Role of endoscopic ultrasound in primary staging and vascular assessment of pancreatic cancer

Role of endoscopic ultrasound in primary staging and vascular assessment of pancreatic cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Role of endoscopic ultrasound in primary staging and vascular assessment of pancreatic cancer Mohammed Ali Ahmed El-Nady, Mustafa Ahmed Haridy, Amro Metwally Hassan, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2415814/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: computed tomography (CT) of the abdomen with contrast is the gold standard method for primary evaluation of pancreatic cancer as regard to staging and vascular assessment. however, not all patients can be evaluated by contrast enhanced CT abdomen as those with allergy to the contrast agent, pregnancy, renal impairment, in addition to hazards of radiation and non-availability of tissue sampling in CECT abdomen .so this study was designed to evaluate the diagnostic ability of Endoscopic Ultrasound for staging and vascular assessment of pancreatic cancer in comparison to CT abdomen with contrast. Method: fifty patients with cancer pancreas were evaluated by EUS as regard staging and vascular invasion. Vascular assessment was done by dividing the EUS findings into three types in accordance with the relationship between tumors and major vessels, type 1, clear invasion, encasement of vessel by a tumor or tumor that contact a vessel wall more than 180 o ; type2, Abutment, a tumor that contacts a vessel wall but less than 180 o and type 3, clear non-invasion, existence of distance between a tumor and a vessel. We regarded types 1 and type 2 as signs of vascular invasion and types 3 as sign of vascular non-invasion, these findings were compared with the findings of CT abdomen with contrast. The endoscopist was blind to CT result before EUS examination. Result: as regard to staging of pancreatic cancer EUS showed sensitivity, specificity and accuracy of 100% for all. and as regard vascular invasion EUS showed sensitivity, specificity and accuracy of 100% ,95.93% and 96% respectively for venous invasion and 95.65% ,100% and 99.5% for arterial invasion. Conclusion: EUS can evaluate staging and vascular invasion of pancreatic cancer with very high sensitivity, specificity and accuracy to the extend it can replace CT in primary evaluation, with superiority of EUS due to tissue sampling. CT Abdomen EUS Vascular invasion Pancreatic cancer Figures Figure 1 Figure 2 Figure 3 Introduction cancer pancreas is one of abdominal tumors with very bad prognosis. Five-year survival rate doesn’t exceed 10% 1 . It is the sixth common cancer and the third cause of cancer related deaths in the USA and the seventh leading cause worldwide 2 . In absence of metastatic lesions, Surgical resection of the tumor with safety margins is the only curative treatment up till now, but unfortunately the tumor is usually diagnosed at late stage of the disease and surgery could be performed in very limited cases 3 . The size of the tumor is not deciding factor in surgical resection of pancreatic cancer but the presence of metastasis or the invasion of adjacent major vessels (including the common hepatic artery CHA, superior mesenteric artery SMA, superior mesenteric artery, portal vein SMV, portal vein PV, Celiac artery CA, splenic artery SPA and splenic vein SPV) significantly affect the possibility of resection 4 . Although computed tomography with intravenous contrast is now the gold standard for primary staging of pancreatic cancer, some patients cannot be assessed by CT abdomen with contrast due to allergy to the contrast agent, renal impairment and pregnancy 5 . EUS is an endoscopic imaging which provides in detail and high-resolution imaging of the pancreas compared with CT through the addition of an ultrasound transducer on endoscope. It can give accurate image without harmful nephrotoxic contrast 6 . Endoscopic ultrasonography is essential in the diagnosis by tissue sampling (FNA or FNB) and in the loco-regional staging of pancreatic cancer. The progress in EUS techniques make it an important tool in the management, staging and vascular evaluation of pancreatic cancer 7 . However, there is no consensus on the role of EUS in primary assessment of pancreatic cancer 5 . So that this study was designed to examine the diagnostic ability of endoscopic ultrasonography (EUS) for staging and major vascular invasion in pancreatic cancer in comparisons to CECT abdomen. Patients And Methods Study design: Cross section study. Methods: The study was conducted on fifty patients with proved pancreatic cancer by Histopathological examination, selected from ninety-three patients suggested to have pancreatic focal lesion by abdominal ultrasound referred to Al-Ibrashi endoscopy unit at Cairo university Hospital in the period from January 2020 to march 2022 (Excluding the period from March 2020 to September 2020, when the Internal Medicine Hospital at Cairo university was converted into an isolation hospital of Covid 19 patients ) where they were subjected to: 1. History and clinical examination. 2. Routine lab investigations include: AST, ALT, serum bilirubin, INR after a mid-night fast, as well as fasting blood sugar and, complete blood count, and renal function. 3. Tumor marker as CEA and CA19.9. 4. EUS examinations was performed by using: 7.5 MHz endoscope Pentax FG 38UX and Hitachi ultrasound EUB 525. All EUS examinations were performed under general anesthesia FNAB was taken from pancreatic neoplasm to confirm malignancy by Echo tip 22 gauge or 19 gauge according to availability of the needle. and Locoregional staging was performed according to the general rules of American Joint Committee on Cancer 8 th edition. We divided the EUS findings into three types in accordance with the relationship between tumors and major vessels, type 1, clear invasion, encasement of vessel by a tumor or tumor that contact a vessel wall more than 180 o ; type2, Abutment, a tumor that contacts a vessel wall but less than 180 o and type 3, clear non-invasion, existence of distance between a tumor and a vessel. We regarded types 1 and type 2 as signs of vascular invasion and types 3 as signs of vascular non-invasion 8 We evaluated PV, SMV, HA, CA and SMA for tumors in the pancreatic head, and splenic vein (SPV) and splenic artery (SPA) for tumors in the pancreatic body or tail. In each case, both the main arteries and veins was evaluated. The endoscopist was blind to CT result before EUS examination. 5. Abdominal contrast-enhanced computed tomography scanning was done by using muti-detector scanning with a 16 channel multi-detector CT scanner: GE CT/Bright speed Elite scanner (General Electric medical system) with I.V contrast injected by automatic pump injector. We compared between EUS findings and Abdominal contrast-enhanced computed tomography findings -which is gold standard in pancreatic neoplasm staging- as regard staging and vascular invasion Inclusion criteria : Included patient who had pancreatic cancer confirmed by FNAB and 18 years old or more. Exclusion criteria : Patient was excluded from this study if they were: age under 18 years. Gastric surgery. Pregnant or breastfeeding women; History of radiation therapy or chemotherapy. Any contraindication for CT abdomen with contrast as chronic renal failure or allergy to contrast material. Negative FNAB for malignancy. Ethics consideration: -The study is conducted in accordance with Helsinki standards as revised in 2013 and approved by the ethics committee of Al-Azhar-Assiut Faculty of Medicine. -Before any data was collected, each patient was informed about the study's purpose. -Those who agreed to participate in the research provided verbal and written consent. - The data's privacy was guaranteed. Statistical analysis: The collected data were revised, organized, tabulated and statistically analyzed using Statistical analysis of statistical package for social sciences (SPSS) for windows. (Version 2 6 , produced by IBM SPSS Inc., Chicago, USA). Categorical variables were reported as number and percentages and continuous variables, as Mean ± standard deviation (SD), medians and range. Student t test (two-tailed) and paired t test were used to compare continuous data. Fisher’s exact test and Qi square test were used to compare categorical data. The sensitivity, specificity, NPV, PPV and accuracy of EUS diagnosis for vascular invasion were calculated by using Excel program. Results The study was conducted at Cairo University Hospital in the period from January 2020 to march 2022. Where 93 patients with suspected pancreatic tumor underwent EUS evaluation. Thirty-nine patients were excluded from the study due to non-malignant pancreatic lesion by histopathology, and four patients were excluded from the study due to failure of CT to detect pancreatic lesion. Only 50 patients, who met the criteria of the study were included. Our results showed: Table (1): Demographic characteristics of the studied patients: Total N=50 Parameters All cases N=50 Minimal Maximal Age (years) Mean + SD 62 . 32 ± 7 .82 46 78 Gender: N % Male 36 72% Female 14 28% Smoking: N % Non-smoker 18 36% Smoker 32 64% The age of the studied patients was ( 62 . 