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Robles-Medranda C, Del Valle R, Puga-Tejada M, Arevalo-Mora M, Cunto D, Egas-Izquierdo M, Estrada-Guevara L, Bunces-Orellana O, Moreno-Zambrano D, Alcivar-Vasquez J, Alvarado-Escobar H, Merfea RC, Barreto-Perez J, Rodriguez J, Calle-Loffredo D, Pitanga-Lukashok H, Baquerizo-Burgos J, Tabacelia D. Assessing EUS-guided radiofrequency ablation in unresectable pancreatic ductal adenocarcinoma: a single-center historic cohort study. Gastrointest Endosc 2024; 100:250-258. [PMID: 38518978 DOI: 10.1016/j.gie.2024.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 02/16/2024] [Accepted: 03/17/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND AND AIMS EUS-guided radiofrequency ablation (EUS-RFA) has emerged as an alternative for the local treatment of unresectable pancreatic ductal adenocarcinoma (PDAC). We assessed the feasibility and safety of EUS-RFA in patients with unresectable PDAC. METHODS This study followed an historic cohort compounded by locally advanced (LA-) and metastatic (m)PDAC-naïve patients who underwent EUS-RFA between October 2019 and March 2022. EUS-RFA was performed with a 19-gauge needle electrode with a 10-mm active tip for energy delivery. Study primary endpoints were feasibility, safety, and clinical follow-up, whereas secondary endpoints were performance status (PS), local control, and overall survival (OS). RESULTS Twenty-six patients were selected: 15 with locally advanced pancreatic duct adenocarcinoma (LA-PDAC) and 11 with metastatic pancreatic duct adenocarcinoma (mPDAC). Technical success was achieved in all patients with no major adverse events. Six months after EUS-RFA, OS was seen in 11 of 26 patients (42.3%), with significant PS improvement (P = .03). Local control was achieved, with tumor reduction from 39.5 mm to 26 mm (P = .04). A post-treatment hypodense necrotic area was observed at the 6-month follow-up in 11 of 11 patients who were still alive. Metastatic disease was a significant factor for worsening OS (hazard ratio, 5.021; 95% confidence interval, 1.589-15.87; P = .004). CONCLUSIONS EUS-RFA for the treatment of pancreatic adenocarcinoma is a minimally invasive and safe technique that may have an important role as targeted therapy for local treatment of unresectable cases and as an alternative for poor surgical candidates. Also, RFA may play a role in downstaging cancer with a potential increase in OS in nonmetastatic cases. Large prospective cohorts are required to evaluate this technique in clinical practice.
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Affiliation(s)
| | - Raquel Del Valle
- Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Miguel Puga-Tejada
- Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Martha Arevalo-Mora
- Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | - Domenica Cunto
- Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | | | | | | | | | | | | | - Ruxandra C Merfea
- Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | | | - Jorge Rodriguez
- Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador
| | | | | | | | - Daniela Tabacelia
- Elias Emergency University Hospital, Bucharest, Romania; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
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2
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Xue K, Liu X, Xu X, Hou S, Wang L, Tian B. Perioperative outcomes and long-term survival of cryosurgery on unresectable pancreatic cancer: a systematic review and meta-analysis. Int J Surg 2024; 110:4356-4369. [PMID: 38537056 PMCID: PMC11254304 DOI: 10.1097/js9.0000000000001407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/11/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Pancreatic cancer (PC) continues to rank as one of the deadliest forms of cancer, with the majority of patients being diagnosed with unresectable disease. The implementation of cryoablation-based comprehensive treatment is expected to lead to a reduction in tumour size and potentially achieve complete resection. However, the availability of systematic and evidence-based treatment guidelines for cryoablation in pancreatic cancer is currently limited. MATERIALS AND METHODS A computerized search was conducted in the Medline, Embase, Cochrane Library databases, and Clinicaltrials to retrieve studies published from August 1987 to June 2023. The perioperative outcomes and long-term survival of patients with locally advanced pancreatic cancer (LAPC) or metastatic pancreatic cancer (mPC) who underwent cryosurgery were systematically collected. Heterogeneity was assessed using Cochran's Q test, and a funnel plot was implemented to evaluate publication bias. Data were pooled and analyzed using Stata 14.0 software. The Newcastle-Ottawa Quality Assessment Form tool was employed for quality evaluation. RESULTS Nine studies, including 368 patients, were identified. The pooled overall incidence rate was 4% (95% CI: 0-14%; I²=54.06%) for acute pancreatitis, 0% (95% CI: 0-0%; I²=0.0%) for delayed gastric emptying, 