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Xiao D, Zhu L, Xiong S, Yan X, Jiang Q, Wang A, Jia Y. Outcomes of endoscopic ultrasound-guided ablation and minimally invasive surgery in the treatment of pancreatic insulinoma: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1367068. [PMID: 38645424 PMCID: PMC11026617 DOI: 10.3389/fendo.2024.1367068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/25/2024] [Indexed: 04/23/2024] Open
Abstract
Background and aims Most pancreatic insulinomas can be treated by minimally invasive modalities. The aim of this meta-analysis was to assess the clinical outcomes of endoscopic ultrasound (EUS)-guided ablation and minimally invasive surgery (MIS) in the treatment of pancreatic insulinoma. Materials and methods Online databases were searched for relevant studies. The primary aim was to compare the rates of adverse events (AEs) and the secondary aims were to compare the clinical and technical success rates, length of hospital stays, and symptom recurrence rates between EUS and MIS approaches. Results Eight studies with 150 patients were identified that reported EUS-guided ablation outcomes, forming the EUS group, and 9 studies with 236 patients reported MIS outcomes, forming the MIS group. The pooled median age of the included patients in the EUS group was greater than that of the MIS group (64.06 vs. 44.98 years old, p < 0.001). Also, the technical success rate was significantly higher in the EUS group (100% vs. 96.6%, p = 0.025), while the clinical success was significantly higher (6%) in the MIS group (94% vs. 98.7%, p = 0.021). The AE rates (18.7% vs. 31.1%, p = 0.012) and severe AE rates (1.3% vs. 7.9%, p = 0.011) were significantly lower in the EUS group. The median length of hospital stay in the EUS group (2.68 days, 95% CI: 1.88-3.48, I2 = 60.3%) was significantly shorter than in the MIS group (7.40 days, 95% CI: 6.22-8.58, I2 = 42.2%, p < 0.001). The recurrence rate was significantly higher in the EUS group (15.3% vs. 1.3%, p < 0.001). Conclusions EUS-guided ablation is associated with a lower AE rate and a shorter length of hospital stay, but a higher recurrence rate for the treatment of insulinoma compared with MIS. The EUS approach may be an alternative, even first-line, treatment for poor surgery candidates.
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Affiliation(s)
- Dan Xiao
- Department of Gastroenterology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, Hubei, China
| | - Li Zhu
- Gastrointestinal Surgery, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, Hubei, China
| | - Si Xiong
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, Hubei, China
| | - Xu Yan
- Internal Medicine Department, University Hospital, Wuhan Institute of Technology, Wuhan, Hubei, China
| | - Qin Jiang
- Department of Gastroenterology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, Hubei, China
| | - Ao Wang
- Department of Gastroenterology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, Hubei, China
| | - Yegui Jia
- Department of Gastroenterology, The Sixth Hospital of Wuhan, Affiliated Hospital of Jianghan University, Wuhan, Hubei, China
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Khoury T, Sbeit W, Fusaroli P, Campana D, Brighi N, Napoleon B, Lisotti A. Safety and efficacy of endoscopic ultrasound-guided radiofrequency ablation for pancreatic neuroendocrine neoplasms: Systematic review and meta-analysis. Dig Endosc 2024; 36:395-405. [PMID: 37702096 DOI: 10.1111/den.14681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/10/2023] [Indexed: 09/14/2023]
Abstract
OBJECTIVE Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has been constantly increasing, particularly in the treatment of pancreatic neuroendocrine neoplasms (pNENs). While emerging data in this field are accumulating, we aimed to assess the pooled efficacy and safety of EUS-RFA for pNENs. METHODS The PubMed/Medline, Embase, and Cochrane Library databases search was conducted to identify studies reporting EUS-RFA of pNENs with outcomes of interest (efficacy and safety). The primary outcome was radiological response. Efficacy was assessed by the pooled clinical response rate, whereas safety was assessed by the pooled adverse events (AEs) rate. Heterogeneity was assessed using I2. Pooled estimates and the 95% confidence interval (CI) were calculated using a random-effect model. RESULTS Eleven studies involving 292 patients were included. The pooled technical success rate was 99.2% (95% CI 97.9-99.9%), with no heterogeneity. The pooled complete radiological response was 87.1% (95% CI 80.1-92.8%). The pooled partial response was 11.4% (95% CI 6.2-18.1%). The pooled clinical response rate for functional pNENs was 94.9% (95% CI 90.7-97.9%), with no heterogeneity. The pooled incidence of AEs was 20.0% (95% CI 14.0-26.7%); most AEs were mild to moderate in grade, while the pooled incidence of severe AEs was 0.9% (95% CI 0.2-2.3%). The most common AEs were transient mild abdominal pain in 19 patients (6.5%), and mild to moderate pancreatitis in 23 patients (7.9%). No cases of mortality were reported. CONCLUSION Endoscopic ultrasound-guided radiofrequency ablation resulted on a feasible approach for pNENs treatment, with excellent technical success, high radiological and clinical response, and acceptable AE rate.
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Affiliation(s)
- Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Bologna, Italy
| | - Davide Campana
- Department of Experimental, Diagnostic and Specialty Medicine, Sant'Orsola-Malpighi University Hospital, ENETS Center of Excellence, Bologna, Italy
| | - Nicole Brighi
- Department of Medical Oncology, IRCCS Romagna Institute for the Study of Tumors "Dino Amadori", Meldola, Italy
| | - Bertrand Napoleon
- Department of Gastroenterology, Jean Mermoz Private Hospital, Ramsay Health, Lyon, France
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Bologna, Italy
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Biermann MR, Sundar P, Veeramachaneni H, Chawla S, Patel V, Orr J, Keilin S, Willingham FF. Radiofrequency ablation for the management of symptomatic pancreatic insulinomas. VideoGIE 2024; 9:45-50. [PMID: 38239186 PMCID: PMC10793174 DOI: 10.1016/j.vgie.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
Background and Aims Insulinomas are among the most common types of functional pancreatic neuroendocrine tumors and can cause debilitating, recurrent, symptomatic hypoglycemia. Pancreatic resection can be curative, but many patients are not candidates for major pancreatic surgery. EUS-guided radiofrequency ablation (EUS-RFA) is a novel minimally invasive technique for ablation of pancreatic tumors. Methods In this article and accompanying video, we describe the EUS-RFA ablation device, provide instructions for device setup, and review outcomes of a case series of EUS-RFA for symptomatic insulinomas. We also review the current literature describing EUS-RFA for symptomatic pancreatic insulinomas. Results This series of patients in the United States, as well as studies performed in other countries, suggests normalization of insulin levels that appears to be sustained over months to years following the procedure. There has been a favorable adverse event profile in the case series reported to date. Conclusions EUS-RFA is emerging as a promising option for the management of symptomatic insulinomas, particularly for patients who are poor surgical candidates or who decline surgery.
