Interventional endoscopic ultrasonography for pancreatic cancer

Endoscopic Ultrasonography is a Promising Tool for Preoperative Prediction of the Operability of Pancreatic Carcinoma

This work discussed the efficiency of endoscopic ultrasonography (EUS) as a diagnostic modality for early detection of pancreatic cancer. The present study was constructed by doing imaging modalities EUS on 24 patients admitted to surgery department in the faculty of medicine with suspected pancreatic malignancy. Pancreatic cancer was found more in older ages above 55 years predominately in males coming from rural areas presenting with abdominal pain with or without jaundice. Histopathological examination revealed that ductal adenocarcinoma represented by 70.83% of cases. This study also shows significant elevation in serum CA19-9 in the presenting cases to confirm a close relation between cancer pancreas and CA19-9 as a good biochemical marker for PC. EUS was found to be able to detect masses less than 20 mm in diameter. Moreover, EUS can accurately detect the mass nature. EUS showed correct information as regards lymph node involvement and vascular invasion which affected the results of respectability of pancreatic masses. Finally, this study clearly showed that EUS is an accurate pre-operative tool in the assessment of nodal staging, vascular invasion, and respectability in patients with pancreatic adenocarcinoma.

Effects of EUS-guided intratumoral injection of oligonucleotide STNM01 on tumor growth, histology, and overall survival in patients with unresectable pancreatic cancer

BACKGROUND AND AIMS

Carbohydrate sulfotransferase 15 (CHST15) promotes tumor growth and invasion and is considered to be an emergent therapeutic target for pancreatic cancer. The aim of this study was to evaluate the safety and efficacy of EUS-guided fine-needle injection (EUS-FNI) of STNM01, the double-stranded RNA oligonucleotide that specifically represses CHST15, for use in patients with pancreatic cancer.

METHODS

Six patients with unresectable pancreatic cancer, treated at Tokyo Metropolitan Geriatric Hospital, were used in this open-labeled, investigator-initiated trial. A total of 16 mL STNM01 (250 nM) was injected into the tumor through EUS-FNI. The study's primary endpoint was safety, with a secondary endpoint of tumor response 4 weeks after the initial injection. Some patients received a series of infusions as extensions. The local expression of CHST15 and overall survival (OS) were also evaluated.

RESULTS

There were no adverse events. The mean tumor diameter changed from 30.7 to 29.3 mm 4 weeks after injection. Four patients exhibited necrosis of tumor in biopsy specimens. CHST15 was highly expressed at baseline, with 2 patients showing large reductions of CHST15 at week 4. The mean OS of these 2 patients was 15 months, whereas it was 5.7 months for the other 4 patients.

CONCLUSIONS

EUS-FNI of STNM01 in pancreatic cancer is safe and feasible. The CHST15 reduction could predict tumor progression and OS. Injections of STNM01 during the beginning of treatment may reduce CHST15 and warrants further investigation.

Endoscopy-guided ablation of pancreatic lesions: Technical possibilities and clinical outlook

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP)-guided ablation procedures are emerging as a minimally invasive therapeutic alternative to radiological and surgical treatments for locally advanced pancreatic cancer (LAPC), pancreatic neuroendocrine tumours (PNETs), and pancreatic cystic lesions (PCLs). The advantages of treatment under endoscopic control are the real-time imaging guidance and the possibility to reach a deep target like the pancreas. Currently, radiofrequency probes specifically designed for ERCP or EUS ablation are available as well as hybrid cryotherm probe combining radiofrequency with cryotechnology. To date, many reports and case series have confirmed the safety and feasibility of that kind of ablation technique in the pancreatic setting. Moreover, EUS-guided fine-needle injection is emerging as a method to deliver ablative and anti-tumoral agents inside the tumuor. Ethanol injection has been proposed mostly for the treatment of PCLs and for symptomatic functioning PNETs, and the use of gemcitabine and paclitaxel is also interesting in this setting. EUS-guided injection of chemical or biological agents including mixed lymphocyte culture, oncolytic viruses, and immature dendritic cells has been investigated for the treatment of LAPC. Data on the long-term efficacy of these approaches, and large prospective randomized studies are needed to confirm the real clinical benefits of these techniques for the management of pancreatic lesions.

Endoscopic ultrasound-guided biliary drainage: a review

OPINION STATEMENT

Endoscopic retrograde cholangiography (ERCP) has become the standard tool for diagnosis and treatment of patients with biliary obstruction. However, despite the reported success rate of >90 % in expert centers, the common bile duct may still be occasionally inaccessible due to anatomical or technical issues. Over the past decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as an effective alternative over percutaneous transhepatic biliary drainage (PTBD) or surgical bypass for biliary drainage after unsuccessful ERCP. EUS-BD includes rendezvous techniques (EUS-RV), EUS-guided choledochoduodenostomy (EUS-CDS), and EUS-guided hepatogastrostomy (EUS-HGS). Published data demonstrated high success rates especially for EUS-CDS and EUS-HGS. Complication rates, however, are also higher in these two techniques. The indications and anatomical requirements for the three techniques differ and should be considered complementary to each other. Most reported studies only included a small number of patients, and larger-scaled randomized trials are required to establish the efficacy among various EUS techniques and to compare to traditional means of radiological or surgical drainage.