32 ± 7 .82) years, The majority of them were male (72%) and (64%) of them were smokers. The main complaint of the studied patients: The main clinical presentation of the studied patients was obstructive jaundice by 66% then abdominal pain by 22%. Table (2): Laboratory data of the studied patients: Total N=50 Parameters Mean + SD Range Mean SD Minimum Maximum ALT(U/L) 69.31 66.78 12 276 AST(U/L) 66.78 62.4 12 267 Total Bilirubin(mg/dL) 8.74 7.82 0.41 26.5 Direct Bilirubin(mg/dL) 7.16 6.75 0.20 21.6 Urea (mg/dL) 40.25 13.78 17 76 Creatinine(mg/dL) 1.22 0.24 0.5 1.7 INR 1.10 0.13 1 1.34 RBG (mg/dL) 114.0 31.09 86 230 HB (g/dL) 12.52 1.84 9.6 17.5 RBC (10 6 /mm 3 ) 4.92 0.75 3.77 6.8 MCV (fl) 82.63 11.06 53 102 PLT (10 3 /mm 3 ) 255.57 69.36 112 416 WBC (10 3 /mm 3 ) 9.25 3.29 4.01 17.0 CEA (ng/dL) 14.56 18.54 2.1 76.0 CA19.9 (U/mL) 163.55 186.18 7.0 659 Laboratory investigation of the studied patients presented as mean ± standard deviation and median and range. The Site of pancreatic cancer in the studied patients: The site of pancreatic cancer in studied patients: (92%) of pancreatic cancer were in the Head and (8%) of pancreatic cancer were in the body. Table (3) Size of pancreatic cancer in the studied patients: Total N (50) Size by CT Size by EUS P.value 35.52 + 14.47 mm 35 (18-90) mm 36.26 + 14.38 mm 35 (18-90) mm 0.089 NS +Data are presented as mean ± standard deviation, median and range. *Independent t-test was used. The size of pancreatic cancer (largest dimension) of the studied patients and there was no significant difference between CT and EUS in Measuring the size of pancreatic cancer. Histological type of the studied patients: Table (4) Stage of pancreatic tumor of studied patients: Total Number (50) TNM Staging By CT By EUS P.value T T1 7 5 0.083NS T2 24 25 T3 6 7 T4 13 13 N N0 13 13 0.99NS N1 22 22 N2 15 15 M M0 42 42 0.99NS M1 8 8 IA 5 5 0.99NS IB 7 7 IIA 1 1 IIB 21 21 III 8 8 IV 8 8 +Data are presented as frequency (discrete numbers) * Independent sample t-test was used This table showed the TNM staging of studied patients according to AJCC 8th edition by using CT and EUS which showed no significance difference between them as regard staging or grading, also EUS can stage pancreatic cancer with 100% accuracy. Table (5) Respectability by CT and EUS: Resectability CT EUS p.value Resectable 21 20 0.86NS Borderline resectable 16 16 Non resectable 12 13 This table showed that there was no significant difference between CT and EUS as regard final decision of the pancreatic cancer management. Table (6) Diagnostic Accuracy of EUS in venous invasion after correction of veins number: EUS V CT V Diagnostic potential (%) Venous invasion No venous invasion Total Sensitivity 100% (27/27) Specificity 95.93% (118/123) Venous invasion 27 5 32 PPV 84.38% (27/32) No venous invasion 0 118 118 NPV 100% (118/118) Total 27 123 150 Accuracy 96% (145/150) This table showed the corrected (after correction of veins by considering every vein as separate case) diagnostic ability of EUS for evaluation of venous invasion in pancreatic cancer with sensitivity 100%, sensitivity 95.93%, positive predictive value 84.38%, negative predictive value 100% and Accuracy 96% compared to CT the gold standard for vascular evaluation in cancer pancreas. Table (7) diagnostic Accuracy of EUS in Arterial invasion after correction of Artery number: EUS A CT A Diagnostic potential (%) Arterial invasion No Arterial invasion Total Sensitivity 95.65% (22/23) Specificity 100% (177/177) Arterial invasion 22 0 22 PPV 100% (22/22) No Arteria invasion 1 177 178 NPV 99.44% (177/178) Total 23 177 200 Accuracy 99.5% (199/200) This table showed the corrected (after correction of arteries by considering every artery as separate case) diagnostic ability of EUS for evaluation of Arterial invasion in pancreatic cancer with sensitivity 95.65%, sensitivity 100%, positive predictive value 100%, negative predictive value 99.44% and Accuracy 99.5% compared to CT the gold standard for vascular evaluation in cancer pancreas. Discussion Pancreatic cancer is one of the most aggressive malignant tumors, with a 5-year survival rate of about 10% in the United States of America (USA) 9 . Approximately 80–85% of pancreatic cancer cases are diagnosed in late stage, when the patients can no longer benefit from curative surgery. In a small proportion of individuals, pancreatic cancer is diagnosed in a localized stage, when surgical treatment is possible and recommended. In this situation, the 5-year survival rate can reach up to 20% 1 . Accurate evaluation of vascular invasion in patients with pancreatic cancer is very important to determine the resectability of pancreatic cancer and to predict the prognosis. Although CT with IV contrast is currently the “gold standard” for preoperative staging of pancreatic cancer, not all patients can be evaluated by CT with IV contrast, because a few patients have allergy to the contrast agent, and some patients have decreased renal function 4 . Approximately 0.6% of patients experience allergic reactions on administration of iodinated contrast medium. EUS can accurately evaluate pancreatic cancer without using contrast agent 5 . Our study was conducted was conducted at Cairo University Hospital in the period from January 2020 to march 2022 on 50 patients with cancer pancreas with Age 62 . 32 ± 7 .82 y ranged from 46 y to 78 y ,72% of them were males and 64% of them were smoker which agree with Gohar et al who studied cancer pancreatic patients in Clinical Oncology Department at Menoufia University, Egypt and found that their age 59.27 ± 9.26 y with (35-76) years age range , male predominance by 69.7% and 59.2% of them were smoker 10 . Fujii et al ., examined 57 patients with cancer pancreas their main age were 70 with [IQR, 65–74] years) and male predomince 58% 5 . Dahiya et al did a national survey from 2008 to 2017 in USA and found that In 2008, a slight female predominance was noted (51.9 vs 48.1%, p < 0.0001); however, in 2017, a slight male predominance was observed (50.9 vs 49.1%,p < 0.0001). 11 Cai et al showed that cancer pancreas mainly occurs in elderly individuals with a median age of 70 years at diagnosis, with neglectable percent diagnosed before the age of 55 years 12 . Dahiya et al found that the 65-79 age group had the highest hospitalizations by pancreatic cancer with an increasing percent from 41.6% in 2008 to 45.9% in 2017 (p < 0.0001). 11 . Matsuda explained why Pancreatic cancer more common in elder as they may have age-related pancreatic morphological and pathological changes such as telomere dysfunction 13 Also, Lugo and his colleges showed that cancer pancreas increase in smokers and that pancreatic cancer risk sharply increases even with a low number of cigarettes or after a few years of smoking and that it rapidly decreases a few years after cessation, although it takes almost 20 years to reach that of never smokers which agree with our result 14 . As regard the clinical presentation of pancreatic cancer obstructive jaundice was the main by 66% then abdominal pain by 22 %, but Gohar et al showed that the main complaint in his studied patients were abdominal pain by 75% then obstructive jaundice by 21.1% and this may attriputed to small sample size in each study , 50 vs 72 10 . In our study the site of pancreatic cancer was mainly in the head of pancreas by 92% and the body 8% which were in accordance with Gohar et al .,2018 as 82.9% were in the head and 11.8% were in the body but Fujii and his colleges find that 54.4% of cases were cancer head pancreas and 31.5% of cases were cancer body pancreas 5 . In our study the tumor size were 35 (18-90) mm in contrary with Fujii the size of tumor were 26 (18–33) mm 5 . In our study the common histological type was Ductal adenocarcinoma by 94% which agree with Fujii as ductal adenocarcinoma were the domintat histological type by 92.1% 5 . In our study there were 5 patients with grade IA, 7 patients with grade IB ,1 patient with grade IIA , 21 patients with grade IIB,8 patients with grade III and 8 patients with grade IV while 5 there were 13 patients with grade IA, 18 patients with grade IB ,22 patient with grade IIA , 3 patients with grade IIB,1 patient with grade III and 0 patients with grade IV but in Gohar et al there were 5 patients with grade I,12 patient with grade II,8 patients with grade III and 51patients with grade IV As regard of Resectability in our study 20 patients were resectable ) 40% ( but in Gohar et al only 18 patients were resectable 24% 10 . As regard to the diagnostic ability of EUS of venous invasion our study showed that EUS has high sensitivity, specificity, positive predictive value negative predictive value, and accuracy of venous invasion by 100%, 95.93%, 84.38%, 100%, 96% respectively, which is comparable to ( Fujii et al., 2019) sensitivity, specificity, positive predictive value negative predictive value, and accuracy was 89%, 92% , 84% , 95%, and 91% , respectively, for the major vein invasion 5 . As regard the diagnostic ability of Arterial invasion by EUS our study showed that EUS has high sensitivity, specificity, positive predictive value negative predictive value, and accuracy of Arterial invasion by 95.65%, 100%, 100%, 99.44%, 99.5% respectively, which also comparable to ( Fujii et al., 2019) sensitivity, specificity, positive predictive value negative predictive value, and accuracy was 83%, 94% , 63% , 98%, and 93% , respectively, for the major Arterial invasion. Limitation: The current study acknowledge limitation include: small sample size and using Al-Ibrashi Unit and Internal Medicine Hospital at Cairo University as an isolation hospital during the covid19 pandemic which decrease the number of cases. Another limitation of the study was the need to compare the result of EUS and CT with surgical findings in resectable cases. Conclusion EUS can evaluate staging and vascular invasion of pancreatic cancer with very high sensitivity specificity and accuracy to the extend it may can replace CT in primary evaluation, with superiority of EUS due to tissue sampling and no harmful contrast. Declarations Conflicts of Interest: The authors have no financial conflicts of interest . References Tonini V, Zanni M. Pancreatic cancer in 2021: What you need to know to win. World J Gastroenterol. 