title: When to perform a pancreatoduodenectomy in the absence of positive histology? A consensus statement by the International Study Group of Pancreatic Surgery.
abstract: BACKGROUND
  Pancreatoduodenectomy (PD) provides the best chance for cure in the treatment of patients with localized pancreatic head cancer. In patients with a suspected, clinically resectable pancreatic head malignancy, the need for histologic confirmation before proceeding with PD has not historically been required, but remains controversial.
  
  
  METHODS
  An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the literature and worked together to establish a consensus on when to perform a PD in the absence of positive histology.
  
  
  RESULTS
  The incidence of benign disease after PD for a presumed malignancy is 5-13%. Diagnosis by endoscopic cholangiopancreatography brushings and percutaneous fine-needle aspiration are highly specific, but poorly sensitive. Aspiration biopsy guided by endoscopic ultrasonography (EUS) has greater sensitivity, but it is highly operator dependent and increases expense. The incidence of autoimmune pancreatitis (AIP) in the benign resected specimens is 30-43%. EUS-guided Trucut biopsy, serum levels of immunoglobulin G4, and HISORt (Histology, Imaging, Serology, Other organ involvement, and Response to therapy) are used for diagnosis. If AIP is suspected but not confirmed, the response to a short course of steroids is helpful for diagnosis.
  
  
  CONCLUSIONS
  In the presence of a solid mass suspicious for malignancy, consensus was reached that biopsy proof is not required before proceeding with resection. Confirmation of malignancy, however, is mandatory for patients with borderline resectable disease to be treated with neoadjuvant therapy before exploration for resection. When a diagnosis of AIP is highly suspected, a biopsy is recommended, and a short course of steroid treatment should be considered if the biopsy does not reveal features suspicious for malignancy.
authors.affiliation: Department of General Surgery, Mayo Clinic, Jacksonville, FL. Electronic address: Asbun.Horacio@mayo.edu.
authors.forename: Horacio J
authors.initials: HJ
authors.lastname: Asbun
authors.affiliation: Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland.
authors.forename: Kevin
authors.initials: K
authors.lastname: Conlon
authors.affiliation: Department of Surgery, Clinic Hospital of Barcelona, University of Barcelona, Barcelona, Spain.
authors.forename: Laureano
authors.initials: L
authors.lastname: Fernandez-Cruz
authors.affiliation: Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany.
authors.forename: Helmut
authors.initials: H
authors.lastname: Friess
authors.affiliation: Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India.
authors.forename: Shailesh V
authors.initials: SV
authors.lastname: Shrikhande
authors.affiliation: Department of HPB Surgery, Hopital Edouard Herriot, Lyon, France.
authors.forename: Mustapha
authors.initials: M
authors.lastname: Adham
authors.affiliation: Department of Surgery and Oncology, Pancreas Institute, University of Verona, Verona, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Bassi
authors.affiliation: Department of General-, Visceral- and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Bockhorn
authors.affiliation: Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
authors.forename: Markus
authors.initials: M
authors.lastname: Büchler
authors.affiliation: Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK.
authors.forename: Richard M
authors.initials: RM
authors.lastname: Charnley
authors.affiliation: Department of First Surgery, Agia Olga Hospital, Athens, Greece.
authors.forename: Christos
authors.initials: C
authors.lastname: Dervenis
authors.affiliation: Department of Digestive Surgery, Centre Hospitalier Intercommunal, Poissy, France.
authors.forename: Abe
authors.initials: A
authors.lastname: Fingerhutt
authors.affiliation: Department of Surgery, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Dirk J
authors.initials: DJ
authors.lastname: Gouma
authors.affiliation: Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
authors.forename: Werner
authors.initials: W
authors.lastname: Hartwig
authors.affiliation: Acacdemic Unit of Surgery, Univesity of Glasgow, Glasgow, UK.
authors.forename: Clem
authors.initials: C
authors.lastname: Imrie
authors.affiliation: Department of General-, Visceral- and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Jakob R
authors.initials: JR
authors.lastname: Izbicki
authors.affiliation: Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
authors.forename: Keith D
authors.initials: KD
authors.lastname: Lillemoe
authors.affiliation: First Surgical Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia.
authors.forename: Miroslav
authors.initials: M
authors.lastname: Milicevic
authors.affiliation: Department of General Surgery, Instituto Clinico Humanitas IRCCS, University of Milan, Milan, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Montorsi
authors.affiliation: Department of Molecular and Clinical Cancer Medicine, Liverpool Cancer Research-UK Centre, University of Liverpool, Liverpool, UK.
authors.forename: John P
authors.initials: JP
authors.lastname: Neoptolemos
authors.affiliation: Department of Surgery, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden.
authors.forename: Aken A
authors.initials: AA
authors.lastname: Sandberg
authors.affiliation: Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Michael
authors.initials: M
authors.lastname: Sarr
authors.affiliation: Department of Gastrointestinal Surgery, Penn Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: Charles
authors.initials: C
authors.lastname: Vollmer
authors.affiliation: Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA.
authors.forename: Charles J
authors.initials: CJ
authors.lastname: Yeo
authors.affiliation: St. Luke's Clinic - Center For Pancreatic and Liver Diseases, Boise, ID.
authors.forename: L William
authors.initials: LW
authors.lastname: Traverso
mesh_terms: D014408:Biomarkers, Tumor / Q000097:blood; D044963:Biopsy, Fine-Needle; D002760:Cholangiopancreatography, Endoscopic Retrograde; D003937:Diagnosis, Differential; D006801:Humans; D007074:Immunoglobulin G / Q000097:blood; D010179:Pancreas / Q000473:pathology*; D010190:Pancreatic Neoplasms / Q000175:diagnosis* / Q000601:surgery*; D016577:Pancreaticoduodenectomy; D010818:Practice Patterns, Physicians'; D011300:Preoperative Care
chemical_list: D014408:Biomarkers, Tumor; D007074:Immunoglobulin G