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Affiliation(s)
- Maya R Biermann
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Preeyanka Sundar
- Department of Medicine, Division of Digestive Diseases, Emory University, Atlanta, Georgia
| | - Hima Veeramachaneni
- Department of Medicine, Division of Digestive Diseases, Emory University, Atlanta, Georgia
| | - Saurabh Chawla
- Department of Medicine, Division of Digestive Diseases, Emory University, Atlanta, Georgia
| | - Vaishali Patel
- Department of Medicine, Division of Digestive Diseases, Emory University, Atlanta, Georgia
| | - Jordan Orr
- Department of Medicine, Division of Digestive Diseases, Emory University, Atlanta, Georgia
| | - Steven Keilin
- Department of Medicine, Division of Digestive Diseases, Emory University, Atlanta, Georgia
| | - Field F Willingham
- Department of Medicine, Division of Digestive Diseases, Emory University, Atlanta, Georgia
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Dhar J, Samanta J, Nabi Z, Aggarwal M, Facciorusso A, Conti Bellocchi MC, Crinò SF. Endoscopic ultrasound-guided radiofrequency ablation of pancreatic insulinoma: a state of the art review. Expert Rev Gastroenterol Hepatol 2024; 18:37-53. [PMID: 38383965 DOI: 10.1080/17474124.2024.2321938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 02/19/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Insulinomas are the most common functional pancreatic neuroendocrine tumors (PNETs) that lead to incapacitating hypoglycemia. Guidelines recommend surgical resection as the mainstay of management. However, surgery is fraught with complications, causing significant peri/post-operative morbidity. Since insulinomas are usually benign, solitary, small (<2 cm), and do not need lymphadenectomy, hence, in this regard, endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is now being increasingly performed, to circumvent these adverse events and impairment of pancreatic function. AREAS COVERED A comprehensive literature search was undertaken across various databases (PubMed/MEDLINE, Embase, Scopus), with no language restriction, for relevant articles (case series, reviews, case reports) pertaining to EUS-RFA for insulinoma and PNETs, till October 2023. In this review, we have explicated the role of EUS-RFA for insulinoma management, detailing thoroughly its mechanism of action, EUS-RFA devices with data on its safety and efficacy, and an algorithmic approach for its management. EXPERT OPINION EUS-RFA is being advocated as a 'mini-invasive' option with the potential to replace surgery as a first-line approach for benign, sporadic, solitary, and small (<2 cm) insulinomas. Under real-time guidance, EUS-RFA has immense precision, is safe, predictable, with acceptable safety profile. Presently, it is being frequently performed for high-risk or inoperable candidates. Current need-of-the-hour is a randomized controlled trial to substantiate its role in the therapeutic algorithm for insulinoma management.
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Affiliation(s)
- Jahnvi Dhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Manik Aggarwal
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Antonio Facciorusso
- Department Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Maria Cristina Conti Bellocchi
- Diagnostic and Interventional Endoscopy of the Pancreas, The Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Stefano Francesco Crinò
- Diagnostic and Interventional Endoscopy of the Pancreas, The Pancreas Institute, University Hospital of Verona, Verona, Italy
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Cho SH, Kim DH, Seo DW, Yoo SK, Oh D, Song TJ, Lee SK. Expanded indication for EUS-guided radiofrequency ablation: management of adrenal tumors. Gastrointest Endosc 2023; 98:790-796. [PMID: 37356635 DOI: 10.1016/j.gie.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/27/2023] [Accepted: 06/13/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND AND AIMS EUS-guided radiofrequency ablation (EUS-RFA) has been performed as an alternative to surgery for the treatment of pancreatic tumors. The promising results obtained using this procedure suggest that the indication for EUS-RFA could be expanded to the management of extrapancreatic tumors. Here, we evaluate the feasibility, efficacy, and safety of EUS-RFA in the treatment of left adrenal tumors. METHODS This single-center, prospective study was conducted at Asan Medical Center between January 2016 and November 2021. A total of 11 patients with left adrenal tumors were enrolled in the study. The technical success rate, treatment response, and adverse events were evaluated. RESULTS EUS-RFA was performed successfully in all patients (technical success rate, 100%). The indications for the procedure were an increase in tumor size (n = 8), and adrenal tumor with adrenal hormone excess (n = 3). After a median of 2 EUS-RFA sessions (range, 1-2), 73% of patients had a complete response, and 27% had a partial response. During follow-up, 5 patients experienced self-limiting mild abdominal pain; no moderate or severe adverse events were reported. CONCLUSIONS EUS-RFA showed high technical feasibility, clinical success, and an acceptable safety profile in the treatment of left adrenal tumors. In patients at high surgical risk, EUS-RFA can be considered as an alternative therapeutic modality to surgery for the treatment of left adrenal tumors.