0% (95% CI: 0-1%; I²=0.0%) for postoperative pancreatic fistula (POPF) or bile leakage, 2% (95% CI: 0-5%; I²=0.0%) for bleeding, and 4% (95% CI: 0-12%; I²=70.46%) for fever. The subgroup analysis revealed that the percutaneous treatment group had a lower incidence of complications compared to laparotomy but had higher incidences of POPF, bleeding, and pancreatitis than the intraoperative group. Median overall survival (OS) varied from 5 to 16.2 months. The median survival rates at 6, 12, 24, and 36 months for patients who underwent cryosurgery were as follows: 94.9%, 64.8% (range: 4.8-63.1%), 22.80%, and 9.5%, respectively. CONCLUSION With the advancements in cryoablation and anti-tumour therapy, cryoablation has emerged as a promising treatment modality for patients with unresectable pancreatic cancer. According to existing literature, the combination of cryoablation with radioactive particle implantation or immunotherapy has demonstrated considerable efficacy and safety. However, while the majority of included data is derived from retrospective studies, it is imperative to conduct larger sample sizes or prospective trials for further validation.
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Affiliation(s)
- Kang Xue
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University
| | - Xiaofeng Liu
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University
| | - Xiaolin Xu
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Shengzhong Hou
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University
| | - Li Wang
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University
| | - Bole Tian
- Division of Pancreatic Surgery, Department of General Surgery, West China Hospital, Sichuan University
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3
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Vargas A, Dutta P, Carpenter ES, Machicado JD. Endoscopic Ultrasound-Guided Ablation of Premalignant Pancreatic Cysts and Pancreatic Cancer. Diagnostics (Basel) 2024; 14:564. [PMID: 38473035 DOI: 10.3390/diagnostics14050564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
Pancreatic cancer is on the rise and expected to become the second leading cause of cancer-related death by 2030. Up to a one-fifth of pancreatic cancers may arise from mucinous pancreatic cysts, which are frequently present in the general population. Currently, surgical resection is the only curative approach for pancreatic cancer and its cystic precursors. However, only a dismal proportion of patients are eligible for surgery. Therefore, novel treatment approaches to treat pancreatic cancer and precancerous pancreatic cysts are needed. Endoscopic ultrasound (EUS)-guided ablation is an emerging minimally invasive method to treat pancreatic cancer and premalignant pancreatic cysts. Different ablative modalities have been used including alcohol, chemotherapy agents, and radiofrequency ablation. Cumulative data over the past two decades have shown that endoscopic ablation of mucinous pancreatic cysts can lead to cyst resolution in a significant proportion of the treated cysts. Furthermore, novel data are emerging about the ability to endoscopically ablate early and locally advanced pancreatic cancer. In this review, we aim to summarize the available data on the efficacy and safety of the different EUS-ablation modalities for the management of premalignant pancreatic cysts and pancreatic cancer.
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Affiliation(s)
- Alejandra Vargas
- Department of Medicine, Eastern Virginia Medical School, Norfolk, VA 23510, USA
| | - Priyata Dutta
- Department of Medicine, Trinity Health, Ann Arbor, MI 48197, USA
| | - Eileen S Carpenter
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jorge D Machicado
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI 48109, USA
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4
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Xu R, Zhang K, Ge N, Sun S. EUS-guided interventional therapies for pancreatic diseases. Front Med (Lausanne) 2024; 10:1329676. [PMID: 38259846 PMCID: PMC10801084 DOI: 10.3389/fmed.2023.1329676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 12/26/2023] [Indexed: 01/24/2024] Open
Abstract
Endoscopic ultrasound (EUS) is an integrated diagnostic technique merging endoscope and ultrasound to examine the digestive system. EUS has emerged as a primary diagnostic method for pancreatic diseases due to its distinctive benefits. Over the past four decades, EUS has undergone a transformation, shifting its role from primarily diagnostic to increasingly therapeutic. Additionally, in recent years, EUS has emerged as an increasingly prominent adjunctive or alternative approach to conventional surgical interventions. This review provides a comprehensive analysis of current technological approaches in the treatment of pancreatic diseases. The dynamic interplay with diverse therapeutic approaches has reinvigorated EUS and shaped its trajectory in the management of pancreatic diseases.
