1 Preoperative EUS-guided fine-needle aspiration: effects on peritoneal recurrence and survival in patients with pancreatic cancer
Kim SH et al. Gastrointest Endosc 2018 Jul
- EUS-guided fine-needle aspiration (EUS-FNA) in patients with suspected pancreatic cancer may result in tumor seeding along the needle track;
- Korean researchers retrospectively evaluated the effect of preoperative EUS-FNA on the risk of peritoneal recurrence and long-term outcomes in resected pancreatic câncer;
- 411 patients underwent resection, of whom 90 had preoperative EUS-FNA. Mean follow-up was 16 months;
- 131 patients developed peritoneal recurrence overall and at a similar rate in those who underwent EUS-guided FNA (30%) and those who did not (32%).
- The overall cancer-free survival rate was also similar between groups (25.3 vs 23.7 months, p=0.36);
- The data from this retrospective cohort study showed peritoneal recurrence was not higher in patients undergoing EUS-guided FNA before curative resection for pancreatic cancer
Background and Aims
Endoscopic ultrasound-guided fine-needle aspiration (EUS-guided FNA) is an accurate and relatively safe tissue confirmation method for pancreatic cancer. However, there is concern that this procedure may spread tumor cells along the needle track or within the peritoneum. We aimed to estimate the effect of preoperative EUS-guided FNA on the risk of peritoneal recurrence and long-term outcomes in resected pancreatic cancer.
We retrospectively reviewed records of patients diagnosed with pancreatic cancer who had undergone curative resection between 2009 and 2013 to investigate the overall survival, cancer-free survival, and peritoneal recurrence. Peritoneal recurrence was diagnosed based on image findings or cytology-confirmed ascites.
Of 411 patients, 90 underwent preoperative EUS-guided FNA (EUS-FNA group) whereas 321 did not (non-EUS-FNA group). The median length of follow-up was 16.2 months (range, 2 to 46 months). Peritoneal recurrence occurred in 131 patients: 30% (27/90) in the EUS-FNA group versus 32% (104/321) in the non-EUS-FNA group (P = .66). Cancer-free survival or overall survival was not significantly different between the 2 groups: median overall survival of 25.3 months in the EUS-FNA group versus 23.7 months in the non-EUS-FNA group (P = .36); median cancer free survival of 12.7 months in the EUS-FNA group versus 11.6 months in the non-EUS-FNA group (P = .38).
Preoperative EUS-guided FNA for pancreatic cancer was not associated with an increased rate of peritoneal recurrence or mortality. Therefore, EUS-guided FNA is an accurate and safe method to obtain suspicious pancreatic mass tissue.
2. The usefulness of contrast-enhanced harmonic EUS-guided fine-needle aspiration for evaluationof hepatic lesions (with video)
Oh D et al. Gastrointest Endosc 2018 May.
- Liver lesions are frequently sampled by radiologists using transabdominal ultrasound or computed tomography (CT) to guide needle biopsy;
- Recently EUS-guided liver biopsy was described;
- Contrast-enhanced EUS (CE-EUS) is frequently used to evaluate solid pancreatic lesions;
- In this single-center study researchers evaluated the use of CE-EUS to assist in the detection of small hepatic masses and to conduct EUS-guided biopsy in 30 patients.
- CE-EUS allowed the detection of 7 additional lesions not visible on standard B-mode and the successful acquisition of tissue in all 30 patients after a mean of 2 passes.
- EUS-FNA provided an accurate diagnosis in 87% (26/30) of the cases without significant adverse events;
- The authors conclude that endoscopic ultrasound for biopsy of liver lesions is feasible and accurate.
BACKGROUND AND AIMS:
Small hepatic masses frequently do not have distinct margins on B-mode EUS image. Contrast-enhanced harmonic EUS (CEH-EUS) is widely used for evaluating ambiguous pancreatic lesions. However, its role in detecting hepatic lesions and the use of EUS-guided fine-needle aspiration (FNA) are not well evaluated. We tried to investigate the usefulness of CEH-EUS-guided FNA for evaluating hepatic lesions.