2021;27(35):5851–89. Gupta S, Sharma G, Sharma N, et al. Umbilical Nodule Metastasis from Unknown Primary: Diagnostic and Therapeutic Dilemma. Surgery journal (New York, NY). 2022;8(2):e127-e130. Siegel RL, Miller KD, Jemal A. Cancer statistics. 2020. CA: A Cancer Journal for Clinicians. 2020;70(1):7–30. Pekarek L, Fraile-Martinez O, Garcia-Montero C, et al. Towards an updated view on the clinical management of pancreatic adenocarcinoma: Current and future perspectives (Review). Oncology Letters. 2021;22(5). Fujii Y, Matsumoto K, Kato H, et al. Diagnostic Ability of Convex-Arrayed Endoscopic Ultrasonography for Major Vascular Invasion in Pancreatic Cancer. Clin Endosc. 2019;52(5):479–85. Yousaf MN, Chaudhary FS, Ehsan A, et al. Endoscopic ultrasound (EUS) and the management of pancreatic cancer. BMJ Open Gastroenterol. 2020;7(1). Zakaria A, Al-Share B, Klapman JB, et al. The Role of Endoscopic Ultrasonography in the Diagnosis and Staging of Pancreatic Cancer. Cancers. 2022;14(6):1373. Amin MB, Greene FL, Edge SB, et al. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more “personalized” approach to cancer staging. Cancer J Clin. 2017;67(2):93–9. Gheorghe G, Diaconu CC, Ionescu V, et al. Risk Factors for Pancreatic Cancer: Emerging Role of Viral Hepatitis. J Pers Med. 2022;12(1):83. Gohar S, Megahid F, Rizk M, et al. Clinical Outcome of Exocrine Pancreatic Adenocarcinoma: A Single Center Experience. Res Oncol. 2017;13(2):33–9. Dahiya DS, Inamdar S, Perisetti A, et al. Decreasing length of stay and inpatient mortality associated with pancreatic cancer hospitalizations: A United States national survey from 2008 to 2017. Pancreatology: official journal of the International Association of Pancreatology. 2022;22(5):590–7. Cai J, Chen H, Lu M, et al. Advances in the epidemiology of pancreatic cancer: Trends, risk factors, screening, and prognosis. Cancer Lett. 2021;520:1–11. Matsuda Y. Age-related morphological changes in the pancreas and their association with pancreatic carcinogenesis. Pathol Int. 2019;69(8):450–62. Lugo A, Peveri G, Bosetti C, et al. Strong excess risk of pancreatic cancer for low frequency and duration of cigarette smoking: A comprehensive review and meta-analysis. Eur J Cancer. 2018;104:117–26. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2415814","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":163156392,"identity":"35ace949-499b-4456-a489-42f9a0d3a575","order_by":0,"name":"Mohammed Ali Ahmed El-Nady","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"Ali Ahmed","lastName":"El-Nady","suffix":""},{"id":163156395,"identity":"6f81ec0b-0d7d-4985-95aa-fa53a56497c6","order_by":1,"name":"Mustafa Ahmed 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patients\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-2415814/v1/2df0aa988cbf1685a744c624.png"},{"id":30906590,"identity":"9aa1d2f4-fadf-48c9-93b9-625aef866429","added_by":"auto","created_at":"2022-12-29 21:39:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":17923,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe Site of pancreatic cancer in the studied patients.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-2415814/v1/84d081c43dd45be36e491d97.png"},{"id":30906591,"identity":"c5760faf-ea7b-47ae-b46a-995f38230c43","added_by":"auto","created_at":"2022-12-29 21:39:07","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":31814,"visible":true,"origin":"","legend":"\u003cp\u003eshowed The Histological Type of pancreatic cancer in studied patients, the majority of them were Ductal adenocarcinoma (94%).\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-2415814/v1/59eb65acfeb6c2474b154a3c.png"},{"id":32253877,"identity":"2269a96a-d7ca-4a40-b4d5-51b85d0e9f8b","added_by":"auto","created_at":"2023-01-31 07:29:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":594138,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2415814/v1/eb671a70-f600-42a7-afe5-5c522869a4b3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Role of endoscopic ultrasound in primary staging and vascular assessment of pancreatic cancer","fulltext":[{"header":"Introduction","content":"\u003cp\u003ecancer pancreas is one of abdominal tumors with very bad prognosis. Five-year survival rate doesn\u0026rsquo;t exceed 10%\u003csup\u003e1\u003c/sup\u003e. It is the sixth common cancer and the third cause of cancer related deaths in the USA and the seventh leading cause worldwide\u003csup\u003e2\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn absence of metastatic lesions, Surgical resection of the tumor with safety margins \u0026nbsp; is the only curative treatment up till now, but unfortunately the tumor is usually diagnosed at late stage of the disease and surgery could be performed in very limited cases\u003csup\u003e3\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe size of the tumor is not\u0026nbsp;deciding\u0026nbsp;factor\u0026nbsp;in surgical resection of pancreatic cancer but the presence of metastasis or the invasion of adjacent major vessels (including the common hepatic artery CHA, superior mesenteric artery SMA, superior mesenteric artery, portal vein SMV, portal vein PV, Celiac artery CA, splenic artery SPA and splenic vein SPV) significantly affect the possibility of resection\u003csup\u003e4\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAlthough computed tomography with intravenous contrast is now the gold standard for primary staging of pancreatic cancer, some patients cannot be assessed by CT abdomen with contrast due to allergy to the contrast agent, renal impairment and pregnancy\u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eEUS is an endoscopic imaging which provides in detail and high-resolution imaging of the pancreas compared with CT through the addition of an ultrasound transducer on endoscope. It can give accurate image without harmful \u0026nbsp;nephrotoxic contrast\u003csup\u003e6\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eEndoscopic ultrasonography is essential in the diagnosis by tissue sampling (FNA or FNB) and in the loco-regional staging of pancreatic cancer. The progress in EUS techniques make it an important tool in the management, staging and vascular evaluation of pancreatic cancer\u003csup\u003e7\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eHowever, there is no consensus on the role of EUS in primary assessment of pancreatic cancer\u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eSo that this study was designed to examine the diagnostic ability of endoscopic ultrasonography (EUS) for staging and major vascular invasion in pancreatic cancer in comparisons to CECT abdomen.\u0026nbsp;\u003c/p\u003e"},{"header":"Patients And Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eStudy design:\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e Cross section study. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eMethods:\u003c/u\u003e\u003c/strong\u003e The study was conducted on fifty patients with proved pancreatic cancer by Histopathological examination, selected from ninety-three patients suggested to have pancreatic focal lesion by abdominal ultrasound referred to Al-Ibrashi endoscopy \u0026nbsp; \u0026nbsp;unit \u0026nbsp; at Cairo university Hospital in the period from January 2020 to march 2022 (Excluding the period from March 2020 to September 2020, when the Internal Medicine Hospital at Cairo university was converted into an isolation hospital of Covid 19 patients ) where they were subjected to:\u003c/p\u003e\n\u003cp\u003e1. History and clinical examination.\u003c/p\u003e\n\u003cp\u003e2. Routine lab investigations include: \u0026nbsp;AST, ALT, serum bilirubin, INR after a mid-night fast, as well as fasting blood sugar and, complete blood count, and renal function.\u003c/p\u003e\n\u003cp\u003e3. Tumor marker as CEA and CA19.9.