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Affiliation(s)
| | | | | | - Siyu Sun
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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5
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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: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [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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6
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Ardeshna DR, Leupold M, Cruz-Monserrate Z, Pawlik TM, Cloyd JM, Ejaz A, Shah H, Burlen J, Krishna SG. Advancements in Microwave Ablation Techniques for Managing Pancreatic Lesions. Life (Basel) 2023; 13:2162. [PMID: 38004302 PMCID: PMC10672411 DOI: 10.3390/life13112162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/26/2023] [Accepted: 10/31/2023] [Indexed: 11/26/2023] Open
Abstract
Thermal ablation, including microwave ablation, has become increasingly important in the management of many solid tumors, including primary and metastatic tumors of the liver, kidney, and lung. However, its adoption to treat pancreatic lesions has been slowed due to concerns about potential adverse events. The success of radiofrequency ablation (RFA) in inoperable pancreatic cancers paved the way for its use in pancreatic neuroendocrine tumors and pancreatic cystic neoplasms (PCLs). In the last decade, other thermal ablation techniques, like microwave ablation, have emerged as alternatives to RFA. Microwaves, with frequencies ranging from 900 to 2450 MHz, generate heat by rapidly oscillating water molecules. Microwave ablation's advantage lies in its ability to achieve higher intra-lesion temperatures and uniform heating compared with RFA. Microwave ablation's application in pancreatic cancer and pancreatic neuroendocrine tumors has demonstrated promise with similar technical success to RFA. Yet, concern for peri-procedure complications, as well as a dearth of studies comparing RFA and microwave ablation, emphasize the need for further research. No studies have evaluated microwave ablation in PCLs. We herein review thermal ablation's potential to treat pancreatic lesions.
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Affiliation(s)
- Devarshi R. Ardeshna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Matthew Leupold
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Zobeida Cruz-Monserrate
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
- The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Timothy M. Pawlik
- The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Jordan M. Cloyd
- The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Aslam Ejaz
- The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Hamza Shah
- The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Jordan Burlen
- The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Somashekar G. Krishna
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
- The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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7
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Testoni SGG, Minici C, Benetti E, Clemente F, Boselli D, Sciorati C, De Monte L, Petrone MC, Enderle M, Linzenbold W, Protti MP, Manfredi A, De Cobelli F, Reni M, Falconi M, Capurso G, Arcidiacono PG, Della-Torre E. Immunomodulatory Effects of Endoscopic Ultrasound-Guided Thermal Ablation in Patients with Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2023; 15:3704. [PMID: 37509365 PMCID: PMC10378428 DOI: 10.3390/cancers15143704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
Immunological consequences of endoscopic ultrasound (EUS)-local thermal ablation (LTA) for pancreatic ductal adenocarcinoma (PDAC) have not been extensively assessed. We aimed to explore EUS-LTA effects on the systemic immune response in PDAC. Peripheral blood was collected from 10 treatment-naïve patients with borderline resectable and locally advanced PDAC, randomly allocated to Nab-paclitaxel plus Gemcitabine chemotherapy (CT-arm, n = 5) or EUS-LTA with HybridTherm Probe plus CT (HTP + CT-arm, n = 5). Twenty healthy donors were included as controls. Flow-cytometry and multiplex assays were used to profile immune cell subsets and measure serum cytokines/chemokines, respectively. At baseline, PDAC patients showed increased circulating monocytes and lower circulating lymphocytes and CD19+ B cells counts compared to healthy controls. After 4 months, CT induced decrease of B regulatory cells, CD4+ cytotoxic T cells and IL-1β. The addition of EUS-HTP to CT selectively decreased the serum levels of APRIL/TNFSF13 as well as T regulatory cells, total, classic and inflammatory monocytes. Serum levels of APRIL/TNFSF13 and total, classic and inflammatory monocytes counts at baseline were associated with worse overall survival. EUS-HTP has the potential to selectively impact on immune cells and cytokines associated with poor outcomes in PDAC.
