A 62-year-old woman from Bangalore undergoes CECT for a 2.8 cm mass in the pancreatic body. The scan shows no vascular involvement, no distant metastases, and regional lymph nodes <1 cm. CA 19-9 is 145 U/mL. She is fit for surgery (ECOG 0). What is the most appropriate next step in management?

Explanation

## Clinical Context This patient has a resectable pancreatic body mass (no vascular involvement, no metastases, fit for surgery). The next step is **tissue diagnosis via EUS-FNA** before committing to major surgery. ## Why Tissue Diagnosis is Essential **Key Point:** Even with radiologically typical pancreatic cancer, tissue confirmation is mandatory before surgery because: - Benign mimics (chronic pancreatitis, focal autoimmune pancreatitis, neuroendocrine tumours) can resemble adenocarcinoma on imaging - Diagnosis changes management (e.g., autoimmune pancreatitis responds to steroids, not surgery) - Histology guides adjuvant therapy decisions **High-Yield:** EUS-FNA is the **gold standard** for tissue diagnosis in pancreatic masses because: 1. High sensitivity (85–95%) and specificity (>95%) [cite:Harrison 21e Ch 297] 2. Real-time ultrasound guidance allows sampling of small lesions 3. Lower morbidity than percutaneous biopsy 4. Can assess vascular invasion and lymph node involvement simultaneously ## Diagnostic Pathway ```mermaid flowchart TD A[Resectable pancreatic mass on CECT]:::outcome --> B[EUS-FNA for tissue diagnosis]:::action B --> C{Adenocarcinoma confirmed?}:::decision C -->|Yes| D[Proceed to distal pancreatectomy + splenectomy]:::action C -->|No| E{Alternative diagnosis?}:::decision E -->|Autoimmune pancreatitis| F[Steroid trial]:::action E -->|Benign| G[Observation or conservative management]:::action D --> H[Adjuvant chemotherapy post-op]:::action ``` **Clinical Pearl:** A tissue diagnosis is not optional—it is the standard of care before pancreatectomy. Proceeding to surgery without histology risks unnecessary major surgery if the lesion is benign or has a different diagnosis.