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Affiliation(s)
- Sung Hyun Cho
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dae Hyeon Kim
- University of Ulsan College of Medicine, Seoul, South Korea
| | - Dong-Wan Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
| | - Seul Ki Yoo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dongwook Oh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Tae Jun Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Koo Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Debraine Z, Borbath I, Deprez P, Bosly F, Maiter D, Furnica RM. Long-term clinical and radiological outcomes of endoscopic ultrasound-guided radiofrequency ablation of benign insulinomas. Clin Endocrinol (Oxf) 2023. [PMID: 37859570 DOI: 10.1111/cen.14981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/26/2023] [Accepted: 10/01/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE In recent years, endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has emerged as an alternative nonsurgical treatment for pancreatic neuroendocrine tumours. The aim of our study was to assess the long-term follow-up of patients treated with EUS-RFA for a sporadic insulinoma in our centre in terms of efficacy, safety and risk of recurrence. DESIGN, PATIENTS AND MEASUREMENTS We retrospectively analysed the data of 11 patients with an insulinoma treated by EUS-RFA in our tertiary centre between June 2018 and April 2022. Clinical and biological, as well as imaging, follow-up was planned at 3, 6, 12 months and then annually. RESULTS In our series, there were nine women and two men with a median age of 65 years. All tumours were sporadic, with a mean size of 11 mm. The procedure allowed an immediate and complete symptomatic and biological remission in all patients without notable complications. Complete radiological resolution of the tumour after ablation was observed in seven patients, and persistence of an asymptomatic tumour residue was observed in four patients. During the mean follow-up period of 26 months, two patients presented a significant but asymptomatic increase of the tumour residue; a second EUS-RFA session was performed in one patient and the other patient is being closely monitored. CONCLUSIONS EUS-RFA treatment of benign insulinomas provides a long-term complete clinical resolution of hypoglycaemia. A long-term follow-up is essential if residual tumour persists after initial EUS-RFA treatment.
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Affiliation(s)
- Zoé Debraine
- Division of Endocrinology and Nutrition, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Ivan Borbath
- Division of Hepatogastroenterology, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Pierre Deprez
- Division of Hepatogastroenterology, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Florence Bosly
- Division of Endocrinology, Clinique Vivalia, Arlon Hospital, Arlon, Belgium
| | - Dominique Maiter
- Division of Endocrinology and Nutrition, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Raluca M Furnica
- Division of Endocrinology and Nutrition, Cliniques Universitaires St Luc, Université Catholique de Louvain, Brussels, Belgium
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Crinò SF, Napoleon B, Facciorusso A, Lakhtakia S, Borbath I, Caillol F, Do-Cong Pham K, Rizzatti G, Forti E, Palazzo L, Belle A, Vilmann P, van Laethem JL, Mohamadnejad M, Godat S, Hindryckx P, Benson A, Tacelli M, De Nucci G, Binda C, Kovacevic B, Jacob H, Partelli S, Falconi M, Salvia R, Landoni L, Larghi A. Endoscopic Ultrasound-guided Radiofrequency Ablation Versus Surgical Resection for Treatment of Pancreatic Insulinoma. Clin Gastroenterol Hepatol 2023; 21:2834-2843.e2. [PMID: 36871765 DOI: 10.1016/j.cgh.2023.02.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/14/2023] [Accepted: 02/21/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is emerging as a safe and effective treatment for pancreatic neuroendocrine tumors. We aimed to compare EUS-RFA and surgical resection for the treatment of pancreatic insulinoma (PI). METHODS Patients with sporadic PI who underwent EUS-RFA at 23 centers or surgical resection at 8 high-volume pancreatic surgery institutions between 2014 and 2022 were retrospectively identified and outcomes compared using a propensity-matching analysis. Primary outcome was safety. Secondary outcomes were clinical efficacy, hospital stay, and recurrence rate after EUS-RFA. RESULTS Using propensity score matching, 89 patients were allocated in each group (1:1), and were evenly distributed in terms of age, sex, Charlson comorbidity index, American Society of Anesthesiologists score, body mass index, distance between lesion and main pancreatic duct, lesion site, size, and grade. Adverse event (AE) rate was 18.0% and 61.8% after EUS-RFA and surgery, respectively (P < .001). No severe AEs were observed in the EUS-RFA group compared with 15.7% after surgery (P < .0001). Clinical efficacy was 100% after surgery and 95.5% after EUS-RFA (P = .160). However, the mean duration of follow-up time was shorter in the EUS-RFA group (median, 23 months; interquartile range, 14-31 months vs 37 months; interquartile range, 17.5-67 months in the surgical group; P < .0001). Hospital stay was significantly longer in the surgical group (11.1 ± 9.7 vs 3.0 ± 2.5 days in the EUS-RFA group; P < .0001). Fifteen lesions (16.9%) recurred after EUS-RFA and underwent a successful repeat EUS-RFA (11 patients) or surgical resection (4 patients). CONCLUSION EUS-RFA is safer than surgery and highly effective for the treatment of PI. If confirmed in a randomized study, EUS-RFA treatment can become first-line therapy for sporadic PI.
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Affiliation(s)
- Stefano Francesco Crinò
- Digestive Endoscopy Unit, The Pancreas Institute, University Hospital of Verona, Verona, Italy.
| | - Bertrand Napoleon
- Service de Gastroentérologie, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Antonio Facciorusso
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | | | - Ivan Borbath
- Department of Hepato-gastroenterology, Cliniques Universitaires St Luc, Brussels, Belgium
| | - Fabrice Caillol
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | | | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Edoardo Forti
- Digestive and Interventional Endoscopy Unit, ASST Niguarda, Milan, Italy
| | | | - Arthur Belle
- Department of Gastroenterology, Cochin Hospital, Paris, France
| | - Peter Vilmann
- Department of Gastroenterology, Herlev-Gentofte Hospital, Herlev, Denmark
| | - Jean-Luc van Laethem
- Hepato-Gastroenterology, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Mehdi Mohamadnejad
- Digestive Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Sebastien Godat
- Division of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Pieter Hindryckx
- Department of Gastroenterology, University of Ghent, Ghent, Belgium
| | - Ariel Benson
- Institute of Gastroenterology and Hepatology, Hadassah Medical Center, Jerusalem, Israel and Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Matteo Tacelli
- Pancreato-biliary Endoscopy and EUS Division, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Germana De Nucci
- Gastroenterology and Endoscopy Unit, ASST Rhodense, Garbagnate Milanese, Milan, Italy
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Ospedale Morgagni-Pierantoni, AUSL Romagna, Forlì, Italy
| | - Bojan Kovacevic
- Department of Gastroenterology, Herlev-Gentofte Hospital, Herlev, Denmark
| | - Harold Jacob
- Institute of Gastroenterology and Hepatology, Hadassah Medical Center, Jerusalem, Israel and Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Stefano Partelli
- Pancreatic and Transplant Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele IRCCS, Università Vita-Salute, Milan, Italy
| | - Massimo Falconi
- Pancreatic and Transplant Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele IRCCS, Università Vita-Salute, Milan, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Department, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luca Landoni
- General and Pancreatic Surgery Department, Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alberto Larghi
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Giovannini M, Marx M. Radiofrequency Ablation of Pancreatic Solid Tumors. Gastrointest Endosc Clin N Am 2023; 33:855-865. [PMID: 37709416 DOI: 10.1016/j.giec.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Today, endoscopic ultrasound-guided radiofrequency ablation has become increasingly accepted for the treatment of different precancerous and neoplastic lesions of the pancreas, particularly in patients who are unfit for surgery. However, thermal ablation has long been suspected to induce pancreatitis or to injure adjacent structures. Published case reports and case series on this topic are of limited size and are often based on a heterogeneous study population, reporting on functional and nonfunctional pancreatic neuroendocrine tumors. Nevertheless, the overall results are promising, with high technical success and relatively low complication rates.
