## Investigation of Choice for Pancreatic Cancer Tissue Diagnosis **Key Point:** EUS-FNA is the gold standard for obtaining tissue diagnosis in pancreatic cancer, especially lesions in the pancreatic head, with sensitivity >85% and specificity >95%. ### Why EUS-FNA is Superior 1. **High diagnostic yield**: Real-time ultrasound visualization allows precise needle placement into the lesion 2. **Safety**: Minimal risk of pancreatitis or peritoneal seeding compared to percutaneous approaches 3. **Staging capability**: Can assess local invasion, vascular involvement, and regional lymph nodes in a single procedure 4. **Tissue quality**: Provides adequate material for histopathology and immunohistochemistry 5. **Accessibility**: Ideal for pancreatic head lesions (most common site) ### Comparison of Diagnostic Modalities | Investigation | Sensitivity | Specificity | Role | Limitation | |---|---|---|---|---| | **EUS-FNA** | 85–95% | 95–100% | Gold standard for tissue diagnosis | Operator-dependent; limited availability | | **CT-guided biopsy** | 80–90% | 95–100% | Alternative for distal pancreatic lesions | Risk of pancreatitis; requires percutaneous approach | | **MRCP** | N/A | N/A | Biliary obstruction assessment, NOT tissue diagnosis | Diagnostic imaging only | | **ERCP + brush cytology** | 30–50% | High | Therapeutic (biliary stent) + diagnostic | Low sensitivity for tissue; mainly therapeutic | **High-Yield:** In a patient with imaging findings suggestive of pancreatic cancer and a need for tissue confirmation, EUS-FNA is the first-line investigation. ERCP is reserved for therapeutic biliary drainage when jaundice is present, not for primary diagnosis. **Clinical Pearl:** The combination of EUS-FNA for diagnosis + staging CT/MRI for metastatic disease assessment is the standard workup pathway in pancreatic cancer. [cite:Harrison 21e Ch 297]
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