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Rimbaş M, Rizzatti G, Tosoni A, Impagnatiello M, Panzuto F, Larghi A. Small nonfunctional pancreatic neuroendocrine neoplasms: Time for a step-up treatment approach? Endosc Ultrasound 2023; 12:1-7. [PMID: 36510866 PMCID: PMC10134916 DOI: 10.4103/eus-d-22-00028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Surgery has been regarded as the only curative treatment for patients with small nonfunctional pancreatic neuroendocrine neoplasms (NF-PNENs) less than 2 cm. Due to the significant adverse event rates of surgery, the European Neuroendocrine Tumor Society issued guidelines favoring surveillance for those patients lacking criteria suggestive of an aggressive disease. Despite the above recommendations, a significant proportion of small NF-PNEN patients still undergo surgery. Recently, several studies have reported the safety and effectiveness of EUS-guided radiofrequency ablation (RFA) for the treatment of small NF-PNENs. The experience with EUS-RFA is, however, limited, but published results indicate a potential role as a minimally invasive alternative treatment for these patients, in particular in those in whom further progression is more probable, before they reach the absolute need for surgery. A step-up approach with EUS-RFA followed by surgery for the failure cases can become a valid option to be validated in clinical studies.
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Affiliation(s)
- Mihai Rimbaş
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Gastroenterology, Colentina Clinical Hospital; Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Gianenerico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alberto Tosoni
- Department of Internal Medicine, Gastroenterology and Hepatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Michele Impagnatiello
- Department of Internal Medicine, Gastroenterology and Hepatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Panzuto
- Department of Medical-Surgical Sciences and Translational Medicine, Digestive Disease Unit, ENETS Center of Excellence, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Thosani N, Cen P, Rowe J, Guha S, Bailey-Lundberg JM, Bhakta D, Patil P, Wray CJ. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) for advanced pancreatic and periampullary adenocarcinoma. Sci Rep 2022; 12:16516. [PMID: 36192558 PMCID: PMC9530230 DOI: 10.1038/s41598-022-20316-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/12/2022] [Indexed: 11/15/2022] Open
Abstract
Long term prognosis and 5-year survival for pancreatic adenocarcinoma (PDAC) remains suboptimal. Endoscopic ultrasound (EUS) guided RFA (EUS-RFA) is an emerging technology and limited data exist regarding safety and long-term outcomes. The aim of this study is to report safety-profile, feasibility and outcomes of EUS-RFA for advanced PDAC. Prospective review of patients with diagnosis of locally-advanced or metastatic PDAC undergoing EUS-RFA between October 2016 to March 2018 with long-term follow up (> 30 months). Study patients underwent a total of 1–4 RFA sessions. All patients were enrolled in longitudinal cohort study and received standard of care chemotherapy. 10 patients underwent EUS-RFA. Location of the lesions was in the head(4), neck(2), body(2), and tail(2). 22 RFA sessions were performed with a range of 1–4 sessions per patient. There were no major adverse events (bleeding, perforation, infection, pancreatitis) in immediate (up to 72 h) and short-term follow up (4 weeks). Mild worsening of existing abdominal pain was noted during post-procedure observation in 12/22 (55%) of RFA treatments. Follow-up imaging demonstrated tumor progression in 2 patients, whereas tumor regression was noted in 6 patients (> 50% reduction in size in 3 patients). Median survival for the cohort was 20.5 months (95% CI, 9.93–42.2 months). Currently, 2 patients remain alive at 61 and 81 months follow-up since initial diagnosis. One patient had 3 cm PDAC with encasement of the portal confluence, abutment of the celiac axis, common hepatic and superior mesenteric artery. This patient had significant reduction in tumor size and underwent standard pancreaticoduodenectomy. In our experience, EUS-RFA was safe, well-tolerated and could be concurrently performed with standard chemotherapy. In this select cohort, median survival was improved when compared to published survival based upon SEER database and clinical trials. Future prospective trials are needed to understand the role of EUS-RFA in overall management of PDAC.
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Affiliation(s)
- Nirav Thosani
- Department of Medicine, Center for Interventional Gastroenterology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Putao Cen
- Department of Medicine, Division of Oncology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Julie Rowe
- Department of Medicine, Division of Oncology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sushovan Guha
- Department of Medicine, Center for Interventional Gastroenterology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | - Dimpal Bhakta
- Department of Medicine, Center for Interventional Gastroenterology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Prithvi Patil
- Department of Medicine, Center for Interventional Gastroenterology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Curtis J Wray
- Department of Surgery, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.164a, Houston, TX, 77030, USA.
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Gollapudi LA, Tyberg A. EUS-RFA of the pancreas: where are we and future directions. Transl Gastroenterol Hepatol 2022; 7:18. [PMID: 35548478 PMCID: PMC9081919 DOI: 10.21037/tgh-2020-11] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/18/2020] [Indexed: 07/30/2023] Open
Abstract
Surgical resection remains the gold standard for pancreatic cancer, high-risk pancreatic neuroendocrine tumors (PNETs) and pancreatic cystic neoplasms (PCNs). However, a majority of pancreatic cancers are unresectable at the time of diagnosis. In addition, surgical resection of pancreatic lesions can be associated with morbidity and mortality. A less-invasive alternative therapeutic intervention to avoid short term and long-term adverse events is desirable, as is a minimally-invasive palliative therapy for unresectable or recurrent pancreatic cancers. Endoscopic ultrasound guided radiofrequency ablation (EUS-RFA) allows for selective tissue ablation with minimal injury to the surrounding tissue. EUS-RFA of pancreatic tumors has shown high clinical and technical success with acceptable side effects in pancreatic lesions, lymph nodes, and the celiac plexus. This paper will review the pathophysiology, available technology, safety and efficacy, and future directions of EUS-RFA.
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Affiliation(s)
- Lakshmi Asritha Gollapudi
- Department of Medicine, Division of Gastroenterology, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
| | - Amy Tyberg
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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