Renner I, Juttner H: Endoscopic retrograde cholangiopancreatography (ERCP) in pancreatic disease: a reassessment of the specificity of ductal abnormalities indifferentiating benign from malignant disease. Radiology 1980;134:347–352.PubMedGoogle Scholar
  11. 11.
    Kim HJ, Kim MH, Lee SK, Yoo KS, Seo DW, Min YI: Tumor vessel: a valuable cholangioscopic clue of malignant biliary stricture. Gastrointest Endosc 2000;52:635–638.CrossRefPubMedGoogle Scholar
  12. 12.
    Gabor Elel TG, Eszter Schafer, et al.: Early diagnosis of pancreatobiliary duct malignancies by brush cytology and biopsy. Pathol Oncol Res 2005;11:145–155.CrossRefGoogle Scholar
  13. 13.
    Logrono R, Kurtycz DF, Molina CP, Trivedi VA, Wong JY, Block KP: Analysis of false-negative diagnoses on endoscopic brush cytology of biliary and pancreatic duct strictures: the experience at 2 university hospitals. Arch Pathol Lab Med 2000;124:387–392.PubMedGoogle Scholar
  14. 14.
    Venu RP, Geenen JE, Kini M, et al.: Endoscopic retrograde brush cytology. A new technique. Gastroenterology 1990;99:1475–1479.PubMedGoogle Scholar
  15. 15.
    Pugliese V, Barone D, Saccomanno S, Conio M, Aste H, Santi L: Tissue sampling from the common bile duct through endoscopic retrograde cholangiopancreatography, endoscopic papillo(sphinctero)tomy and drainage in juxtapapillary malignancies. Surg Endosc 1987;1:83–87.CrossRefPubMedGoogle Scholar
  16. 16.
    Farrell RJ, Jain AK, Brandwein SL, Wang H, Chuttani R, Pleskow DK: The combination of stricture dilation, endoscopic needle aspiration, and biliary brushings significantly improves diagnostic yield from malignant bile duct strictures. Gastrointest Endosc 2001;54:587–594.CrossRefPubMedGoogle Scholar
  17. 17.
    Fogel EL, deBellis M, McHenry L, et al.: Effectiveness of a new long cytology brush in the evaluation of malignant biliary obstruction: a prospective study. Gastrointest Endosc 2006;63:71–77.CrossRefPubMedGoogle Scholar
  18. 18.
    Ryan ME: Cytologic brushings of ductal lesions during ERCP. Gastrointest Endosc 1991;37:139–142.CrossRefPubMedGoogle Scholar
  19. 19.
    Elek G, Gyokeres T, Schafer E, Burai M, Pinter F, Pap A: Early diagnosis of pancreatobiliary duct malignancies by brush cytology and biopsy. Pathol Oncol Res 2005;11:145–155.CrossRefPubMedGoogle Scholar
  20. 20.
    Glasbrenner B, Ardan M, Boeck W, Preclik G, Moller P, Adler G: Prospective evaluation of brush cytology of biliary strictures during endoscopic retrograde cholangiopancreatography. Endoscopy 1999;31:712–717.CrossRefPubMedGoogle Scholar
  21. 21.
    Lee JG, Leung JW, Baillie J, Layfield LJ, Cotton PB: Benign, dysplastic, or malignant – making sense of endoscopic bile duct brush cytology: results in 149 consecutive patients. Am J Gastroenterol 1995;90:722–726.PubMedGoogle Scholar
  22. 22.
    Pugliese V, Conio M, Nicolo G, Saccomanno S, Gatteschi B: Endoscopic retrograde forceps biopsy and brush cytology of biliary strictures: a prospective study. Gastrointest Endosc 1995;42:520–526.CrossRefPubMedGoogle Scholar
  23. 23.
    Sawada Y, Gonda H, Hayashida Y: Combined use of brushing cytology and endoscopic retrograde pancreatography for the early detection of pancreatic cancer. Acta Cytol 1989;33:870–874.PubMedGoogle Scholar
  24. 24.
    Brand B, Thonke F, Obytz S, et al.: Stent retriever for dilation of pancreatic and bile duct strictures. Endoscopy 1999;31:142–145.CrossRefPubMedGoogle Scholar
  25. 25.
    Parasher VK, Huibregtse K: Endoscopic retrograde wire-guided cytology of malignant biliary strictures using a novel scraping brush. Gastrointest Endosc 1998;48:288–290.CrossRefPubMedGoogle Scholar
  26. 26.
    Jailwala J, Fogel EL, Sherman S, et al.: Triple-tissue sampling at ERCP in malignant biliary obstruction. Gastrointest Endosc 2000;51:383–390.CrossRefPubMedGoogle Scholar
  27. 27.