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Affiliation(s)
- Sabrina Gloria Giulia Testoni
- Pancreatico-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Claudia Minici
- IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Elisa Benetti
- Center for Omics Sciences, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget) and Pediatric Immunohematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Francesca Clemente
- Tumor Immunology Unit, Division of Immunology, Transplantation, and Infectious Disease, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Daniela Boselli
- FRACTAL (Flow Cytometry Resource, Advanced Cytometry Technical Applications Laboratory), IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Clara Sciorati
- Division of Immunology, Transplantation & Infectious Diseases, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Lucia De Monte
- Tumor Immunology Unit, Division of Immunology, Transplantation, and Infectious Disease, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Maria Chiara Petrone
- Pancreatico-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Markus Enderle
- Department of Research and Basic Technologies, Erbe Elektromedizin GmbH, Waldhörnlestraße 17, 72072 Tübingen, Germany
| | - Walter Linzenbold
- Department of Research and Basic Technologies, Erbe Elektromedizin GmbH, Waldhörnlestraße 17, 72072 Tübingen, Germany
| | - Maria Pia Protti
- Tumor Immunology Unit, Division of Immunology, Transplantation, and Infectious Disease, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Angelo Manfredi
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Francesco De Cobelli
- Department of Radiology, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Michele Reni
- Department of Medical Oncology, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Gabriele Capurso
- Pancreatico-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreatico-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
| | - Emanuel Della-Torre
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132 Milan, Italy
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8
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Dahiya DS, Chandan S, Ali H, Pinnam BSM, Gangwani MK, Al Bunni H, Canakis A, Gopakumar H, Vohra I, Bapaye J, Al-Haddad M, Sharma NR. Role of Therapeutic Endoscopic Ultrasound in Management of Pancreatic Cancer: An Endoscopic Oncologist Perspective. Cancers (Basel) 2023; 15:3235. [PMID: 37370843 DOI: 10.3390/cancers15123235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 06/08/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023] Open
Abstract
Pancreatic cancer is a highly lethal disease with an aggressive clinical course. Patients with pancreatic cancer are usually asymptomatic until significant progression of their disease. Additionally, there are no effective screening guidelines for pancreatic cancer in the general population. This leads to a delay in diagnosis and treatment, resulting in poor clinical outcomes and low survival rates. Endoscopic Ultrasound (EUS) is an indispensable tool for the diagnosis and staging of pancreatic cancer. In the modern era, with exponential advancements in technology and device innovation, EUS is also being increasingly used in a variety of therapeutic interventions. In the context of pancreatic cancer where therapies are limited due to the advanced stage of the disease at diagnosis, EUS-guided interventions offer new and innovative options. Moreover, due to their minimally invasive nature and ability to provide real-time images for tumor localization and therapy, they are associated with fewer complication rates compared to conventional open and laparoscopic approaches. In this article, we detail the most current and important therapeutic applications of EUS for pancreatic cancer, namely EUS-guided Fine Needle Injections, EUS-guided Radiotherapy, and EUS-guided Ablations. Furthermore, we also discuss the feasibility and safety profile of each intervention in patients with pancreatic cancer to provide gastrointestinal medical oncologists, radiation and surgical oncologists, and therapeutic endoscopists with valuable information to facilitate patient discussions and aid in the complex decision-making process.
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Affiliation(s)
- Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology & Motility, The University of Kansas School of Medicine, Kansas City, KS 66160, USA
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68131, USA
| | - Hassam Ali
- Department of Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC 27834, USA
| | - Bhanu Siva Mohan Pinnam
- Department of Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL 60612, USA
| | | | - Hashem Al Bunni
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Harishankar Gopakumar
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL 61605, USA
| | - Ishaan Vohra
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, IL 61605, USA
| | - Jay Bapaye
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY 14621, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Neil R Sharma
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
- Interventional Oncology & Surgical Endoscopy Programs (IOSE), GI Oncology Tumor Site Team, Parkview Cancer Institute, Parkview Health, Fort Wayne, IN 46845, USA
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9
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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] [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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10
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New Perspectives on Endoscopic Management of Liver and Pancreatic Cancer. Cancers (Basel) 2023; 15:cancers15051549. [PMID: 36900340 PMCID: PMC10001003 DOI: 10.3390/cancers15051549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/13/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Liver and pancreatic cancers are major health issues which represent a clinical and economic burden worldwide [...].
