Clin Endosc.  2018 May;51(3):229-234. 10.5946/ce.2018.063.

Future Perspectives on Endoscopic Ultrasonography-Guided Therapy for Pancreatic Neoplasm

• Paik WH
• Lee SH
• Jang S

• KMID: 2414863
• DOI: http://doi.org/10.5946/ce.2018.063

Abstract

Endoscopic ultrasonography (EUS)-guided therapy with ethanol injection or catheter-based radiofrequency ablation for pancreatic neoplasm has been conducted as a potential alternate treatment modality for patients who are not eligible for surgery. On the basis of the limited number of studies available, EUS-guided ablation therapy with the aforementioned methods for small pancreatic neoplasms has demonstrated promising technical feasibility and safety profiles. To be considered as a legitimate alternative option to surgery, however, EUS-guided ablation therapy must provide a long-term efficacy profile along with the consensus among experts regarding its treatment parameter. This review focuses on the clinical issues and future perspectives of EUS-guided therapy for pancreatic neoplasm.

Keyword

EUS; Pancreatic neoplasms; Treatment outcome; Contraindications; Ethanol

MeSH Terms

Catheter Ablation
Consensus
Endosonography
Ethanol
Humans
Pancreatic Neoplasms*
Treatment Outcome
Ethanol

Figure

• 

  Fig. 1. A 77-year-old man with a pancreatic head cyst. (A) Computed tomography (CT) scan showing a 38-mm cystic lesion in the pancreatic head (white arrow), suspected as having communication with the pancreatic duct (white arrowhead). (B) Endoscopic retrograde pancreatic drainage with a 9-cm, 5-F, single pigtail plastic stent was performed to prevent procedure-related pancreatitis, and then endoscopic ultrasonography-guided ablation therapy was performed with 99% ethanol. (C) After the procedure, complicated fluid collection with pancreatitis-associated phlegmon and ascites along the right paracolic gutter was observed, and a percutaneous drainage tube was inserted. (D) CT scan showing improvement of the complicated fluid collection.

• 

  Fig. 2. A 58-year-old man with a pancreatic neuroendocrine tumor (PNET). (A) Computed tomography (CT) scan showing a 13-mm enhancing nodular lesion with an exophytic feature (white arrow) in the pancreatic body without dilation of the main pancreatic duct. (B) Endoscopic ultrasonography-guided ablation therapy for PNET (white arrowhead) was performed, and 0.6 mL of 99% ethanol was injected in the lesion. (C) A long perfusion decrement of the pancreatic body (lines) on the CT scan obtained 2 days after the procedure. (D) Follow-up CT scan showing improvement of the walled-off necrosis with 2-cm loculated fluid collection (black arrow) at the previous ablation site.

Reference

1. de Jong K, Nio CY, Hermans JJ, et al. High prevalence of pancreatic cysts detected by screening magnetic resonance imaging examinations. Clin Gastroenterol Hepatol. 2010; 8:806–811.

2. Laffan TA, Horton KM, Klein AP, et al. Prevalence of unsuspected pancreatic cysts on MDCT. AJR Am J Roentgenol. 2008; 191:802–807.

3. Dasari A, Shen C, Halperin D, et al. Trends in the incidence, prevalence, and survival outcomes in patients with neuroendocrine tumors in the United States. JAMA Oncol. 2017; 3:1335–1342.

4. Haynes AB, Deshpande V, Ingkakul T, et al. Implications of incidentally discovered, nonfunctioning pancreatic endocrine tumors: short-term and long-term patient outcomes. Arch Surg. 2011; 146:534–538.

5. Han J, Chang KJ. Endoscopic ultrasound-guided direct intervention for solid pancreatic tumors. Clin Endosc. 2017; 50:126–137.

6. Lee SH. [Endoscopic treatment for pancreatic cystic lesions]. Korean J Gastroenterol. 2018; 71:10–17.

7. Choi JH, Lee SH, Choi YH, et al. Clinical outcomes of endoscopic ultrasound-guided ethanol ablation for pancreatic cystic lesions compared with the natural course: a propensity score matching analysis. Therap Adv Gastroenterol. 2018; 11:1756284818759929.

