title: Preoperative diagnosis of extrapancreatic neural invasion in pancreatic cancer.
abstract: OBJECTIVE
  Pancreatic cancer recurs in most patients after resection with curative intent. Recurrence is particularly common in patients with extrapancreatic neural invasion (EPNI), the presence of which correlates with poor prognosis. Macroscopic EPNI may be detected with conventional noninvasive imaging and endoscopic ultrasound (EUS) imaging, but microscopic EPNI has required postoperative pathologic examination of surgical specimens. We report the preoperative diagnosis of cancer infiltration into celiac ganglia. We hypothesized that microscopic pancreatic cancer metastasis to neural ganglia can be detected by EUS-guided biopsy examination.
  
  
  METHODS
  We performed a retrospective review of patients with pancreatic cancer undergoing EUS in whom celiac ganglia were sampled to exclude malignant infiltration.
  
  
  RESULTS
  Six patients with pancreatic cancer underwent EUS-guided fine-needle aspiration or trucut biopsy examination of presumed celiac ganglia. Metastatic cancer was found in ganglia of 2 patients. Specimen review identified adenocarcinoma and neural tissue in the absence of lymphocytes. At laparoscopy, 1 of the 2 patients with positive celiac biopsy specimens also had several unexpected peritoneal metastatic deposits. The other patient was considered to have locally advanced unresectable disease. Both patients are receiving supportive care.
  
  
  CONCLUSIONS
  EPNI may be shown preoperatively in patients with pancreatic cancer using EUS-guided sampling of celiac ganglia. A preoperative diagnosis of EPNI has the potential to improve staging accuracy and patient outcomes.
authors.affiliation: Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota 55905, USA. levy.michael@mayo.edu
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Levy
authors.forename: Mark
authors.initials: M
authors.lastname: Topazian
authors.forename: Gary
authors.initials: G
authors.lastname: Keeney
authors.forename: Jonathan E
authors.initials: JE
authors.lastname: Clain
authors.forename: Ferga
authors.initials: F
authors.lastname: Gleeson
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Rajan
authors.forename: Kenneth K
authors.initials: KK
authors.lastname: Wang
authors.forename: Maurits J
authors.initials: MJ
authors.lastname: Wiersema
authors.forename: Michael
authors.initials: M
authors.lastname: Farnell
authors.forename: Suresh
authors.initials: S
authors.lastname: Chari
mesh_terms: D000230:Adenocarcinoma / Q000175:diagnosis / Q000556:secondary* / Q000601:surgery; D000368:Aged; D000369:Aged, 80 and over; D044963:Biopsy, Fine-Needle; D003937:Diagnosis, Differential; D019160:Endosonography; D005260:Female; D005728:Ganglia, Sympathetic; D006801:Humans; D010535:Laparoscopy; D008297:Male; D010190:Pancreatic Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D010524:Peripheral Nervous System Neoplasms / Q000175:diagnosis / Q000556:secondary* / Q000601:surgery; D011300:Preoperative Care / Q000379:methods*; D012189:Retrospective Studies