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11
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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, LITHUANIA) 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] [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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12
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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] [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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13
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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] [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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14
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Vanella G, Bronswijk M, Arcidiacono PG, Larghi A, Wanrooij RLJV, de Boer YS, Rimbas M, Khashab M, van der Merwe SW. Current landscape of therapeutic EUS: Changing paradigms in gastroenterology practice. Endosc Ultrasound 2023; 12:16-28. [PMID: 36124531 PMCID: PMC10134933 DOI: 10.4103/eus-d-21-00177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Therapeutic EUS has witnessed exponential growth in the last decade, but it has been considered investigational until recently. An increasing body of good-quality evidence is now demonstrating clear advantages over established alternatives, adding therapeutic EUS to management algorithms of complex hepato-pancreato-biliary (HPB) and gastrointestinal (GI) conditions. In this review, the available evidence and clinical role of therapeutic EUS in established and evolving applications will be discussed. A Graphical Summary for each scenario will provide (1) technical steps, (2) anatomical sketch, (3) best-supporting evidence, and (4) role in changing current and future GI practice. Therapeutic EUS has accepted well-established applications such as drainage of symptomatic peripancreatic fluid collections, biliary drainage in failed endoscopic retrograde cholangiopancreatography, and treatment of acute cholecystitis in unfit-for-surgery patients. In addition, good-quality evidence on several emerging indications (e.g., treatment of gastric outlet obstruction, local ablation of pancreatic solid lesions, etc.) is promising. Specific emphasis will be given to how these technical innovations have changed management paradigms and algorithms and expanded the possibilities of gastroenterologists to provide therapeutic solutions to old and emerging clinical needs. Therapeutic EUS is cementing its role in everyday practice, radically changing the treatment of different HPB diseases and other conditions (e.g., GI obstruction). The development of dedicated accessories and increased training opportunities will expand the ability of gastroenterologists to deliver highly effective yet minimally invasive therapies, potentially translating into a better quality of life, especially for oncological and fragile patients.
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Affiliation(s)
- Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, University of Leuven, Leuven; Department of Gastroenterology and Hepatology, Imelda General Hospital, Bonheiden, Belgium
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS; Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, AGEM Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ynto S de Boer
- Department of Gastroenterology and Hepatology, Amsterdam UMC, AGEM Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mihai Rimbas
- Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Schalk W van der Merwe
- Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
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15
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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] [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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16
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Testoni SGG, Petrone MC, Reni M, Di Serio C, Rancoita PM, Rossi G, Balzano G, Linzenbold W, Enderle M, Della-Torre E, De Cobelli F, Falconi M, Capurso G, Arcidiacono PG. EUS-guided ablation with the HybridTherm Probe as second-line treatment in patients with locally advanced pancreatic ductal adenocarcinoma: A case-control study. Endosc Ultrasound 2022; 11:383-392. [PMID: 36255026 PMCID: PMC9688129 DOI: 10.4103/eus-d-21-00200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background and Objectives Data on the clinical efficacy of EUS-guided ablation using the HybridTherm-Probe (EUS-HTP) in locally advanced pancreatic ductal adenocarcinoma (LA-PDAC) are lacking. The aim of the study was to assess the impact of EUS-HTP added to chemotherapy (CT) on overall survival (OS) and progression-free survival (PFS) of LA-PDAC patients with local disease progression (DP) after first-line therapy, compared to CT alone in controls. Methods LA-PDAC cases, prospectively treated by EUS-HTP, were retrospectively compared to matched controls (1:2) receiving standard treatment. Study endpoints were the OS and PFS from local DP after first-line therapy, compared through log-rank test calculating hazard ratios and differences in restricted mean OS/PFS time (RMOST/RMPFST) within prespecified time points (4, 6, and 12 months). Results Thirteen cases and 26 controls were included. Clinical, tumor, and therapy features before and after first-line therapy were case-control balanced. The median OS and PFS were not significantly improved in cases over controls (months: 7 vs. 5 and 5 vs. 3, respectively). At 4 and 6 months, the RMPFST difference was in favor of cases (P = 0.0001 and P = 0.003, respectively). In cases and controls not candidate to further CT (N = 5 and N = 9), the median OS and PFS were not significantly improved in cases over controls (months: 6 vs. 3 and 4 vs. 2, respectively), but the RMPFST difference was in favor of cases at 4 months (P = 0.002). Conclusions In locally progressive PDAC patients experiencing failure of first-line therapy, EUS-HTP achieves a significantly better RMPFST up to 6 months compared to standard treatment, although without a significant impact on OS.