8. Lee LS, Andersen DK, Ashida R, et al. EUS and related technologies for the diagnosis and treatment of pancreatic disease: research gaps and opportunities-summary of a national institute of diabetes and digestive and kidney diseases workshop. Gastrointest Endosc. 2017; 86:768–778.

9. Gómez V, Takahashi N, Levy MJ, et al. EUS-guided ethanol lavage does not reliably ablate pancreatic cystic neoplasms (with video). Gastrointest Endosc. 2016; 83:914–920.

10. Oh HC, Seo DW, Song TJ, et al. Endoscopic ultrasonography-guided ethanol lavage with paclitaxel injection treats patients with pancreatic cysts. Gastroenterology. 2011; 140:172–179.

11. Oh HC, Seo DW, Lee TY, et al. New treatment for cystic tumors of the pancreas: EUS-guided ethanol lavage with paclitaxel injection. Gastrointest Endosc. 2008; 67:636–642.

12. Park JK, Song BJ, Ryu JK, et al. Clinical outcomes of endoscopic ultrasonography-guided pancreatic cyst ablation. Pancreas. 2016; 45:889–894.

13. Choi JH, Seo DW, Song TJ, et al. Long-term outcomes after endoscopic ultrasound-guided ablation of pancreatic cysts. Endoscopy. 2017; 49:866–873.

14. DeWitt JM, Al-Haddad M, Sherman S, et al. Alterations in cyst fluid genetics following endoscopic ultrasound-guided pancreatic cyst ablation with ethanol and paclitaxel. Endoscopy. 2014; 46:457–464.

15. Levy MJ, Thompson GB, Topazian MD, Callstrom MR, Grant CS, Vella A. US-guided ethanol ablation of insulinomas: a new treatment option. Gastrointest Endosc. 2012; 75:200–206.

16. Park DH, Choi JH, Oh D, et al. Endoscopic ultrasonography-guided ethanol ablation for small pancreatic neuroendocrine tumors: results of a pilot study. Clin Endosc. 2015; 48:158–164.

17. Yang D, Inabnet WB 3rd, Sarpel U, DiMaio CJ. EUS-guided ethanol ablation of symptomatic pancreatic insulinomas. Gastrointest Endosc. 2015; 82:1127.

18. Paik WH, Seo DW, Dhir V, Wang HP. Safety and efficacy of EUS-guided ethanol ablation for treating small solid pancreatic neoplasm. Medicine (Baltimore). 2016; 95:e2538.

19. Paik WH, Seo DW. Echoendoscopic ablative therapy for solid pancreatic tumors. J Dig Dis. 2017; 18:135–142.

20. Cho MK, Choi JH, Seo DW. Endoscopic ultrasound-guided ablation therapy for pancreatic cysts. Endosc Ultrasound. 2015; 4:293–298.

21. Lee LS, Wu BU, Banks PA, et al. Utility of commercial DNA analysis in detecting malignancy within pancreatic cysts. JOP. 2013; 15:182–188.

22. Correa-Gallego C, Ferrone CR, Thayer SP, Wargo JA, Warshaw AL, Fernández-Del Castillo C. Incidental pancreatic cysts: do we really know what we are watching? Pancreatology. 2010; 10:144–150.

23. Chiang AL, Lee LS. Clinical approach to incidental pancreatic cysts. World J Gastroenterol. 2016; 22:1236–1245.

24. Jang DK, Song BJ, Ryu JK, et al. Preoperative diagnosis of pancreatic cystic lesions: the accuracy of endoscopic ultrasound and cross-sectional imaging. Pancreas. 2015; 44:1329–1333.

25. Del Chiaro M, Segersvärd R, Pozzi Mucelli R, et al. Comparison of preoperative conference-based diagnosis with histology of cystic tumors of the pancreas. Ann Surg Oncol. 2014; 21:1539–1544.

26. Park JS, Seo DW, Song TJ, et al. Endoscopic ultrasound-guided ablation of branch-duct intraductal papillary mucinous neoplasms: feasibility and safety tests using porcine gallbladders. Dig Endosc. 2016; 28:599–606.

27. Kim MK. Endoscopic ultrasound in gastroenteropancreatic neuroendocrine tumors. Gut Liver. 2012; 6:405–410.

28. Nanno Y, Matsumoto I, Zen Y, et al. Pancreatic duct involvement in well-differentiated neuroendocrine tumors is an independent poor prognostic factor. Ann Surg Oncol. 2017; 24:1127–1133.