Endoscopic ultrasound in gastroenterology: From diagnosis to therapeutic implications

Since its advent in 1980, the scope of endoscopic ultrasound (EUS) has grown to include a wide range of indications, and it is now being incorporated as an integral part of everyday practice in the field of gastroenterology. Its use is extending from an adjuvant imaging aid to utilization as a therapeutic tool for various gastrointestinal disorders. EUS was first used to visualize remote organs, such as the pancreas and abdominal lymph nodes. When fine needle aspiration was introduced, the indications for EUS expanded to include tissue sampling for diagnostic purposes. At the same time, the needle can be used to convey a potential therapy to the internal organs, allowing access to remote sites. In this review, we aim to highlight the expanding spectrum of EUS indications and uses in the field of gastroenterology.

Role of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography in diagnosis and management of pancreatic cancer; comparison with multidetector row computed tomography, magnetic resonance imaging and endoscopic ultrasonography

OBJECTIVES

We aimed to analyze the contribution of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) imaging to the diagnosis and management of pancreatic cancer compared with multidetector row computed tomography (MDCT), magnetic resonance imaging (MRI) and endoscopic ultrasonography (EUS).

MATERIAL AND METHODS

We retrospectively scanned the data of 52 patients who were referred for FDG PET/CT imaging for evaluation of pancreatic lesions greater than 10mm. The diagnostic performances of 4 imaging methods and the impact of PET/CT on the management of pancreatic cancer were defined.

RESULTS

Pancreatic adenocarcinoma was diagnosed in 33 of 52 patients (63%), 15 patients had benign diseases of pancreas (29%), and 4 patients were normal (8%). Sensitivity and NPV of EUS and PET/CT were equal (100%) and higher than MDCT and MRI. Specificity, PPV and NPV of PET/CT were significantly higher than MDCT. However, sensitivities of two imaging methods were not significantly different. There was no significant difference between PET/CT and MRI and EUS for these values. When the cut-off value of SUVmax was 3.2, the most effective sensitivity and specificity values were obtained. PET/CT contributed to the management of pancreatic cancer in 30% of patients.

CONCLUSION

FDG PET/CT is a valuable imaging method for the diagnosis and management of pancreatic cancer, especially when applied along with EUS as first line diagnostic tools.

Clinical next-generation sequencing successfully applied to fine-needle aspirations of pulmonary and pancreatic neoplasms

BACKGROUND

Next-generation sequencing was performed on pulmonary and pancreatic fine-needle aspirations (FNAs) and on paired FNAs and resected primary tumors from the same patient.

METHODS

DNA was isolated in formalin-fixed, paraffin-embedded cell blocks from 16 pulmonary FNAs, 23 pancreatic FNAs, and 5 resected pancreatic primary tumors. Next-generation sequencing was performed for 4561 exons of 287 cancer-related genes and for 47 introns of 19 genes on indexed, adaptor-ligated, hybridization-captured libraries using a proprietary sequencing system (the Illumina HiSeq 2000).

RESULTS

Genomic profiles were generated successfully from 16 of 16 (100%) pulmonary FNAs, which included 14 nonsmall cell lung cancers (NSCLCs) and 2 small cell lung cancers (SCLCs). The NSCLC group included 6 adenocarcinomas, 5 squamous cell carcinomas, and 3 NSCLCs not otherwise specified. Genomic profiles were successfully obtained from 23 of 23 (100%) pancreatic FNAs and from 5 of 5 (100%) matched pancreatic primary tumors, which included 17 ductal adenocarcinomas, 3 mucinous adenocarcinomas, 2 adenocarcinomas NOS, and 1 neuroendocrine tumor. Eighty-one genomic alterations were identified in the 16 pulmonary FNAs (average, 5.1 genomic alterations per patient); and the most common genomic alterations were TP53, RB1, SOX2, PIK3CA, and KRAS. Eighty-seven genomic alterations were identified in the 23 pancreatic tumor FNAs (average, 3.8 genomic alterations per patient); and the most common genomic alterations were KRAS, TP53, CDKN2A/B, SMAD4, and PTEN. Among the pancreatic tumors, there was 100% concordance of 20 genomic alterations that were identified in 5 patient-matched FNA and surgical primary tumor pairs.

CONCLUSIONS

The authors were able to perform next-generation sequencing reliably on FNAs of pulmonary and pancreatic tumors, and the genomic alterations discovered correlated well with those identified in matched resected pancreatic tumors.

Endoscopic ultrasound-guided oncologic therapy for pancreatic cancer

Since the development of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in the early 1990s, its application has been extended to various diseases. For pancreatic cancer, EUS-FNA can obtain specimens from the tumor itself with fewer complications than other methods. Interventional EUS enables various therapeutic options: local ablation, brachytherapy, placement of fiducial markers for radiotherapy, and direct injection of antitumor agents into cancer. This paper will focus on EUS-guided oncologic therapy for pancreatic cancer.

Endoscopic ultrasound-guided choledochoduodenostomy for malignant lower biliary tract obstruction

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) is a novel alternative to percutaneous transhepatic biliary drainage, when endoscopic retrograde cholangiopancreatography is unsuccessful in patients with malignant lower biliary obstruction. Some case series and a few prospective studies of EUS-CDS have reported high technical and functional success rates but with the downside of high early complication rates, albeit mostly nonsevere. In addition, the stents placed by EUS-CDS had a longer patency than transpapillary biliary stents.

Endoscopic palliation of pancreatic cancer

There is no doubt that our long-range goal is to cure pancreatic cancer. Realistically, most of what we can do currently is treat the disabling symptoms of this dreadful disease. Biliary decompression, intestinal stenting, celiac plexus neurolysis, and fiducial placement are some of the endoscopic procedures that aim to provide better quality of life to patients suffering from this disease. A thorough understanding of these options will help patients make good decisions in choosing the proper treatment. Endoscopists who perform these procedures must possess great skills, but importantly, they must also be compassionate and act with good judgment.