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Affiliation(s)
- Sabrina Gloria Giulia Testoni
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | - Maria Chiara Petrone
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | - Michele Reni
- Department of Oncology, Pancreas Translational and Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | - Clelia Di Serio
- Vita-Salute San Raffaele University, CUSSB, University Centre for Statistics in the Biomedical Sciences, Milan, Italy
| | - Paola Maria Rancoita
- Vita-Salute San Raffaele University, CUSSB, University Centre for Statistics in the Biomedical Sciences, Milan, Italy
| | - Gemma Rossi
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | - Gianpaolo Balzano
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | | | | | - Emanuel Della-Torre
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, Pancreas Translational and Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | - Francesco De Cobelli
- Department of Radiology and Center for Experimental Imaging, Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University, San Raffaele Hospital, Milan, Italy
| | - Massimo Falconi
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University, San Raffaele Hospital, Milan, Italy
| | - Gabriele Capurso
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, San Raffaele Hospital, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, Vita-Salute San Raffaele University, San Raffaele Hospital, Milan, Italy,Address for correspondence Prof. 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, Via Olgettina 60, 20132, Milan, Italy. E-mail:
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17
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Abstract
Pancreatobiliary malignancies have poor prognosis, and many patients are inoperable at the time of diagnosis. When surgical resection is impossible, systemic chemotherapy or radiotherapy is traditionally conducted with trial of immunotherapy or gene therapy lately. With the rapid development of endoscopic instruments and accessories in recent years, not only endoscopic early detection, characterization, and staging but also endoscopic palliative management of the pancreatobiliary malignancies is expanding the horizons. Endoscopic management is often preferred due to similar efficacy to surgical management with less morbidity. Here, we review the methodology and treatment outcome of various endoscopic management strategies in pancreatobiliary malignancies including endoscopic complication management, local palliative therapy, endoscopy-assisted therapy, and pain control utilizing endoscopic retrograde cholangiopancreatography or endoscopic ultrasound.
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18
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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: 13] [Impact Index Per Article: 6.5] [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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19
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Ardeshna DR, Woods E, Tsung A, Krishna SG. An update on EUS-guided ablative techniques for pancreatic cystic lesions. Endosc Ultrasound 2022; 11:432-441. [PMID: 35313421 PMCID: PMC9921977 DOI: 10.4103/eus-d-21-00178] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pancreatic cystic lesions (PCLs) are increasingly being recognized due to improvements and widespread use of cross-sectional imaging. With an estimated prevalence of 15% in general population, incidentally discovered PCLs represent a dilemma in management. While pancreatectomies offer a chance of cure, the morbidity is considerable in patients with high surgical risks. More recently, EUS-guided approaches for cyst ablation are being offered in clinical trials for the management of PCLs. EUS-chemoablation studies have progressed from first investigating safety and efficacy of EUS-guided alcohol lavage to single-agent paclitaxel ablation. Recent studies have shown that alcohol lavage may not be required, and long-term resolution can be achieved by chemoablation alone. EUS-guided lauromacrogol ablation and EUS-guided radiofrequency ablation (RFA) are new techniques that have shown promising results in a few small studies. Overall, the current literature suggests that EUS-guided paclitaxel ablation has better cyst resolution rates compared to other existing minimally invasive techniques including ethanol injection, lauromacrogol ablation, or RFA. This article will review EUS-guided PCL ablation approaches and future directions the field is headed into.