29. Canellas R, Burk KS, Parakh A, Sahani DV. Prediction of pancreatic neuroendocrine tumor grade based on CT features and texture analysis. AJR Am J Roentgenol. 2018; 210:341–346.

30. Gan SI, Thompson CC, Lauwers GY, Bounds BC, Brugge WR. Ethanol lavage of pancreatic cystic lesions: initial pilot study. Gastrointest Endosc. 2005; 61:746–752.

31. Matthes K, Mino-Kenudson M, Sahani DV, Holalkere N, Brugge WR. Concentration-dependent ablation of pancreatic tissue by EUS-guided ethanol injection. Gastrointest Endosc. 2007; 65:272–277.

32. Caillol F, Poincloux L, Bories E, et al. Ethanol lavage of 14 mucinous cysts of the pancreas: a retrospective study in two tertiary centers. Endosc Ultrasound. 2012; 1:48–52.

33. DiMaio CJ, DeWitt JM, Brugge WR. Ablation of pancreatic cystic lesions: the use of multiple endoscopic ultrasound-guided ethanol lavage sessions. Pancreas. 2011; 40:664–668.

34. DeWitt J, McGreevy K, Schmidt CM, Brugge WR. EUS-guided ethanol versus saline solution lavage for pancreatic cysts: a randomized, double-blind study. Gastrointest Endosc. 2009; 70:710–723.

35. Vazquez-Sequeiros E, Maluf-Filho F. Endosonography-guided ablation of pancreatic cystic tumors: is it justified? Gastrointest Endosc. 2016; 83:921–923.

36. Armellini E, Crinò SF, Ballarè M, Occhipinti P. Endoscopic ultrasound-guided radiofrequency ablation of a pancreatic neuroendocrine tumor. Endoscopy. 2015; 47 Suppl 1 UCTN:E600–E601.

37. Pai M, Habib N, Senturk H, et al. Endoscopic ultrasound guided radiofrequency ablation, for pancreatic cystic neoplasms and neuroendocrine tumors. World J Gastrointest Surg. 2015; 7:52–59.

38. Lakhtakia S, Ramchandani M, Galasso D, et al. EUS-guided radiofrequency ablation for management of pancreatic insulinoma by using a novel needle electrode (with videos). Gastrointest Endosc. 2016; 83:234–239.

39. Moyer MT, Sharzehi S, Mathew A, et al. The safety and efficacy of an alcohol-free pancreatic cyst ablation protocol. Gastroenterology. 2017; 153:1295–1303.

40. Lakhtakia S, Seo DW. Endoscopic ultrasonography-guided tumor ablation. Dig Endosc. 2017; 29:486–494.

41. Oh HC, Seo DW, Kim SC. Portal vein thrombosis after EUS-guided pancreatic cyst ablation. Dig Dis Sci. 2012; 57:1965–1967.

42. Silviu UB, Daniel P, Claudiu M, et al. Endoscopic ultrasound-guided radiofrequency ablation of the pancreas: an experimental study with pathological correlation. Endosc Ultrasound. 2015; 4:330–335.

43. Girelli R, Frigerio I, Salvia R, Barbi E, Tinazzi Martini P, Bassi C. Feasibility and safety of radiofrequency ablation for locally advanced pancreatic cancer. Br J Surg. 2010; 97:220–225.

44. Nakai Y, Iwashita T, Park DH, Samarasena JB, Lee JG, Chang KJ. Diagnosis of pancreatic cysts: EUS-guided, through-the-needle confocal laser-induced endomicroscopy and cystoscopy trial: DETECT study. Gastrointest Endosc. 2015; 81:1204–1214.

45. Attili F, Pagliari D, Rimbaș M, et al. Endoscopic ultrasound-guided histological diagnosis of a mucinous non-neoplastic pancreatic cyst using a specially designed through-the-needle microforceps. Endoscopy. 2016; 48 Suppl 1:E188–E189.

46. Karia K, Waxman I, Konda VJ, et al. Needle-based confocal endomicroscopy for pancreatic cysts: the current agreement in interpretation. Gastrointest Endosc. 2016; 83:924–927.