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4. EUS examinations was performed by using: 7.5 MHz endoscope Pentax FG 38UX and Hitachi ultrasound EUB 525. All EUS examinations were performed under general anesthesia FNAB was taken from pancreatic neoplasm to confirm malignancy by Echo tip 22 gauge or 19 gauge according to availability of the needle. and \u0026nbsp; Locoregional staging was performed according to the general rules of American Joint Committee on Cancer 8\u003csup\u003eth\u003c/sup\u003e edition. We divided the EUS findings into three types in accordance with the relationship between tumors and major vessels, type 1, clear invasion, encasement of vessel by a tumor or tumor that contact a vessel wall more than 180\u003csup\u003eo\u003c/sup\u003e; type2, Abutment, a tumor that contacts a vessel wall but less than 180\u003csup\u003eo\u003c/sup\u003e and type 3, clear non-invasion, existence of distance between a tumor and a vessel. We regarded types 1 and type 2 as signs of vascular invasion and types 3 as signs of vascular non-invasion \u003cstrong\u003e\u003csup\u003e8\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe evaluated PV, SMV, HA, CA and SMA for tumors in the pancreatic head, and splenic vein (SPV) and splenic artery (SPA) for tumors in the pancreatic body or tail. In each case, both the main arteries and veins was evaluated. The endoscopist was blind to CT result before EUS examination.\u003c/p\u003e\n\u003cp\u003e5. Abdominal contrast-enhanced computed tomography\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003escanning was done by using muti-detector scanning with a 16 channel multi-detector CT scanner: GE CT/Bright speed Elite scanner (General Electric medical system) with I.V contrast injected by automatic pump injector.\u003c/p\u003e\n\u003cp\u003eWe compared between EUS findings and Abdominal contrast-enhanced computed tomography findings -which is gold standard in pancreatic neoplasm staging- as regard staging and vascular invasion\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eInclusion criteria\u003c/u\u003e\u003c/strong\u003e: Included patient who had pancreatic cancer confirmed by FNAB and 18 years old or more.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eExclusion criteria\u003c/u\u003e\u003c/strong\u003e: Patient was excluded from this study if they were:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eage under 18 years.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eGastric surgery.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePregnant or breastfeeding women;\u003c/li\u003e\n \u003cli\u003eHistory of radiation therapy or chemotherapy.\u003c/li\u003e\n \u003cli\u003eAny contraindication for CT abdomen with contrast as chronic renal failure or allergy to contrast material.\u003c/li\u003e\n \u003cli\u003eNegative FNAB for malignancy.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthics consideration:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e-The study is conducted in accordance with Helsinki standards as revised in 2013 and approved by the ethics committee of Al-Azhar-Assiut Faculty of Medicine.\u003c/p\u003e\n\u003cp\u003e-Before any data was collected, each patient was informed about the study\u0026apos;s purpose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e-Those who agreed to participate in the research provided verbal and written consent.\u003c/p\u003e\n\u003cp\u003e\u003cspan dir=\"RTL\"\u003e-\u003c/span\u003eThe data\u0026apos;s privacy was guaranteed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eStatistical analysis:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The collected data were revised, organized, tabulated and statistically analyzed using Statistical analysis of statistical package for social sciences (SPSS) for windows. (Version 2\u003cspan dir=\"RTL\"\u003e6\u003c/span\u003e, produced by IBM SPSS Inc., Chicago, USA). Categorical variables were reported as number and percentages and continuous\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003evariables, as Mean \u0026plusmn; standard deviation (SD), medians and range.\u0026nbsp;Student t test (two-tailed) and paired t test\u0026nbsp;were used to compare continuous data. Fisher\u0026rsquo;s exact test and Qi square test were used to compare categorical data.\u003c/p\u003e\n\u003cp\u003eThe sensitivity, specificity, NPV, PPV and accuracy of EUS diagnosis\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003efor vascular invasion were calculated by using Excel program.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study was conducted\u0026nbsp;at Cairo University Hospital in the period from January 2020 to march 2022. Where 93 patients with suspected pancreatic tumor underwent EUS evaluation. Thirty-nine patients were excluded from the study due to non-malignant pancreatic lesion by histopathology, and four patients were excluded from the study due to failure of CT to detect pancreatic lesion. Only 50 patients, who met the criteria of the study were included.\u003cstrong\u003e\u003cem\u003e\u003cu\u003e\u0026nbsp;Our results showed:\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (1): Demographic characteristics of the studied patients:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTotal N=50\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" cellspacing=\"0\" width=\"592\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.108108108108105%\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"25.16891891891892%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll cases\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=50\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.95945945945946%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMinimal\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.763513513513512%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaximal\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.108108108108105%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u0026nbsp;\u003c/strong\u003eMean \u003cu\u003e+\u003c/u\u003e SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"25.16891891891892%\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e62\u003c/span\u003e.\u003cspan dir=\"RTL\"\u003e32\u003c/span\u003e\u0026plusmn;\u003cspan dir=\"RTL\"\u003e7\u003c/span\u003e.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.95945945945946%\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.763513513513512%\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.108108108108105%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.655405405405405%\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"41.722972972972975%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.108108108108105%\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.655405405405405%\"\u003e\n \u003cp\u003e72%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"41.722972972972975%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.108108108108105%\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.655405405405405%\"\u003e\n \u003cp\u003e28%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"41.722972972972975%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.108108108108105%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSmoking:\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.655405405405405%\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"41.722972972972975%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.108108108108105%\"\u003e\n \u003cp\u003eNon-smoker\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.655405405405405%\"\u003e\n \u003cp\u003e36%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"41.722972972972975%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.108108108108105%\"\u003e\n \u003cp\u003eSmoker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.513513513513514%\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.655405405405405%\"\u003e\n \u003cp\u003e64%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"41.722972972972975%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eThe age of the studied patients was (\u003cspan dir=\"RTL\"\u003e62\u003c/span\u003e.\u003cspan dir=\"RTL\"\u003e32\u003c/span\u003e\u0026plusmn;\u003cspan dir=\"RTL\"\u003e7\u003c/span\u003e.82) years, The majority of them were male (72%) and (64%) of them were smokers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe main complaint of the studied patients:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe main clinical presentation of the studied patients was obstructive jaundice by 66% then abdominal pain by 22%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (2): Laboratory data of the studied patients:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTotal N=50\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"569\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" width=\"31.514084507042252%\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameters\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"33.62676056338028%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u003cu\u003e+\u003c/u\u003e SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" width=\"34.859154929577464%\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.55242966751918%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.55242966751918%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.06393861892583%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMinimum\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.831202046035806%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaximum\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.403508771929825%\"\u003e\n \u003cp\u003e\u003cstrong\u003eALT(U/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e69.