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Affiliation(s)
- Marc Giovannini
- Paoli-Calmettes Institute, 232 Boulevard St-Marguerite, Marseille Cedex 9 13273, France.
| | - Mariola Marx
- Unit of Hepato-Gastroenterology, CHUV, Rue Du Bugnon 46 Street, Lausanne 1011, Switzerland
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Di Gialleonardo L, Tripodi G, Rizzatti G, Ainora ME, Spada C, Larghi A, Gasbarrini A, Zocco MA. Endoscopic Ultrasound-Guided Locoregional Treatments for Solid Pancreatic Neoplasms. Cancers (Basel) 2023; 15:4718. [PMID: 37835413 PMCID: PMC10571848 DOI: 10.3390/cancers15194718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/23/2023] [Accepted: 09/24/2023] [Indexed: 10/15/2023] Open
Abstract
Solid pancreatic neoplasms are one of the most diagnosed gastrointestinal malignancies thanks to the current and progressive advances in radiologic methods. Endoscopic ultrasound-guided techniques have over time gained a prominent role in the differential diagnosis and characterization of these pancreatic lesions, including pancreatic cancer, neuroendocrine tumors, and metastases. Recently, several endoscopic ultrasound-guided locoregional treatment techniques, which are divided into thermal ablative techniques and non-thermal injection techniques, have been developed and applied in different settings for the treatment of solid pancreatic neoplasms. The most common ablative techniques are radiofrequency, microwave, laser, photodynamic therapy and hybrid techniques such as hybrid cryothermal ablation. The most common injection techniques are ethanol injection, immunotherapy and brachytherapy. In this review, we update evidence about the efficacy and safety of endoscopic ultrasound-guided locoregional treatments for solid pancreatic neoplasms.
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Affiliation(s)
- Luca Di Gialleonardo
- CEMAD Digestive Diseases Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (L.D.G.); (M.E.A.); (A.G.)
| | - Giulia Tripodi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (G.T.); (G.R.); (C.S.); (A.L.)
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (G.T.); (G.R.); (C.S.); (A.L.)
| | - Maria Elena Ainora
- CEMAD Digestive Diseases Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (L.D.G.); (M.E.A.); (A.G.)
| | - Cristiano Spada
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (G.T.); (G.R.); (C.S.); (A.L.)
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (G.T.); (G.R.); (C.S.); (A.L.)
| | - Antonio Gasbarrini
- CEMAD Digestive Diseases Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (L.D.G.); (M.E.A.); (A.G.)
| | - Maria Assunta Zocco
- CEMAD Digestive Diseases Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy; (L.D.G.); (M.E.A.); (A.G.)
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Napoléon B, Lisotti A, Caillol F, Gasmi M, Ah-Soune P, Belle A, Charachon A, Cholet F, Eyraud PY, Grandval P, Gonzalez JM, Habersetzer F, Koch S, Le Rhun M, Mangialavori L, Musquer N, Palazzo M, Poincloux L, Privat J, Sportes A, Stouvenot M, Subtil C, Thomassin L, Vanbiervliet G, Vidal G, Vuitton L, Giovannini M, Barthet M. Risk factors for EUS-guided radiofrequency ablation adverse events in patients with pancreatic neoplasms: a large national French study (RAFPAN study). Gastrointest Endosc 2023; 98:392-399.e1. [PMID: 37059368 DOI: 10.1016/j.gie.2023.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND AND AIMS EUS-guided radiofrequency ablation (EUS-RFA) has been described as a potentially curative option for solid and cystic pancreatic neoplasms. We aimed to assess the safety and efficacy of pancreatic EUS-RFA in a large study population. METHODS A retrospective study retrieving all consecutive patients who underwent pancreatic EUS-RFA during 2019 and 2020 in France was conducted. Indication, procedural characteristics, early and late adverse events (AEs), and clinical outcomes were recorded. Risk factors for AEs and factors related to complete tumor ablation were assessed on univariate and multivariate analyses. RESULTS One hundred patients (54% men, 64.8 ± 17.6 years old) affected by 104 neoplasms were included. Sixty-four neoplasms were neuroendocrine neoplasms (NENs), 23 were metastases, and 10 were intraductal papillary mucinous neoplasms with mural nodules. No procedure-related mortality was observed, and 22 AEs were reported. Proximity of pancreatic neoplasms (≤1 mm) to the main pancreatic duct was the only independent risk factor for AEs (odds ratio [OR), 4.10; 95% confidence interval [CI), 1.02-15.22; P = .04). Fifty-nine patients (60.2%) achieved a complete tumor response, 31 (31.6%) a partial response, and 9 (9.2%) achieved no response. On multivariate analysis, NENs (OR, 7.95; 95% CI, 1.66-51.79; P < .001) and neoplasm size <20 mm (OR, 5.26; 95% CI, 2.17-14.29; P < .001) were independently related to complete tumor ablation. CONCLUSIONS The results of this large study confirm an overall acceptable safety profile for pancreatic EUS-RFA. Close proximity (≤1 mm) to the main pancreatic duct represents an independent risk factor for AEs. Good clinical outcomes in terms of tumor ablation were observed, especially for small NENs.