    Rustgi AK, Kelsey PB, Guelrud M, Saini S, Schapiro RH: Malignant tumors of the bile ducts: diagnosis by biopsy during endoscopic cannulation. Gastrointest Endosc 1989;35:248–251.CrossRefPubMedGoogle Scholar
  28. 28.
    Shah RJ, Langer DA, Antillon MR, Chen YK: Cholangioscopy and cholangioscopic forceps biopsy in patients with indeterminate pancreaticobiliary pathology. Clin Gastroenterol Hepatol 2006;4:219–225.CrossRefPubMedGoogle Scholar
  29. 29.
    Sugiyama M, Atomi Y, Wada N, Kuroda A, Muto T: Endoscopic transpapillary bile duct biopsy without sphincterotomy for diagnosing biliary strictures: a prospective comparative study with bile and brush cytology. Am J Gastroenterol 1996;91:465–467.PubMedGoogle Scholar
  30. 30.
    Kubota Y, Takaoka M, Tani K, et al.: Endoscopic transpapillary biopsy for diagnosis of patients with pancreaticobiliary ductal strictures. Am J Gastroenterol 1993;88:1700–1704.PubMedGoogle Scholar
  31. 31.
    Almoguera C, Shibata D, Forrester K, Martin J, Arnheim N, Perucho M: Most human carcinomas of the exocrine pancreas contain mutant c-K-ras genes. Cell 1988;53:549–554.CrossRefPubMedGoogle Scholar
  32. 32.
    Barkin JS: Diagnostic approach to pancreatic cancer. Gastroenterol Clin North Am 1999;28:709–722.CrossRefPubMedGoogle Scholar
  33. 33.
    Liu F, Li ZS, Xu GM, et al.: Detection of K-ras gene mutation at codon 12 by pancreatic duct brushing for pancreatic cancer. Hepatobiliary Pancreat Dis Int 2003;2:313–317.PubMedGoogle Scholar
  34. 34.
    Van Laethem JL, Vertongen P, Deviere J, et al.: Detection of c-Ki-ras gene codon 12 mutations from pancreatic duct brushings in the diagnosis of pancreatic tumours. Gut 1995;36:781–787.CrossRefPubMedGoogle Scholar
  35. 35.
    Yan L, McFaul C, Howes N, et al.: Molecular analysis to detect pancreatic ductal adenocarcinoma in high-risk groups. Gastroenterology 2005;128:2124–2130.CrossRefPubMedGoogle Scholar
  36. 36.
    Schutte M, Hruban RH, Geradts J, et al.: Abrogation of the Rb/p16 tumor-suppressive pathway in virtually all pancreatic carcinomas. Cancer Res 1997;57:3126–3130.PubMedGoogle Scholar
  37. 37.
    Satake K, Chung YS, Yokomatsu H, et al.: A clinical evaluation of various tumor markers for the diagnosis of pancreatic cancer. Int J Pancreatol 1990;7:25–36.PubMedGoogle Scholar
  38. 38.
    Hess V, Glimelius B, Grawe P, et al.: CA 19–9 tumour-marker response to chemotherapy in patients with advanced pancreatic cancer enrolled in a randomised controlled trial. Lancet Oncol 2008;9:132–138.CrossRefPubMedGoogle Scholar
  39. 39.
    Zhou GX, Huang JF, Zhang H, Chen JP: Diagnosis of pancreatic cancer by cytology and telomerase activity in exfoliated cells obtained by pancreatic duct brushing during endoscopy. Hepatobiliary Pancreat Dis Int 2007;6:308–311.PubMedGoogle Scholar
  40. 40.
    Engelken FJ, Bettschart V, Rahman MQ, Parks RW, Garden OJ: Prognostic factors in the palliation of pancreatic cancer. Eur J Surg Oncol 2003;29:368–373.CrossRefPubMedGoogle Scholar
  41. 41.
    Chen VK, Arguedas MR, Baron TH: Expandable metal biliary stents before pancreaticoduodenectomy for pancreatic cancer: a Monte-Carlo decision analysis. Clin Gastroenterol Hepatol 2005;3:1229–1237.CrossRefPubMedGoogle Scholar
  42. 42.
    Wasan SM, Ross WA, Staerkel GA, Lee JH: Use of expandable metallic biliary stents in resectable pancreatic cancer. Am J Gastroenterol 2005;100:2056–2061.CrossRefPubMedGoogle Scholar
  43. 43.
    Kimura Y, Takada T, Kawarada Y, et al.: Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo guidelines. J Hepatobiliary Pancreat Surg 2007;14:15–26.CrossRefPubMedGoogle Scholar
  44. 44.
    Lee CC, Chang IJ, Lai YC, Chen SY, Chen SC: Epidemiology and prognostic determinants of patients with bacteremic cholecystitis or cholangitis. Am J Gastroenterol 2007;102:563–569.CrossRefPubMedGoogle Scholar
  45. 45.