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e66.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.19298245614035%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.719298245614034%\"\u003e\n \u003cp\u003e276\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.403508771929825%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAST(U/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e66.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e62.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.19298245614035%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.719298245614034%\"\u003e\n \u003cp\u003e267\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.403508771929825%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Bilirubin(mg/dL) \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e8.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e7.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.19298245614035%\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.719298245614034%\"\u003e\n \u003cp\u003e26.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.403508771929825%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDirect Bilirubin(mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e7.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e6.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.19298245614035%\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.719298245614034%\"\u003e\n \u003cp\u003e21.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.403508771929825%\"\u003e\n \u003cp\u003e\u003cstrong\u003eUrea (mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e40.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e13.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.19298245614035%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.719298245614034%\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.403508771929825%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCreatinine(mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.19298245614035%\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.719298245614034%\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.403508771929825%\"\u003e\n \u003cp\u003e\u003cstrong\u003eINR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.19298245614035%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.719298245614034%\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.403508771929825%\"\u003e\n \u003cp\u003e\u003cstrong\u003eRBG (mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e114.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e31.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.19298245614035%\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.719298245614034%\"\u003e\n \u003cp\u003e230\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.403508771929825%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHB (g/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e12.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e1.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.19298245614035%\"\u003e\n \u003cp\u003e9.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.719298245614034%\"\u003e\n \u003cp\u003e17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.403508771929825%\"\u003e\n \u003cp\u003e\u003cstrong\u003eRBC (10\u003csup\u003e6\u0026nbsp;\u003c/sup\u003e/mm\u003csup\u003e3\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e4.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.19298245614035%\"\u003e\n \u003cp\u003e3.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.719298245614034%\"\u003e\n \u003cp\u003e6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.403508771929825%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMCV (fl)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e82.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e11.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.19298245614035%\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.719298245614034%\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.403508771929825%\"\u003e\n \u003cp\u003e\u003cstrong\u003ePLT (10\u003csup\u003e3\u003c/sup\u003e/mm\u003csup\u003e3\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e255.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e69.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.19298245614035%\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.719298245614034%\"\u003e\n \u003cp\u003e416\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.403508771929825%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWBC (10\u003csup\u003e3\u0026nbsp;\u003c/sup\u003e/mm\u003csup\u003e3\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e9.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e3.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.19298245614035%\"\u003e\n \u003cp\u003e4.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.719298245614034%\"\u003e\n \u003cp\u003e17.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.403508771929825%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCEA (ng/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e14.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e18.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.19298245614035%\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.719298245614034%\"\u003e\n \u003cp\u003e76.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.403508771929825%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCA19.9 (U/mL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e163.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.842105263157894%\"\u003e\n \u003cp\u003e186.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.19298245614035%\"\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.719298245614034%\"\u003e\n \u003cp\u003e659\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eLaboratory investigation of the studied patients presented as mean \u0026plusmn; standard deviation and median and range.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Site of pancreatic cancer in the studied patients:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe site of pancreatic cancer in studied patients: (92%) of pancreatic cancer were in the Head and (8%) of pancreatic cancer were in the body.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (3) Size of pancreatic cancer in the studied patients:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Total N (50)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eSize by CT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eSize by EUS\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003eP.value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e35.52\u003cu\u003e+\u003c/u\u003e 14.47 mm\u003c/p\u003e\n \u003cp\u003e35 (18-90) mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e36.26\u003cu\u003e+\u003c/u\u003e 14.38 mm\u003c/p\u003e\n \u003cp\u003e35 (18-90) mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e0.089 NS\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e+Data are presented as mean \u0026plusmn; standard deviation, median and range.\u003c/p\u003e\n\u003cp\u003e*Independent t-test was used.\u003c/p\u003e\n\u003cp\u003eThe size of pancreatic cancer (largest dimension) of the studied patients and there was no significant difference between CT and EUS in Measuring the size of pancreatic cancer.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eHistological type of the studied patients:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (4) Stage of pancreatic tumor of studied patients:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eTotal Number (50)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"554\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTNM Staging\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e\u003cstrong\u003eBy CT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e\u003cstrong\u003eBy EUS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP.value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" width=\"13.743218806509946%\"\u003e\n \u003cp\u003e\u003cstrong\u003eT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.39240506329114%\"\u003e\n \u003cp\u003e\u003cstrong\u003eT1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.95479204339964%\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.95479204339964%\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" width=\"24.95479204339964%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.083NS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.58407079646018%\"\u003e\n \u003cp\u003e\u003cstrong\u003eT2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.70796460176991%\"\u003e\n \u003cp\u003e\u003cstrong\u003e24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.70796460176991%\"\u003e\n \u003cp\u003e\u003cstrong\u003e25\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.58407079646018%\"\u003e\n \u003cp\u003e\u003cstrong\u003eT3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.70796460176991%\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.70796460176991%\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.58407079646018%\"\u003e\n \u003cp\u003e\u003cstrong\u003eT4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.70796460176991%\"\u003e\n \u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.70796460176991%\"\u003e\n \u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" width=\"13.743218806509946%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.39240506329114%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.95479204339964%\"\u003e\n \u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.95479204339964%\"\u003e\n \u003cp\u003e\u003cstrong\u003e13\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" width=\"24.95479204339964%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.99NS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.58407079646018%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.70796460176991%\"\u003e\n \u003cp\u003e\u003cstrong\u003e22\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.70796460176991%\"\u003e\n \u003cp\u003e\u003cstrong\u003e22\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.58407079646018%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.70796460176991%\"\u003e\n \u003cp\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.70796460176991%\"\u003e\n \u003cp\u003e\u003cstrong\u003e15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"13.743218806509946%\"\u003e\n \u003cp\u003e\u003cstrong\u003eM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"11.39240506329114%\"\u003e\n \u003cp\u003e\u003cstrong\u003eM0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.95479204339964%\"\u003e\n \u003cp\u003e\u003cstrong\u003e42\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.95479204339964%\"\u003e\n \u003cp\u003e\u003cstrong\u003e42\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"24.95479204339964%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.99NS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"18.58407079646018%\"\u003e\n \u003cp\u003e\u003cstrong\u003eM1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.70796460176991%\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"40.70796460176991%\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.99NS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIIA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIIB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003e21\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003e21\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIII\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e+Data are presented as frequency (discrete numbers)\u003c/p\u003e\n\u003cp\u003e* Independent sample t-test was used\u003c/p\u003e\n\u003cp\u003eThis table showed the TNM staging of studied patients according to AJCC 8th edition by using CT and EUS which showed no significance difference between them as regard staging or grading, also EUS can stage pancreatic cancer with 100% accuracy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (5) Respectability by CT and EUS:\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"672\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"31.25%\"\u003e\n \u003cp\u003eResectability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.75%\"\u003e\n \u003cp\u003e\u003cem\u003eCT\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e\u003cem\u003eEUS\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e\u003cem\u003ep.value\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"31.25%\"\u003e\n \u003cp\u003eResectable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"18.75%\"\u003e\n \u003cp\u003e\u003cem\u003e21\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e\u003cem\u003e20\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e\u003cem\u003e0.86NS\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"41.666666666666664%\"\u003e\n \u003cp\u003eBorderline resectable\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e\u003cem\u003e16\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cem\u003e16\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"41.666666666666664%\"\u003e\n \u003cp\u003eNon resectable\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25%\"\u003e\n \u003cp\u003e\u003cem\u003e12\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"33.333333333333336%\"\u003e\n \u003cp\u003e\u003cem\u003e13\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;This table showed that there was no significant difference between CT and EUS as regard final decision of the pancreatic cancer management.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (6) Diagnostic Accuracy of EUS in venous invasion after correction of veins number:\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"699\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 15.3833%;\" valign=\"top\" width=\"22.889842632331902%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEUS V\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 50.0252%;\" width=\"43.06151645207439%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; CT V\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 15.853%;\" valign=\"top\" width=\"34.04864091559371%\"\u003e\n \u003cp\u003eDiagnostic potential\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 15.6182%;\" width=\"29.900332225913623%\"\u003e\n \u003cp\u003eVenous invasion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 24.308%;\" width=\"38.205980066445186%\"\u003e\n \u003cp\u003eNo venous invasion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 10.099%;\" width=\"31.893687707641195%\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 8.2201%;\" valign=\"top\" width=\"57.38396624472574%\"\u003e\n \u003cp\u003eSensitivity\u003c/p\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.5155%;\" valign=\"top\" width=\"42.61603375527426%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003cp\u003e(27/27)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 8.2201%;\" valign=\"top\" width=\"57.38396624472574%\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eSpecificity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.5155%;\" valign=\"top\" width=\"42.61603375527426%\"\u003e\n \u003cp\u003e95.93%\u003c/p\u003e\n \u003cp\u003e(118/123)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 15.3833%;\" valign=\"top\" width=\"22.922636103151863%\"\u003e\n \u003cp\u003eVenous invasion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.6182%;\" valign=\"top\" width=\"12.893982808022923%\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.308%;\" valign=\"top\" width=\"16.4756446991404%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.099%;\" valign=\"top\" width=\"13.753581661891117%\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.2201%;\" valign=\"top\" width=\"19.484240687679083%\"\u003e\n \u003cp\u003ePPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.5155%;\" valign=\"top\" width=\"14.469914040114613%\"\u003e\n \u003cp\u003e84.38%\u003c/p\u003e\n \u003cp\u003e(27/32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 15.3833%;\" valign=\"top\" width=\"22.922636103151863%\"\u003e\n \u003cp\u003eNo venous invasion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.6182%;\" valign=\"top\" width=\"12.893982808022923%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.308%;\" valign=\"top\" width=\"16.4756446991404%\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.099%;\" valign=\"top\" width=\"13.753581661891117%\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.2201%;\" valign=\"top\" width=\"19.484240687679083%\"\u003e\n \u003cp\u003eNPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.5155%;\" valign=\"top\" width=\"14.469914040114613%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003cp\u003e(118/118)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 15.3833%;\" valign=\"top\" width=\"22.922636103151863%\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15.6182%;\" valign=\"top\" width=\"12.893982808022923%\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24.308%;\" valign=\"top\" width=\"16.4756446991404%\"\u003e\n \u003cp\u003e123\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10.099%;\" valign=\"top\" width=\"13.753581661891117%\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.2201%;\" valign=\"top\" width=\"19.484240687679083%\"\u003e\n \u003cp\u003eAccuracy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.5155%;\" valign=\"top\" width=\"14.469914040114613%\"\u003e\n \u003cp\u003e96%\u003c/p\u003e\n \u003cp\u003e(145/150)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThis table showed the corrected (after correction of veins by considering every vein as separate case) diagnostic ability of EUS for evaluation of venous invasion in pancreatic cancer with sensitivity 100%, sensitivity 95.93%, positive predictive value 84.38%, negative predictive value 100% and Accuracy 96% compared to CT the gold standard for vascular evaluation in cancer pancreas.