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Affiliation(s)
- Bertrand Napoléon
- Digestive Endoscopy Unit, Hopital Privé Jean Mermoz, Ramsay Santé, Lyon, France
| | - Andrea Lisotti
- Digestive Endoscopy Unit, Hopital Privé Jean Mermoz, Ramsay Santé, Lyon, France
| | - Fabrice Caillol
- Digestive Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | - Mohamed Gasmi
- Digestive Endoscopy Unit, Hôpital Nord, Marseille, France
| | | | - Arthur Belle
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Franck Cholet
- Digestive Endoscopy Unit, University Hospital, Brest, France
| | - Pierre-Yves Eyraud
- Hepato-Gastroenterology Department, University Hospital, Grenoble, France
| | | | | | | | - Stéphane Koch
- Digestive Endoscopy Unit, Jean Minjoz Hospital, Besançon, France
| | - Marc Le Rhun
- Gastroenterology, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Luigi Mangialavori
- Digestive Endoscopy Unit, Hopital Privé A Brillard, Ramsay Sante, Nogent sur Marne, France
| | - Nicolas Musquer
- Gastroenterology, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Maxime Palazzo
- Digestive Endoscopy Unit, Beaujon University Hospital, Clichy-la-Garenne, France
| | - Laurent Poincloux
- Digestive Endoscopy Unit, Estaing University Hospital, Clermont-Ferrand, France
| | | | - Adrien Sportes
- Digestive Endoscopy, Institut Arnault Tzanck Gastroenterology Unit, Saint-Laurent-du-Var, France
| | | | - Clement Subtil
- Digestive Endoscopy Unit, University Hospital, Bordeaux, France
| | - Lucie Thomassin
- Department of Gastroenterology, Rouen University Hospital, University of Rouen, France
| | | | - Guillaume Vidal
- Digestive Endoscopy Unit, Estaing University Hospital, Clermont-Ferrand, France
| | - Lucine Vuitton
- Digestive Endoscopy Unit, Jean Minjoz Hospital, Besançon, France
| | - Marc Giovannini
- Digestive Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | - Marc Barthet
- Digestive Endoscopy Unit, Hôpital Nord, Marseille, France
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11
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Elkelany OO, Karaisz FG, Davies B, Krishna SG. An Overview of Pancreatic Neuroendocrine Tumors and an Update on Endoscopic Techniques for Their Management. Curr Oncol 2023; 30:7566-7580. [PMID: 37623030 PMCID: PMC10453483 DOI: 10.3390/curroncol30080549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/25/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023] Open
Abstract
The growing importance of advanced endoscopy in the diagnosis and treatment of pancreatic neuroendocrine neoplasms (PanNETs) necessitates a comprehensive understanding of various biochemical markers, genetic testing methods, radiological techniques, and treatment approaches that encompass multiple disciplines within and beyond gastrointestinal oncology. This review aims to highlight key aspects of these topics, with a specific focus on emerging EUS-guided procedures for the management of PanNETs.
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Affiliation(s)
- Osama O. Elkelany
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Fred G. Karaisz
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Benjamin Davies
- College of Medicine, The Ohio State University, Columbus, OH 43201, USA
| | - Somashekar G. Krishna
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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12
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Borrelli de Andreis F, Boškoski I, Mascagni P, Schepis T, Bianchi A, Schinzari G, Annicchiarico BE, Quero G, Tortora G, Alfieri S, Gasbarrini A, Costamagna G, Spada C, Attili F. Safety and efficacy of endoscopic ultrasound-guided radiofrequency ablation for pancreatic insulinoma: A single-center experience. Pancreatology 2023; 23:543-549. [PMID: 37236853 DOI: 10.1016/j.pan.2023.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/28/2023] [Accepted: 05/13/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND/OBJECTIVES Insulinomas are rare, functioning pancreatic neuroendocrine neoplasms (pNEN), whose gold standard therapy is surgical resection. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is a recent technique that has emerged as a minimally invasive therapeutic option for patients with pancreatic lesions not eligible for surgery. In this study, we aimed to describe a series of patients with unresectable pancreatic insulinoma treated with EUS-RFA. METHODS This is a single-center, retrospective study including all consecutive patients with functioning pancreatic insulinoma undergoing EUS-RFA for surgical unfitness or surgery refusal, between March 2017 and September 2021. Technical success (i.e., complete mass ablation), adverse event rate and severity, clinical and radiologic outcomes (i.e., symptom remission with a normal concentration of blood glucose, and the presence of intralesional necrosis), and post-procedural follow-up were assessed. RESULTS A total of 10 patients (mean age: 67.1 ± 10.1years; F:M 7:3) were included. The mean size of insulinoma was 11.9 ± 3.3 mm. Technical success and clinical remission were achieved in 100% of patients. Only one (10%) patient was successfully treated with two RFA sessions. Two procedure-related early adverse events occurred, including two (20%) cases of mild abdominal pain. No major complications were observed. The complete radiologic response within 3 months after EUS-RFA was observed in all patients (100%). After a median follow-up of 19.5 (range12-59) months, symptom remission and persistent euglycemia were assessed in all the patients. CONCLUSIONS Data from this case series suggest that EUS-RFA is a feasible and safe therapeutic approach for pancreatic insulinomas in patients unwilling or unable to undergo surgery with medium-term efficacy.