    Huibregtse K, Katon RM, Coene PP, Tytgat GN: Endoscopic palliative treatment in pancreatic cancer. Gastrointest Endosc 1986;32:334–338.CrossRefPubMedGoogle Scholar
  46. 46.
    Smith AC, Dowsett JF, Russell RC, Hatfield AR, Cotton PB: Randomised trial of endoscopic stenting versus surgical bypass in malignant low bileduct obstruction. Lancet 1994;344:1655–1660.CrossRefPubMedGoogle Scholar
  47. 47.
    Speer AG, Cotton PB, Russell RC, et al.: Randomised trial of endoscopic versus percutaneous stent insertion in malignant obstructive jaundice. Lancet 1987;2:57–62.CrossRefPubMedGoogle Scholar
  48. 48.
    Artifon EL, Sakai P, Cunha JE, et al.: Surgery or endoscopy for palliation of biliary obstruction due to metastatic pancreatic cancer. Am J Gastroenterol 2006;101:2031–2037.CrossRefPubMedGoogle Scholar
  49. 49.
    Bories E, Pesenti C, Caillol F, Lopes C, Giovannini M: Transgastric endoscopic ultrasonography-guided biliary drainage: results of a pilot study. Endoscopy 2007;39:287–291.CrossRefPubMedGoogle Scholar
  50. 50.
    Luman W, Cull A, Palmer KR: Quality of life in patients stented for malignant biliary obstructions. Eur J Gastroenterol Hepatol 1997;9:481–484.PubMedGoogle Scholar
  51. 51.
    Sherman S: Endoscopic palliation of malignant bile duct obstruction: Improvement in quality of life (abstract). Gastrointest Endosc 1996;43:AB321.Google Scholar
  52. 52.
    Ballinger AB, McHugh M, Catnach SM, Alstead EM, Clark ML: Symptom relief and quality of life after stenting for malignant bile duct obstruction. Gut 1994;35:467–470.CrossRefPubMedGoogle Scholar
  53. 53.
    Abraham NS, Barkun JS, Barkun AN: Palliation of malignant biliary obstruction: a prospective trial examining impact on quality of life. Gastrointest Endosc 2002;56:835–841.CrossRefPubMedGoogle Scholar
  54. 54.
    Speer AG, Cotton PB, MacRae KD: Endoscopic management of malignant biliary obstruction: stents of 10 French gauge are preferable to stents of 8 French gauge. Gastrointest Endosc 1988;34:412–417.CrossRefPubMedGoogle Scholar
  55. 55.
    Pereira-Lima JC, Jakobs R, Maier M, Benz C, Kohler B, Riemann JF: Endoscopic biliary stenting for the palliation of pancreatic cancer: results, survival predictive factors, and comparison of 10-French with 11.5-French gauge stents. Am J Gastroenterol 1996;91:2179–2184.PubMedGoogle Scholar
  56. 56.
    Matsuda Y, Shimakura K, Akamatsu T: Factors affecting the patency of stents in malignant biliary obstructive disease: univariate and multivariate analysis. Am J Gastroenterol 1991;86:843–849.PubMedGoogle Scholar
  57. 57.
    Das A, Sivak MV, Jr.: Endoscopic palliation for inoperable pancreatic cancer. Cancer Control 2000;7:452–457.PubMedGoogle Scholar
  58. 58.
    Prat F, Chapat O, Ducot B, et al.: A randomized trial of endoscopic drainage methods for inoperable malignant strictures of the common bile duct. Gastrointest Endosc 1998;47:1–7.CrossRefPubMedGoogle Scholar
  59. 59.
    Davids PH, Groen AK, Rauws EA, Tytgat GN, Huibregtse K: Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction. Lancet 1992;340:1488–1492.CrossRefPubMedGoogle Scholar
  60. 60.
    Kaassis M, Boyer J, Dumas R, et al.: Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study. Gastrointest Endosc 2003;57:178–182.CrossRefPubMedGoogle Scholar
  61. 61.
    Knyrim K, Wagner HJ, Pausch J, Vakil N: A prospective, randomized, controlled trial of metal stents for malignant obstruction of the common bile duct. Endoscopy 1993;25:207–212.CrossRefPubMedGoogle Scholar
  62. 62.
    Carr-Locke DL, Ball TJ, Connes PJ, Cotton PB, Geenen JE, Hawes RH, et al.: Multicenter, randomised trial of Wallstent biliary endoprosthesis versus plastic stents. (abstract). Gastrointest Endosc 1993;39:310.Google Scholar
  63. 63.
    Moses PL, Alan BN, Gordon SR, Mitty RD, Branch MS, Kowalski TE: A randomized multicenter trial comparing plastic to covered metal stents for the palliation of lower malignant biliary obstruction. Gastrointest Endosc 2006;63:AB289.CrossRefGoogle Scholar
  64. 64.
