Preoperative Assessment of Solid Pancreatic Lesions Associated with Chronic Pancreatitis

Distinguishing solid pancreatic lesions arising in the background of chronic pancreatitis represents an important diagnostic challenge because mass-forming inflammatory lesions and pancreatic cancer share overlapping clinical, serological, and radiological features and their discrimination might delay the curative treatment. The features of chronic pancreatitis such as fibrosis, calcifications with acoustic shadowing, parenchymal atrophy, and main pancreatic duct abnormalities, may either mimic pancreatic ductal adenocarcinoma or obscure small malignant lesions, thereby limiting the performance of conventional imaging modalities. Surveillance for pancreatic cancer in chronic pancreatitis is recommended only for selected high-risk patients with hereditary pancreatitis; however, in patients with non-hereditary chronic pancreatitis, clinical vigilance for red flags (new-onset diabetes, weight loss, jaundice, rising CA19-9) should prompt urgent imaging diagnosis and tissue acquisition. This review summarizes the current evidence on the diagnostic preoperative assessment of solid pancreatic lesions in chronic pancreatitis, highlighting the roles of computed tomography, magnetic resonance imaging, endoscopic ultrasound, and histopathological assessment. Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) has become the preferred method for tissue diagnosis because of its superior ability to obtain histological core specimens, although the tumors may present low cellularity and the correct targeting is often difficult. False-negative results, or misinterpretation of well-differentiated carcinoma as a benign condition remain real concerns because they delay the appropriate treatment. For these reasons a non-diagnostic biopsy should be interpreted cautiously by a multidisciplinary team especially when the suspicion for cancer is high.