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Affiliation(s)
- Devarshi R. Ardeshna
- Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Edward Woods
- College of Medicine, Ohio State University, Columbus, Ohio, USA
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Somashekar G. Krishna
- Division of Gastroenterology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio, USA,Address for correspondence Dr. Somashekar G. Krishna, Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, Suite 262, Columbus, Ohio 43210, USA. E-mail:
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20
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Spadaccini M, Di Leo M, Iannone A, von den Hoff D, Fugazza A, Galtieri PA, Pellegatta G, Maselli R, Anderloni A, Colombo M, Siersema PD, Carrara S, Repici A. Endoscopic ultrasound-guided ablation of solid pancreatic lesions: A systematic review of early outcomes with pooled analysis. World J Gastrointest Oncol 2022; 14:533-542. [PMID: 35317325 PMCID: PMC8918998 DOI: 10.4251/wjgo.v14.i2.533] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/03/2021] [Accepted: 12/31/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is emerging as a complementary therapeutic approach for pancreatic solid masses. However, results of published data are difficult to interpret because of a retrospective design and small sample size.
AIM To systematically review data on EUS-RFA for solid lesions and to pool the results of the different experiences in order to provide more consistent evidence in terms of safety and efficacy.
METHODS A comprehensive systematic literature search on the main databases was performed to identify articles in which patients with pancreatic solid lesions underwent EUS-RFA. The primary outcomes were procedure-related adverse events (AEs) and mortality. Secondary outcomes were the technical success rate and the effects on primary tumor growth. Statistical analyses were performed using Stata version 14.0.
RESULTS In total, 14 studies were included, with 120 patients undergoing 153 ablations of 129 solid pancreatic lesions. The STARmed technology was used in seven studies, the Habib system in six studies, and the HybridTherm probe in one study. The pooled technical success rate was 99.0% (I2: 25.82%). The pooled overall AE rate was 8.0% (I2: 11.46%). Excluding mild AEs, the pooled rates of serious AEs was 1.0% (I2: 0%). No mortality related to the procedure was reported.
CONCLUSION The present pooled analysis confirms the safety and feasibility of EUS-RFA.
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Affiliation(s)
- Marco Spadaccini
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milan, Italy
| | - Milena Di Leo
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Andrea Iannone
- Endoscopy Unit, Azienda Ospedale Policlinico, Bari 70124, Italy
| | - Daan von den Hoff
- Endoscopy Unit, Radboud University Medical Center, Nijmegen 6525 GA, Netherlands
| | - Alessandro Fugazza
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Piera Alessia Galtieri
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Gaia Pellegatta
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Roberta Maselli
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milan, Italy
| | - Andrea Anderloni
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Matteo Colombo
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Peter D Siersema
- Endoscopy Unit, Radboud University Medical Center, Nijmegen 6525 GA, Netherlands
| | - Silvia Carrara
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Alessandro Repici
- Endoscopic Unit, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milan, Italy
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21
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Sbeit W, Napoléon B, Khoury T. Endoscopic ultrasound role in pancreatic adenocarcinoma treatment: A review focusing on technical success, safety and efficacy. World J Gastroenterol 2022; 28:332-347. [PMID: 35110953 PMCID: PMC8771609 DOI: 10.3748/wjg.v28.i3.332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/22/2021] [Accepted: 01/06/2022] [Indexed: 02/06/2023] Open
Abstract
The impressive technological advances in recent years have rapidly translated into the shift of endoscopic ultrasound (EUS) from diagnostic modality into an interventional and therapeutic tool. Despite the great advance in its diagnosis, the majority of pancreatic adenocarcinoma cases are inoperable when diagnosed, thus demanding alternative optional therapies. EUS has emerged as an easy, minimally invasive modality targeting this carcinoma with different interventions that have been reported recently. In this review we summarize the evolving role of interventional therapeutic EUS in pancreatic adenocarcinoma management.