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Affiliation(s)
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Italy
| | - Pietro Mascagni
- Digestive Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Institute of Image-Guided Surgery, IHU-Strasbourg, France
| | - Tommaso Schepis
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio Bianchi
- Endocrinology and Diabetology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Schinzari
- Comprehensive Cancer Center, Medical Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Giuseppe Quero
- Digestive Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giampaolo Tortora
- Comprehensive Cancer Center, Medical Oncology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Internal Medicine and Gastroenterology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica Del Sacro Cuore di Roma, Italy
| | - Cristiano Spada
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Fabia Attili
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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13
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Marasco M, Galasso D, Larghi A, Panzuto F. When Should We Adopt EUS-Guided Radiofrequency Ablation in Pancreatic Neuroendocrine Tumors? J Clin Med 2023; 12:4581. [PMID: 37510695 PMCID: PMC10380401 DOI: 10.3390/jcm12144581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 06/12/2023] [Indexed: 07/30/2023] Open
Abstract
Pancreatic neuroendocrine neoplasms (PanNENs) are rare and heterogeneous diseases that account for less than 2% of all cases of pancreatic cancer and only 30% of digestive neuroendocrine neoplasia, even if their incidence and prevalence continue to rise globally [...].
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Affiliation(s)
- Matteo Marasco
- Digestive Diseases Unit, Sant'Andrea University Hospital, ENETS Center of Excellence, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Domenico Galasso
- Unité de Gastro-Entérologie Service de Médicine Interne, Hôpital Riviera-Chablais, 1847 Rennaz, Switzerland
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Francesco Panzuto
- Digestive Diseases Unit, Sant'Andrea University Hospital, ENETS Center of Excellence, Via di Grottarossa 1035, 00189 Rome, Italy
- Department of Medical-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Via Giorgio Nicola Papanicolau snc, 00189 Rome, Italy
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14
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Prete AM, Gonda TA. Endoscopic Ultrasound-Guided Local Ablative Therapies for the Treatment of Pancreatic Neuroendocrine Tumors and Cystic Lesions: A Review of the Current Literature. J Clin Med 2023; 12:jcm12093325. [PMID: 37176764 PMCID: PMC10179349 DOI: 10.3390/jcm12093325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/02/2023] [Accepted: 05/05/2023] [Indexed: 05/15/2023] Open
Abstract
Since its emergence as a diagnostic modality in the 1980s, endoscopic ultrasound (EUS) has provided the clinician profound access to gastrointestinal organs to aid in the direct visualization, sampling, and subsequent identification of pancreatic pathology. In recent years, advancements in EUS as an interventional technique have promoted the use of local ablative therapies as a minimally invasive alternative to the surgical management of pancreatic neuroendocrine tumors (pNETs) and pancreatic cystic neoplasms (PCNs), especially for those deemed to be poor operative candidates. EUS-guided local therapies have demonstrated promising efficacy in addressing a spectrum of pancreatic neoplasms, while also balancing local adverse effects on healthy parenchyma. This article serves as a review of the current literature detailing the mechanisms, outcomes, complications, and limitations of EUS-guided local ablative therapies such as chemical ablation and radiofrequency ablation (RFA) for the treatment of pNETs and PCNs, as well as a discussion of future applications of EUS-guided techniques to address a broader scope of pancreatic pathology.
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Affiliation(s)
- Alexander M Prete
- Department of Medicine, New York University (NYU) Grossman School of Medicine, New York, NY 10016, USA
| | - Tamas A Gonda
- Division of Gastroenterology and Hepatology, New York University (NYU) Langone Health, New York, NY 10016, USA
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15
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Rossi G, Petrone MC, Healey AJ, Arcidiacono PG. Approaching Small Neuroendocrine Tumors with Radiofrequency Ablation. Diagnostics (Basel) 2023; 13:diagnostics13091561. [PMID: 37174952 PMCID: PMC10177414 DOI: 10.3390/diagnostics13091561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Abstract
In recent years, small pancreatic neuroendocrine tumors (pNETs) have shown a dramatic increase in terms of incidence and prevalence, and endoscopic ultrasound (EUS) radiofrequency ablation (RFA) is one potential method to treat the disease in selected patients. As well as the heterogeneity of pNET histology, the studies reported in the literature on EUS-RFA procedures for pNETs are heterogeneous in terms of ablation settings (particularly ablation powers), radiological controls, and radiological indications. The aim of this review is to report the current reported experience in EUS-RFA of small pNETs to help formulate the procedure indications and ablation settings. Another aim is to evaluate the timing and the modality of the radiological surveillance after the ablation. Moreover, new studies on large-scale series are needed in terms of the safety and long-term oncological efficacy of RFA on these small lesions.
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Affiliation(s)
- Gemma Rossi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita Salute San Raffaele University, 20132 Milan, Italy
| | - Maria Chiara Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita Salute San Raffaele University, 20132 Milan, Italy
| | - Andrew J Healey
- Department of Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita Salute San Raffaele University, 20132 Milan, Italy
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16
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Abstract
PURPOSE OF REVIEW Patients with pancreatic tumors may have limited treatment options. Pancreatic tumor ablation is a novel and emerging treatment modality which can now be performed using endoscopic ultrasound (EUS) guidance. This modality is well suited to guide energy delivery for radiofrequency ablation (RFA) and microwave ablation. These approaches provide minimally invasive, nonsurgical methods for delivering energy to ablate pancreatic tumors in situ. This review summarizes the current data and safety profile for ablation in managing pancreatic cancer and pancreatic neuroendocrine tumors. RECENT FINDINGS RFA uses thermal energy to induce cell death by coagulative necrosis and protein denaturation. Studies have reported increased overall survival in patients with pancreatic tumors treated with EUS-guided RFA in a multimodality systemic approach and when used in palliative surgeries. Radiofrequency ablation may have corollary benefits in inducing an immune-modulatory effect. Tumor marker carbohydrate antigen 19-9 has been reported to decrease in response to RFA. Microwave ablation is an emerging modality. SUMMARY RFA utilizes focal thermal energy to induce cell death. RFA has been applied through open, laparoscopic, and radiographic modalities. EUS-guided approaches are now allowing RFA and microwave ablation to be performed for pancreatic tumors in situ.