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (7) diagnostic Accuracy of EUS in Arterial invasion after correction of Artery number:\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"698\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" width=\"22.349570200573066%\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEUS A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" width=\"41.977077363896846%\"\u003e\n \u003cp\u003eCT A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" width=\"35.673352435530084%\"\u003e\n \u003cp\u003eDiagnostic potential\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"16.051660516605168%\"\u003e\n \u003cp\u003eArterial invasion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"20.66420664206642%\"\u003e\n \u003cp\u003eNo Arterial invasion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" width=\"17.343173431734318%\"\u003e\n \u003cp\u003eTotal\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.538745387453876%\"\u003e\n \u003cp\u003eSensitivity\u003c/p\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"21.40221402214022%\"\u003e\n \u003cp\u003e95.65%\u003c/p\u003e\n \u003cp\u003e(22/23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"53.4136546184739%\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eSpecificity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"46.5863453815261%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003cp\u003e(177/177)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"22.349570200573066%\"\u003e\n \u003cp\u003eArterial invasion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.464183381088825%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.045845272206304%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.46704871060172%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.054441260744987%\"\u003e\n \u003cp\u003ePPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.6189111747851%\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003cp\u003e(22/22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"22.349570200573066%\"\u003e\n \u003cp\u003eNo Arteria invasion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.464183381088825%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.045845272206304%\"\u003e\n \u003cp\u003e177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.46704871060172%\"\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.054441260744987%\"\u003e\n \u003cp\u003eNPV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.6189111747851%\"\u003e\n \u003cp\u003e99.44% (177/178)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"22.349570200573066%\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"12.464183381088825%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.045845272206304%\"\u003e\n \u003cp\u003e177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"13.46704871060172%\"\u003e\n \u003cp\u003e200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"19.054441260744987%\"\u003e\n \u003cp\u003eAccuracy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"16.6189111747851%\"\u003e\n \u003cp\u003e99.5%\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(199/200)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThis table showed the corrected (after correction of arteries by considering every artery as separate case) diagnostic ability of EUS for evaluation of Arterial invasion in pancreatic cancer with sensitivity 95.65%, sensitivity 100%, positive predictive value 100%, negative predictive value 99.44% and Accuracy 99.5% compared to CT the gold standard for vascular evaluation in cancer pancreas.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePancreatic cancer is one of the most aggressive malignant tumors, with a 5-year survival rate of about 10% in the United States of America (USA)\u003cstrong\u003e\u003cem\u003e\u003csup\u003e9\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eApproximately 80\u0026ndash;85% of pancreatic cancer cases are diagnosed in late stage, when the patients can no longer benefit from curative surgery. In a small proportion of individuals, pancreatic cancer is diagnosed in a localized stage, when surgical treatment is possible and recommended. In this situation, the 5-year survival rate can reach up to 20%\u003cstrong\u003e\u003cem\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccurate evaluation of vascular invasion in patients with pancreatic cancer is very important to determine the resectability of pancreatic cancer and to predict the prognosis. Although CT with IV contrast is currently the \u0026ldquo;gold standard\u0026rdquo; for preoperative staging of pancreatic cancer, not all patients can be evaluated by CT with IV contrast, because a few patients have allergy to the contrast agent, and some patients have decreased renal function\u003cstrong\u003e\u003cem\u003e\u003csup\u003e4\u003c/sup\u003e.\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eApproximately 0.6% of patients experience allergic reactions on administration of iodinated contrast medium. EUS can accurately evaluate pancreatic cancer without using contrast agent\u003cstrong\u003e\u003cem\u003e\u003csup\u003e5\u003c/sup\u003e.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study was conducted was conducted at Cairo University Hospital in the period from January 2020 to march 2022 on 50 patients with cancer pancreas with Age\u0026nbsp;\u003cspan dir=\"RTL\"\u003e62\u003c/span\u003e.\u003cspan dir=\"RTL\"\u003e32\u003c/span\u003e\u0026plusmn;\u003cspan dir=\"RTL\"\u003e7\u003c/span\u003e.82 y ranged from 46 y to 78 y ,72% of them were males and 64% of them were smoker\u0026nbsp;which agree with \u003cstrong\u003e\u003cem\u003eGohar et al\u0026nbsp;\u003c/em\u003e\u003c/strong\u003ewho studied cancer pancreatic patients in Clinical Oncology Department at Menoufia University, Egypt and found that their age 59.27 \u0026plusmn; 9.26 y with (35-76) years \u0026nbsp;age range , male predominance by 69.7% and 59.2% of them were smoker\u003cstrong\u003e\u003cem\u003e\u003csup\u003e10\u003c/sup\u003e.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFujii et al\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e., examined 57 patients with cancer pancreas their main age were 70 with [IQR, 65\u0026ndash;74] years) and male predomince 58%\u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDahiya et al\u003c/em\u003e\u003c/strong\u003e did a national survey from 2008 to 2017 \u0026nbsp;in USA and found that In 2008, a slight female predominance was noted (51.9 vs 48.1%, p \u0026lt; 0.0001); however, in 2017, a slight male predominance was observed (50.9 vs 49.1%,p \u0026lt; 0.0001).\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003csup\u003e11\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCai et al\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eshowed that cancer pancreas mainly occurs in elderly individuals with a median age of 70 years at diagnosis, with neglectable percent diagnosed before the age of 55 years\u003cstrong\u003e\u003cem\u003e\u003csup\u003e12\u003c/sup\u003e.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDahiya et al\u003c/em\u003e\u003c/strong\u003e found that the 65-79 age group had the highest hospitalizations by pancreatic cancer with an increasing percent from 41.6% in 2008 to 45.9% in 2017 (p \u0026lt; 0.0001).\u003cstrong\u003e\u003cem\u003e\u003csup\u003e11\u003c/sup\u003e.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMatsuda\u003c/em\u003e\u003c/strong\u003e explained why Pancreatic cancer more common in elder as they may \u0026nbsp;have age-related pancreatic morphological and pathological changes such as telomere dysfunction \u003cstrong\u003e\u003cem\u003e\u003csup\u003e13\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAlso, Lugo and his colleges showed that cancer pancreas increase in smokers and that pancreatic cancer risk sharply increases even \u0026nbsp;with a low number of cigarettes or after a few years of smoking and that it rapidly decreases a few years after cessation, although it takes almost 20 years to reach that of never\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003esmokers which agree with our \u0026nbsp; result \u003cstrong\u003e\u003cem\u003e\u003csup\u003e14\u003c/sup\u003e\u003c/em\u003e\u003c/strong\u003e.\u003cstrong\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs regard the clinical presentation of pancreatic cancer\u0026nbsp;\u003cem\u003eobstructive jaundice was the main by 66% then abdominal pain by 22\u003c/em\u003e%, but \u003cstrong\u003e\u003cem\u003eGohar et al\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eshowed that the main complaint in his studied patients were abdominal pain by 75% then obstructive jaundice by 21.1% and this may attriputed to small sample size in each study , 50 vs 72\u003csup\u003e10\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn our study the site of pancreatic cancer was mainly in the head of pancreas by 92% and the body 8% which were in accordance with \u003cstrong\u003e\u003cem\u003eGohar et al .,2018 \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eas 82.9% were in the head and 11.8% were in the body but \u003cstrong\u003e\u003cem\u003eFujii\u003c/em\u003e\u003c/strong\u003e and his colleges find that 54.4% of cases were cancer head pancreas and 31.5% of cases were cancer body pancreas \u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn our study the tumor size were\u0026nbsp;35 (18-90) mm in contrary with\u0026nbsp;\u003cstrong\u003e\u003cem\u003eFujii\u003c/em\u003e\u003c/strong\u003e the size of tumor\u0026nbsp;were 26 (18\u0026ndash;33) mm\u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn our study the common histological type was Ductal adenocarcinoma by 94% which agree with\u0026nbsp;\u003cstrong\u003e\u003cem\u003eFujii\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eas ductal adenocarcinoma were the domintat histological type by 92.1%\u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eIn our study there were 5 patients with grade IA, 7 patients with grade IB ,1 patient with grade IIA , 21 patients with grade IIB,8 patients with grade III and 8 patients with grade IV while\u0026nbsp;\u003csup\u003e5\u003c/sup\u003e there were 13 patients with grade IA, 18 patients with grade IB ,22 patient with grade IIA , 3 patients with grade IIB,1 patient with grade III and 0 patients with grade IV\u0026nbsp;but in\u0026nbsp;\u003cstrong\u003e\u003cem\u003eGohar et al\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e there were 5 patients with grade I,12 patient with grade II,8 patients with grade III and 51patients with grade IV\u003c/p\u003e\n\u003cp\u003eAs regard of Resectability in our study 20 patients were resectable\u003cspan dir=\"RTL\"\u003e)\u003c/span\u003e 40%\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003cspan dir=\"RTL\"\u003e(\u003c/span\u003ebut in\u0026nbsp;\u003cstrong\u003e\u003cem\u003eGohar et al\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eonly 18 patients were resectable 24%\u003csup\u003e10\u003c/sup\u003e\u003cstrong\u003e\u003cem\u003e.