Thirty consecutive patients with hepatic masses underwent CEH-EUS and CEH-EUS-guided FNA between September 2010 and November 2016.
Twenty-eight patients (93.3%) had malignant tumors and 2 patients (6.7%) had benign hepatic masses. Before contrast enhancement, 73.3% of the hepatic lesions (22/30) in the patient cohort were visible on B-mode. After contrast enhancement, 93.3% of these hepatic lesions (28/30) were distinguishable from the surrounding liver parenchyma. The technical success rate was 100%. The median tumor size on EUS and the number of needle passes were 24.5 mm (interquartile range [IQR] 14.5 – 40.8) and 2 (IQR 2 – 3), respectively. The diagnostic accuracy of CEH-EUS-guided FNA was 86.7% (26/30 cases). There were no procedure-related adverse events.
CEH-EUS-guided FNA can be a safe and efficient method for the diagnosis of hepatic masses. It can result in a high diagnostic accuracy in cases where the hepatic lesions are poorly visible in conventional EUS.
3. Non-superiority of lumen-apposing metal stents over plastic stents for drainage of walled-off necrosis (WON) in a randomised trial.
Bang JY et al. Gut 2018 Jun
- The advantage of lumen-apposing metal stents (LAMS) over plastic stents for the drainage of pancreatic WON is unclear;
- In this randomized prospective trial the authors compared LAMS and plastic stents in the treatment of WON in 60 patients;
- The researchers found no difference in the primary outcome (number of procedures to achieve success) or in overall treatment success or hospital length of stay;
- LAMS were associated with higher stent-related adverse events and procedure costs but shorter procedure duration.
Although lumen-apposing metal stents (LAMS) are increasingly used for drainage of walled-off necrosis (WON), their advantage over plastic stents is unclear. We compared efficacy of LAMS and plastic stents for WON drainage.
Patients with WON were randomised to endoscopic ultrasound-guided drainage using LAMS or plastic stents. Primary outcome was comparing total number of procedures to achieve treatment success defined as symptom relief in conjunction with WON resolution on CT at 6 months. Secondary outcomes were treatment success, procedure duration, clinical/stent-related adverse events, readmissions, length of hospital stay (LOS) and costs.
60 patients underwent LAMS (n=31) or plastic stent (n=29) placement. There was no significant difference in total number of procedures performed (median 2 (range 2-7) LAMS vs 3 (range 2-7) plastic, p=0.192), treatment success, clinical adverse events, readmissions, LOS and overall treatment costs between cohorts. Although procedure duration was shorter (15 vs 40 min, p<0.001), stent-related adverse events (32.3% vs 6.9%, p=0.01) and procedure costs (US$12 155 vs US$6609, p<0.001) were higher with LAMS. Significant stent-related adverse events were observed ≥3 weeks postintervention in LAMS cohort. Interim audit resulted in protocol amendment where CT scan was obtained at 3 weeks postintervention followed by LAMS removal if WON had resolved. After protocol amendment, there was no significant difference in adverse events between cohorts.
Except for procedure duration, there was no significant difference in treatment outcomes between LAMS and plastic stents. To minimise adverse events with LAMS, patients should undergo follow-up imaging and stent removal at 3 weeks if WON has resolved.
4.Endoscopic ultrasound elastography of small solid pancreatic lesions: a multicenter study
Ignee A et al. Endoscopy 2018 Apr
- Elastography is a safe and easy to use technology to measure the stiffness (elastic properties) of a lesion during EUS (EUS-E), in comparison with the surrounding parenchyma;
- In this multicenter retrospective study the authors evaluated the accuracy of EUS-E for diagnosing malignancy in 218 patients with solid pancreatic lesions ≤15 mm;
- The lesions were categorized as “stiff” (i.e., stiffer than the surrounding pancreas) or “soft”;
- Stiffness of a target lesion had sensitivity of 84%, specificity of 67%, positive-predictive value of 56%, and negative-predictive value of 89% for the diagnosis of malignancy;
- The results show a high negative predictive value of EUS-E “soft pattern” for ruling out malignancy.