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Affiliation(s)
| | - Anna M Goebel
- Emory University School of Medicine, Emory University
| | - Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University, Atlanta, Georgia, USA
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17
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Armellini E, Facciorusso A, Crinò SF. Efficacy and Safety of Endoscopic Ultrasound-Guided Radiofrequency Ablation for Pancreatic Neuroendocrine Tumors: A Systematic Review and Metanalysis. Medicina (Kaunas) 2023; 59:medicina59020359. [PMID: 36837560 PMCID: PMC9963038 DOI: 10.3390/medicina59020359] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/21/2023] [Accepted: 01/29/2023] [Indexed: 02/16/2023]
Abstract
Introduction: The development of dedicated endoscopes and the technical evolution of endoscopic ultrasound (EUS) have allowed a direct approach to pancreatic neoplastic lesions both for diagnosis and treatment. Among the more promising targets are pancreatic neuroendocrine tumors (Pan-NETs). Aim: to describe the evolution of endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) with particular attention to the treatment of PanNETs, focusing on safety and clinical efficacy of the technique. Methods: MEDLINE, Scopus, and Cochrane Library databases were searched for studies reporting about EUS-RFA for the treatment of PanNETs. Studies with outcomes of interest were selected and results were reported to describe clinical success, complications, fol-low-ups, and electrodes used. Clinical success was defined as the disappearance of clinical symp-toms for functional (F-) PanNETs and as complete ablation per nonfunctional (NF)-PanNETs. The pooled data were analyzed by a random-effects model. Results: Nineteen studies were selected, including 183 patients (82 males, 44.8%) with 196 lesions (101 F-PanNETs and 95 NF-PanNETs). Pooled estimates for the overall AE rates for the clinical efficacy were 17.8% (95% CI 9.1-26.4%) and 95.1% (95% CI 91.2-98.9%) for F-PanNETs and 24.6% (95% CI 7.4-41.8%) and 93.4% (95% CI 88.4-98.4%) for NF-PanNETs. Conclusions: EUS-RFA appears to be a mini-invasive technique with a good safety and efficacy profile for the treatment of F- and NF-PanNETs. EUS-RFA could be of-fered as possible alternative to surgery for the treatment of low-grade NF- or F-PanNETs, especially for those patients that are not eligible or are at high-risk for surgery.
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Affiliation(s)
- Elia Armellini
- Gastroenterology Unit, Asst-Bergamoest, 24068 Bergamo, Italy
- Correspondence:
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
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18
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Karaisz FG, Elkelany OO, Davies B, Lozanski G, Krishna SG. A Review on Endoscopic Ultrasound-Guided Radiofrequency Ablation (EUS-RFA) of Pancreatic Lesions. Diagnostics (Basel) 2023; 13:diagnostics13030536. [PMID: 36766643 PMCID: PMC9914142 DOI: 10.3390/diagnostics13030536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/27/2023] [Accepted: 01/29/2023] [Indexed: 02/05/2023] Open
Abstract
The morbidity associated with pancreatectomies limits surgical options for high-risk patients with pancreatic neoplasms that warrant resection. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) offers a minimally invasive and potentially definitive means to treat pancreatic neuroendocrine tumors and precancerous pancreatic cystic lesions. In addition, EUS-RFA may play a role in the treatment and palliation of non-surgical cases of pancreatic adenocarcinoma. The efficacy of RFA appears to be further enhanced by systemic immunomodulatory effects. Here, we review current studies on the developing role of EUS-RFA in these pancreatic pathologies.
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Affiliation(s)
- Fred G. Karaisz
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Osama O. Elkelany
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Benjamin Davies
- College of Medicine, The Ohio State University, Columbus, OH 43210, USA
| | - Gerard Lozanski
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus OH 43210, USA
| | - Somashekar G. Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
- Correspondence:
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19
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Khoury T, Sbeit W, Napoléon B. Endoscopic ultrasound guided radiofrequency ablation for pancreatic tumors: A critical review focusing on safety, efficacy and controversies. World J Gastroenterol 2023; 29:157-170. [PMID: 36683710 PMCID: PMC9850956 DOI: 10.3748/wjg.v29.i1.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/21/2022] [Accepted: 12/14/2022] [Indexed: 01/04/2023] Open
Abstract
The role of endoscopic ultrasound (EUS) in the last two decades has shifted from a diagnostic tool to an important therapeutic tool treating mainly pancreato-biliary disorders. In recent years, its applications for treating pancreatic diseases have broadened, including the implementation of radiofrequency ablation (RFA), which has been traditionally used for treating solid tumors. In this critical in-depth review, we summarized all the papers throughout the literature regarding EUS-RFA for pancreatic neuroendocrine neoplasms, adenocarcinoma, and pancreatic cystic lesions. Overall, for pancreatic neuroendocrine neoplasms we identified 16 papers that reported 96 patients who underwent EUS-RFA, with acceptable adverse events that were rated mild to moderate and a high complete radiological resolution rate of 90%. For pancreatic adenocarcinoma, we identified 8 papers with 121 patients. Adverse events occurred in 13% of patients, mostly rated mild. However, no clear survival benefit was demonstrated. For pancreatic cystic lesions, we identified 4 papers with 38 patients. The adverse events were mostly mild and occurred in 9.1% of patients, and complete or partial radiological resolution of the cysts was reported in 36.8%. Notably, the procedure was technically feasible for most of the patients. Nevertheless, a long road remains before this technique finds its definite place in guidelines due to several controversies. EUS-RFA for pancreatic tumors seems to be safe and effective, especially for pancreatic neuroendocrine neoplasms, but multicenter prospective trials are needed to consider this treatment as a gold standard.
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Affiliation(s)
- Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Nahariya 2210001, Israel
| | - Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, Nahariya 2210001, Israel
| | - Bertrand Napoléon
- Department of Endoscopy Unit, Private Hospital Jean Mermoz, Lyon 69008, France
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20
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Marc B, Monino L, Rimbas M. EUS-guided intra-tumoral therapies. Best Pract Res Clin Gastroenterol 2022; 60-61:101817. [PMID: 36577536 DOI: 10.1016/j.bpg.2022.101817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
EUS-guided treatments for focal tumor lesions has been developed since 20 years using at onset of the technique mainly local and guided alcohol injection [1-4]. Pancreatic tumors are the most assessed targeted lesions for EUS treatment because of their accessibility and because EUS management could be a safe alternative to surgery. More and more pancreatic tumors are discovered mainly fortuitously due to the advances in conventional imaging (abdominal ultrasound, CT, MRI) resulting in the question of surgical management of an asymptomatic pancreatic lesion ("incidentaloma") [5-8]. The lesions detected include mostly pancreatic cystic neoplasms (PCN) and neuroendocrine tumors (NET) mainly well differentiated. Clinically, NET are mostly non-functional and do not induce secretory disorders [5-8]. Once their nature is yielded by diagnostic tests like EUS-FNA, incidental nonfunctional NET currently lead to difficult management when their largest diameter is less than 2 cm [2,4,9,10]. EUS-guided treatment for pancreatic adenocarcinoma have also been developed with recent prospective observational study and randomized control study [11,12]. Thus, therapeutic surgical choices could be challenged by EUS- guided treatment [2,4,9].