\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs regard to the diagnostic ability of EUS of venous invasion our study showed that EUS has high sensitivity, specificity, positive predictive value negative predictive value, and accuracy \u0026nbsp; \u0026nbsp;of venous invasion by 100%, 95.93%,\u0026nbsp;84.38%, 100%, 96% respectively, which is comparable to\u0026nbsp;(\u003cstrong\u003e\u003cem\u003eFujii et al., 2019)\u003c/em\u003e\u003c/strong\u003e sensitivity, specificity, positive predictive value negative predictive value, and accuracy\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003ewas 89%, 92% , 84% , 95%, and 91% , respectively, for the major vein invasion\u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAs regard the diagnostic ability of Arterial invasion by EUS our study showed that EUS has high sensitivity, specificity, positive predictive value negative predictive value, and accuracy \u0026nbsp; \u0026nbsp;of Arterial invasion by 95.65%, 100%,\u0026nbsp;100%, 99.44%, 99.5% respectively, which also comparable to\u0026nbsp;(\u003cstrong\u003e\u003cem\u003eFujii et al., 2019)\u003c/em\u003e\u003c/strong\u003e sensitivity, specificity, positive predictive value negative predictive value, and accuracy\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003ewas 83%, 94% , 63% , 98%, and 93% , respectively, for the major Arterial invasion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitation:\u0026nbsp;\u003c/strong\u003eThe current study acknowledge limitation include: small sample size and using\u0026nbsp;Al-Ibrashi Unit and Internal Medicine Hospital at Cairo University as an isolation hospital during the covid19 pandemic which decrease the number of cases.\u003c/p\u003e\n\u003cp\u003eAnother limitation of the study was the need to compare the result of EUS and CT with surgical findings in resectable cases.\u003c/p\u003e"},{"header":"Conclusion","content":"EUS can evaluate staging and vascular invasion of pancreatic cancer with very high sensitivity specificity and accuracy to the extend it may can replace CT in primary evaluation, with superiority of EUS due to tissue sampling and no harmful contrast."},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e The authors have no financial conflicts of interest\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eTonini V, Zanni M. Pancreatic cancer in 2021: What you need to know to win. World J Gastroenterol. 2021;27(35):5851\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGupta S, Sharma G, Sharma N, et al. Umbilical Nodule Metastasis from Unknown Primary: Diagnostic and Therapeutic Dilemma. Surgery journal (New York, NY). 2022;8(2):e127-e130.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSiegel RL, Miller KD, Jemal A. Cancer statistics. 2020. CA: A Cancer Journal for Clinicians. 2020;70(1):7\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePekarek L, Fraile-Martinez O, Garcia-Montero C, et al. Towards an updated view on the clinical management of pancreatic adenocarcinoma: Current and future perspectives (Review). Oncology Letters. 2021;22(5).\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFujii Y, Matsumoto K, Kato H, et al. Diagnostic Ability of Convex-Arrayed Endoscopic Ultrasonography for Major Vascular Invasion in Pancreatic Cancer. Clin Endosc. 2019;52(5):479\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eYousaf MN, Chaudhary FS, Ehsan A, et al. Endoscopic ultrasound (EUS) and the management of pancreatic cancer. BMJ Open Gastroenterol. 2020;7(1).\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZakaria A, Al-Share B, Klapman JB, et al. The Role of Endoscopic Ultrasonography in the Diagnosis and Staging of Pancreatic Cancer. Cancers. 2022;14(6):1373.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAmin MB, Greene FL, Edge SB, et al. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more \u0026ldquo;personalized\u0026rdquo; approach to cancer staging. Cancer J Clin. 2017;67(2):93\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGheorghe G, Diaconu CC, Ionescu V, et al. Risk Factors for Pancreatic Cancer: Emerging Role of Viral Hepatitis. J Pers Med. 2022;12(1):83.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGohar S, Megahid F, Rizk M, et al. Clinical Outcome of Exocrine Pancreatic Adenocarcinoma: A Single Center Experience. Res Oncol. 2017;13(2):33\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDahiya DS, Inamdar S, Perisetti A, et al. Decreasing length of stay and inpatient mortality associated with pancreatic cancer hospitalizations: A United States national survey from 2008 to 2017. Pancreatology: official journal of the International Association of Pancreatology. 2022;22(5):590\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCai J, Chen H, Lu M, et al. 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Eur J Cancer. 2018;104:117\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"CT Abdomen, EUS, Vascular invasion, Pancreatic cancer","lastPublishedDoi":"10.21203/rs.3.rs-2415814/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2415814/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003ecomputed tomography (CT) of the abdomen with contrast is the gold standard method for primary evaluation of pancreatic cancer as regard to staging and vascular assessment. however, not all patients can be evaluated by contrast enhanced CT abdomen as those with allergy to the contrast agent, pregnancy, renal impairment, in addition to hazards of radiation and non-availability of tissue sampling in CECT abdomen .so this study was designed to evaluate the diagnostic ability of Endoscopic Ultrasound for staging and vascular assessment of pancreatic cancer in comparison to CT abdomen with contrast.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003e fifty patients with cancer pancreas were evaluated by EUS as regard staging and vascular invasion.\u0026nbsp; Vascular assessment was done by dividing the EUS findings into three types in accordance with the relationship between tumors and major vessels, type 1, clear invasion, encasement of vessel by a tumor or tumor that contact a vessel wall more than 180\u003csup\u003eo\u003c/sup\u003e; type2, Abutment, a tumor that contacts a vessel wall but less than 180\u003csup\u003eo\u003c/sup\u003e and type 3, clear non-invasion, existence of distance between a tumor and a vessel. We regarded types 1 and type 2 as signs of vascular invasion and types 3 as sign of vascular non-invasion, these findings were compared with the findings of CT abdomen with contrast. The endoscopist was blind to CT result before EUS examination.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResult: \u003c/strong\u003eas regard to staging of pancreatic cancer EUS showed sensitivity, specificity and accuracy of 100% for all. and as regard vascular invasion EUS showed sensitivity, specificity and accuracy of 100% ,95.93% and 96% respectively for venous invasion and 95.65% ,100% and 99.5% for arterial invasion.\u003cstrong\u003e \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e EUS can evaluate staging and vascular invasion of pancreatic cancer with very high sensitivity, specificity and accuracy to the extend it can replace CT in primary evaluation, with superiority of EUS due to tissue sampling.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Role of endoscopic ultrasound in primary staging and vascular assessment of pancreatic cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-12-29 21:39:02","doi":"10.21203/rs.3.rs-2415814/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8ec5dd69-5448-4d7c-b0d6-26ce7db468c5","owner":[],"postedDate":"December 29th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-01-31T07:29:22+00:00","versionOfRecord":[],"versionCreatedAt":"2022-12-29 21:39:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2415814","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2415814","identity":"rs-2415814","version":["v1"]},"buildId":"oE6Zbj460LM0Up2FdVbMZ","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}