    Rosch T, Schinner S: Comparison of three different plastic stents for malignant biliary obstruction (abstract). Endoscopy 1997;29:E51.CrossRefGoogle Scholar
  65. 65.
    Soderlund C, Linder S: Covered metal versus plastic stents for malignant common bile duct stenosis: a prospective, randomized, controlled trial. Gastrointest Endosc 2006;63:986–995.CrossRefPubMedGoogle Scholar
  66. 66.
    Kahaleh M, Tokar J, Conaway MR, et al.: Efficacy and complications of covered Wallstents in malignant distal biliary obstruction. Gastrointest Endosc 2005;61:528–533.CrossRefPubMedGoogle Scholar
  67. 67.
    Moss AC, Morris E, Leyden J, MacMathuna P: Do the benefits of metal stents justify the costs? A systematic review and meta-analysis of trials comparing endoscopic stents for malignant biliary obstruction. Eur J Gastroenterol Hepatol 2007;19:1119–1124.CrossRefPubMedGoogle Scholar
  68. 68.
    DeWitt J, Kahaleh M: The Role of endoscopy in the evaluation of suspected pancreatic malignancy. In Clinical Update American Society for Gastrointestinal Endoscopy, Richard C.K. Wong (ed). 2008;16:1–4.Google Scholar
  69. 69.
    Yeoh KG, Zimmerman MJ, Cunningham JT, Cotton PB: Comparative costs of metal versus plastic biliary stent strategies for malignant obstructive jaundice by decision analysis. Gastrointest Endosc 1999;49:466–471.Clinical Update American Society for Gastrointestinal EndoscopyCrossRefPubMedGoogle Scholar
  70. 70.
    Arguedas MR, Heudebert GH, Stinnett AA, Wilcox CM: Biliary stents in malignant obstructive jaundice due to pancreatic carcinoma: a cost-effectiveness analysis. Am J Gastroenterol 2002;97:898–904.CrossRefPubMedGoogle Scholar
  71. 71.
    Srikureja W, Chang KJ: Endoscopic palliation of pancreatic adenocarcinoma. Curr Opin Gastroenterol 2005;21:601–605.CrossRefPubMedGoogle Scholar
  72. 72.
    Moparty B, Carr-Locke DL: Metal or plastic stent for malignant biliary obstruction: what’s got the most bang for your buck? Eur J Gastroenterol Hepatol 2007;19:1041–1042.CrossRefPubMedGoogle Scholar
  73. 73.
    Carr-Locke DL: Metal stents for distal biliary malignancy: have we got you covered? Gastrointest Endosc 2005;61:534–536.CrossRefPubMedGoogle Scholar
  74. 74.
    Telford JJ, Carr-Locke DL, Baron TH, et al.: Palliation of patients with malignant gastric outlet obstruction with the enteral Wallstent: outcomes from a multicenter study. Gastrointest Endosc 2004;60:916–920.CrossRefPubMedGoogle Scholar
  75. 75.
    Adler Y, Wiser I, Vaturi M, et al.: Association between electrocardiographic pattern and level of C-reactive protein in patients with first anterior wall acute myocardial infarction. Cardiology 2002;97:122–126.CrossRefPubMedGoogle Scholar
  76. 76.
    Morris-Stiff G, Hassn A, Young WT: Self-expanding metal stents for duodenal obstruction in advanced pancreatic adenocarcinoma. HPB (Oxford) 2008;10:134–137.Google Scholar
  77. 77.
    Wassef W, Syed I: Designer stents: are we there yet? Gastrointest Endosc 2007;66:804–808.CrossRefPubMedGoogle Scholar
  78. 78.
    Meng B, Wang J, Zhu N, Meng QY, Cui FZ, Xu YX: Study of biodegradable and self-expandable PLLA helical biliary stent in vivo and in vitro. J Mater Sci Mater Med 2006;17:611–617.CrossRefPubMedGoogle Scholar
  79. 79.
    Suk KT, Kim JW, Kim HS, et al.: Human application of a metallic stent covered with a paclitaxel-incorporated membrane for malignant biliary obstruction: multicenter pilot study. Gastrointest Endosc 2007;66:798–803.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Folasade P. May
    • 1
    • 3
  • Field F. Willingham
    • 1
    • 2
    • 3
  • David L. Carr-Locke
    • 1
    • 3
  1. 1.Department of Medicine, Gastrointestinal Unit, Massachusetts General HospitalHarvard Medical SchoolBostonUSA
  2. 2.Department of Medicine, Division of Gastroenterology, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA
  3. 3.Director of the Endoscopy Institute, Brigham and Women’s HospitalDivision of GastroenterologyBostonUSA

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