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Affiliation(s)
- Barthet Marc
- Aix Marseille Université, Service de Gastro-entérologie, Hôpital Nord, Chemin des Bourrely, 13915, Marseille, cedex 20, France.
| | | | - Mihai Rimbas
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
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21
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Abstract
Recently, endoscopic ultrasound (EUS)-guided ablation therapy has been reported as a less invasive therapy for patients with pancreatic neoplasms. Some ablation techniques, including injective ablation (using ethanol or other ablative agents), radiofrequency ablation (RFA), photodynamic therapy, and laser ablation, have been described in the literature. Among these, injective ablation and RFA are more frequently used for treating pancreatic neoplasms. Few studies have evaluated the effectiveness of EUS-guided ethanol ablation (EUS-EA) for potentially malignant solid neoplasms (neuroendocrine neoplasms or solid pseudopapillary neoplasms) and have reported a complete response (CR) rate of 60-80%. In addition, the CR rate after EUS-RFA for these lesions has been reported to be 55-100%, with no additional procedure-related adverse events (AEs). Regarding the amelioration of the symptoms of an insulinoma, the success rates of both the therapies were found to be excellent. Regarding complete tumor ablation, EUS-RFA appeared to be superior to EUS-EA. Although EUS-RFA has been reported as a safe treatment for pancreatic cancers, its effectiveness remains inadequate. Some studies have examined the effectiveness of EUS-guided injection ablation therapy for pancreatic cystic neoplasms (PCNs) and have reported CR rates that range from 35% to 79%. Alcohol-free chemotherapeutic agent ablation appears to be effective, with a low risk of AEs. However, studies on the effectiveness of EUS-RFA for PCNs are limited. In the future, EUS-guided ablation therapy could become a more widely used approach for potentially malignant and malignant pancreatic lesions.
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Affiliation(s)
- Kazuyuki Matsumoto
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
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Caillol F, Ratone JP, Marx M, Dahel Y, Hoibian S, Provansal M, Giovannini M. Radiofrequency ablation of malignant cervical lymph nodes: an unusual treatment for dysphagia. Endoscopy 2022; 55:E199-E200. [PMID: 36368666 PMCID: PMC9829772 DOI: 10.1055/a-1965-3599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Fabrice Caillol
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | | | - Mariola Marx
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | - Yanis Dahel
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | - Solene Hoibian
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
| | | | - Marc Giovannini
- Endoscopy Unit, Paoli Calmettes Institute, Marseille, France
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23
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Marya NB, Levy MJ. EUS-guided intratumoral therapies: more time on the treadmill. Gastrointest Endosc 2022; 95:1264-1267. [PMID: 35410729 DOI: 10.1016/j.gie.2022.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/19/2022] [Indexed: 12/11/2022]
Affiliation(s)
- Neil B Marya
- UMass Chan Medical School, Worcester, Massachusetts, USA
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24
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Papaefthymiou A, Laskaratos FM, Koffas A, Manolakis A, Gkolfakis P, Coda S, Sodergren M, Suzuki N, Toumpanakis C. State of the Art in Endoscopic Therapy for the Management of Gastroenteropancreatic Neuroendocrine Tumors. Curr Treat Options Oncol 2022; 23:1014-1034. [PMID: 35511346 DOI: 10.1007/s11864-022-00986-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 12/13/2022]
Abstract
OPINION STATEMENT Gastroenteropancreatic neuroendocrine neoplasms (GEP NENs) comprise a heterogeneous group of slow growing tumors arising from the neuroendocrine cells of the gastrointestinal (GI) tract. Although they are considered relatively rare, their incidence is rising and it is believed that the more frequent use of endoscopy and imaging studies have at least in part contributed to the increased diagnosis especially of localized neoplasms. The management of these neoplasms should be guided by a multidisciplinary NEN team following appropriate staging investigations. Localized neoplasms of the GI tract may be suitable for endoscopic therapy, while patients with pancreatic NENs, unsuitable for surgery, should be considered for endoscopic ultrasound (EUS)-guided ablation. In this review, we discuss the evidence regarding endoscopic resection of luminal NENs and EUS-guided therapy of pancreatic NENs. The efficacy, safety, and other longer-term outcomes of these techniques are summarized. In conclusion, this review of endoscopic therapies for localized NENs may be a useful guide for NEN clinicians and endoscopists who are considering these therapeutic options for the management of focal GEP NENs.
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Affiliation(s)
- Apostolis Papaefthymiou
- Department of Gastroenterology, General University Hospital of Larisa, Mezourlo, 41110, Larisa, Greece.,First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, 54124, Thessaloniki, Macedonia, Greece
| | | | - Apostolos Koffas
- Department of Gastroenterology, General University Hospital of Larisa, Mezourlo, 41110, Larisa, Greece
| | - Anastasios Manolakis
- Department of Gastroenterology, General University Hospital of Larisa, Mezourlo, 41110, Larisa, Greece
| | - Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, 1070, Brussels, Belgium
| | - Sergio Coda
- Digestive Diseases Centre, Barking Havering and Redbridge University Hospitals NHS Trust, London, UK
| | - Mikael Sodergren
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, London, UK
| | - Christos Toumpanakis
- Neuroendocrine Tumour Unit (ENETS Centre of Excellence) Centre for Gastroenterology, Royal Free Hospital, London, UK
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