The prevalence of malignancy in patients with small solid pancreatic lesions is low; however, early diagnosis is crucial for successful treatment of these cases. Therefore, a method to reliably distinguish between benign and malignant small solid pancreatic lesions would be highly desirable. We investigated the role of endoscopic ultrasound (EUS) elastography in this setting.
Patients with solid pancreatic lesions ≤ 15 mm in size and a definite diagnosis were included. Lesion stiffness relative to the surrounding pancreatic parenchyma, as qualitatively assessed and documented at the time of EUS elastography, was retrospectively compared with the final diagnosis obtained by fine-needle aspiration/biopsy or surgical resection.
218 patients were analyzed. The average size of the lesions was 11 ± 3 mm; 23 % were ductal adenocarcinoma, 52 % neuroendocrine tumors, 8 % metastases, and 17 % other entities; 66 % of the lesions were benign. On elastography, 50 % of lesions were stiffer than the surrounding pancreatic parenchyma (stiff lesions) and 50 % were less stiff or of similar stiffness (soft lesions). High stiffness of the lesion had a sensitivity of 84 % (95 % confidence interval 73 % - 91 %), specificity of 67 % (58 % - 74 %), positive predictive value (PPV) of 56 % (50 % - 62 %), and negative predictive value (NPV) of 89 % (83 % - 93 %) for the diagnosis of malignancy. For the diagnosis of pancreaticductal adenocarcinoma, the sensitivity, specificity, PPV, and NPV were 96 % (87 % - 100 %), 64 % (56 % - 71 %), 45 % (40 % - 50 %), and 98 % (93 % - 100 %), respectively.
In patients with small solid pancreatic lesions, EUS elastography can rule out malignancy with a high level of certainty if the lesion appears soft. A stiff lesion can be either benign or malignant.
5.Endoscopic ultrasound-guided radiofrequency ablation for management of benign solid pancreatic tumors
Choi JH et al. Endoscopy 2018 May
- Radiofrequency ablation (RFA) is a well-established technique to ablate dysplastic and neoplastic tissue via local thermal coagulative necrosis. Its use in the pancreas is limited;
- Endoscopic ultrasound-guided RFA (EUS-RFA) allows real-time imaging guidance and precise localization;
- A new EUS-RFA probe passed through a modified 19G needle allows access to the pancreas;
- The authors evaluated the feasibility of EUS-RFA in 10 patients (median FU 13 months): 7 NETs, 2 solid pseudopappilary tumors and 1 insulinoma. (median diameter: 20mm);
- Multiple sessions were required in 4 patients;
- 7 patients had radiologic complete response; 1 patient developed abdominal pain and 1 had acute pancreatitis;
- EUS-RFA may become an alternative to surgery for the management of small pancreatic lesions.
Radiofrequency ablation (RFA) has been increasingly employed in experimental and clinical settings for the managementof pancreatic lesions. This study aimed to assess the safety and efficacy of endoscopic ultrasound (EUS)-guided RFA for benign solidpancreatic tumors.
In a single-center, prospective study, 10 patients with benign solid pancreatic tumors underwent EUS-RFA. After the RFA electrode had been inserted into the pancreatic mass, the radiofrequency generator was activated to deliver 50 W of ablation power.
Among the 10 patients, 16 sessions of EUS-RFA were successfully performed. Diagnoses included nonfunctioning neuroendocrine tumor (n = 7), solid pseudopapillary neoplasm (n = 2), and insulinoma (n = 1); the median largest diameter of the tumors was 20 mm (range 8 - 28 mm). During follow-up (median 13 months), radiologic complete response was achieved in seven patients. Two adverse events (12.4 %; 1 moderate and 1 mild) occurred.
EUS-RFA may be a safe and potentially effective treatment option in selected patients with benign solid pancreatic tumors. Multiple sessions may be required if there is a remnant tumor, and adverse events must be carefully monitored.