The article by Drs. Levy and Wiersema is an excellent overview of the indications, technical nuances, and efficacy of endoscopic ultrasound in the diagnosis and staging of pancreatic neoplasms. Endoscopic ultrasonography was introduced into the diagnostic armamentarium for gastroenterology approximately 15 years ago. Although the literature suggests a general increase in the utility and experience with endoscopic ultrasound, the technique remains most effective in the hands of experienced experts like Drs. Levy and Wiersema. Their article is a complete and thorough review of the indications and expected accuracy of the technique when evaluating a variety of different pancreatic lesions.
The authors, however, understate the technical expertise required to achieve the level of results summarized in their overview. There is no question that endoscopic ultrasound has become a common procedure used in centers specializing in pancreatic diseases. It must be clearly understood, however, that this is a very operator-dependent technology. The ability to accurately characterize pancreatic masses as inflammatory or neoplastic is very much dependent upon the technical skills of the person performing the endoscopic ultrasound. Similarly, its utility for obtaining tissue biopsy using endoscopic ultrasound fine-needle aspiration (FNA) techniques is directly related to the aggressiveness, experience, and technical competency of the physician performing the study.
Advantages and Limitations
In their review, the authors carefully and appropriately point out the strengths and weaknesses of this technique. One limitation that deserves more attention is the impact that operator inexperience can have on the utility of the procedure when interpreting what often may be ambiguous or equivocal images of complicated pancreatic lesions. This is the most obvious drawback of the procedure, since it needs to be done in centers of excellence by physicians with significant experience and considerable diagnostic skills.
The authors thoroughly review endoscopic ultrasound and its utility in the diagnosis and staging of pancreatic solid mass and cystic lesions. The technique of endoscopic ultrasound has become essential in the characterization and localization of pancreatic islet tumors. As they pointed out, the endoscopic ultrasound’s ability to successfully localize small islet cell tumors imbedded in the substance of the pancreatic parenchyma has diminished the utilization of invasive technology such as venous sampling and angiography.
Cost-Effectiveness
Both of the latter techniques are considerably more expensive than endoscopic ultrasound, and are associated with potential morbidity not found in endoscopic ultrasound. Use of endoscopic ultrasound technology has resulted in significant cost savings in terms of localizing neuroendocrine tumors and assessing resectability of the pancreas.
A 70-year-old man with a history of localized prostate cancer treated with whole-pelvis radiation therapy with a boost to the prostate, in conjunction with androgen deprivation therapy 7 years prior, presented with lower back pain. A bone scan revealed an area of activity in the sacrum. What is the most likely diagnosis?