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Affiliation(s)
- Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, Faculty of Medicine in the Galilee, Bar-Ilan University, Nahariya 2221006, Israel
| | - Bertrand Napoléon
- Department of Endoscopy Unit, Private Hospital Jean Mermoz, Ramsay Generale de Sante, Lyon 69008, France
| | - Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Faculty of Medicine in the Galilee, Bar-Ilan University, Nahariya 2221006, Israel
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22
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Dhar J, Samanta J. Role of therapeutic endoscopic ultrasound in gastrointestinal malignancy- current evidence and future directions. Clin J Gastroenterol 2022; 15:11-29. [PMID: 35028906 DOI: 10.1007/s12328-021-01559-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 11/11/2021] [Indexed: 12/31/2022]
Abstract
Endoscopic ultrasound (EUS) has come a long way from a mere diagnostic tool to an advanced therapeutic modality. With the advent of better technologies and accessories, EUS has found ground in the management of gastrointestinal (GI) malignancies, not only for diagnosis but also for therapeutic purposes. EUS can tackle a host of conditions, including hepato-pancreatico-biliary malignancies. Advances and experience in various EUS-guided biliary drainage techniques have enabled the endosonologist to tackle biliary obstruction when conventional techniques of endoscopic retrograde cholangiopancreatography (ERCP) and/or percutaneous transhepatic biliary drainage (PTBD) fails. More and more emerging data not only establishes the safety of EUS-BD but also demonstrates superior efficacy over PTBD and sometimes even ERCP. Malignant gastric outlet obstruction can now be safely managed with EUS-guided gastroenterostomy. Starting from pain management in malignant tumors through celiac plexus neurolysis to various tumor ablative therapies, EUS has forged ahead over percutaneous treatment or surgical options in the management of GI malignancies. Additional data is now coming up on the prospects of EUS-guided immunotherapy and biological therapy for tumor management. The future of EUS therapeutics in the field of GI malignancies is bright. With increasing evidence, this modality becoming a key player in management of a host of complex clinical conditions arising out of GI malignancies is in the offing. This review focuses on elucidating the role of therapeutic EUS in the management of GI malignancies, a synopsis of various techniques, data on its safety and efficacy as well as future advancements in this domain.
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Affiliation(s)
- Jahnvi Dhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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Heger U, Hackert T. Can local ablative techniques replace surgery for locally advanced pancreatic cancer? J Gastrointest Oncol 2021; 12:2536-2546. [PMID: 34790414 DOI: 10.21037/jgo-20-379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/04/2020] [Indexed: 12/25/2022] Open
Abstract
In the treatment of pancreatic ductal adenocarcinoma (PDAC) the best chance at long term survival or cure has to date always included the complete surgical removal of the tumor. However, locally advanced pancreatic cancer (LAPC), about 25% of all newly diagnosed PDAC, is defined by its primary technical unresectability due to infiltration of visceral arteries and absence of metastasis. Induction therapies, especially FOLFIRINOX treatment, together with technical surgical advancement have increased the numbers for conversion to secondary resectability. Recent data on resections after induction therapy show promising, almost doubled survival compared to palliative treatment. Yet, around 70% of LAPC remain unresectable after induction therapy, often due to persistent local invasion. As locally ablative techniques are becoming more widely available this review examines their possible applicability to substitute for surgery in these cases which we propose to group under the new term "Inconvertible LAPC". The need for defining this novel subgroup who might benefit from ablative treatment is based on the findings in our review that high-level evidence on ablative techniques for PDAC is largely lacking and the latest effective, harmonized treatment guidelines for LAPC are not often incorporated in these studies. The "inconvertible LAPC" label requires persistent unresectability after staging and induction therapy of LAPC according to current guidelines followed by liberal indication for aggressive surgical exploration at a center equipped for extended pancreatic resections. Ideally, this specification of a new, distinct patient group will also put it in the spotlight more, hopefully prompt more trials designed to generate robust evidence and optimize transferability of study results.
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Affiliation(s)
- Ulrike Heger
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital, Heidelberg, Germany
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24
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Testoni SGG, Petrone MC, Reni M, Rossi G, Barbera M, Nicoletti V, Gusmini S, Balzano G, Linzenbold W, Enderle M, Della-Torre E, De Cobelli F, Doglioni C, Falconi M, Capurso G, Arcidiacono PG. Efficacy of Endoscopic Ultrasound-Guided Ablation with the HybridTherm Probe in Locally Advanced or Borderline Resectable Pancreatic Cancer: A Phase II Randomized Controlled Trial. Cancers (Basel) 2021; 13:4512. [PMID: 34572743 PMCID: PMC8464946 DOI: 10.3390/cancers13184512] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/31/2021] [Accepted: 09/01/2021] [Indexed: 11/30/2022] Open
Abstract
Endoscopic ultrasound-ablation with HybridTherm-Probe (EUS-HTP) significantly reduces tumour volume (TV) in locally-advanced pancreatic ductal adenocarcinoma (LA-PDAC). We aimed at investigating the clinical efficacy of EUS-HTP plus chemotherapy versus chemotherapy (HTP-CT and CT arms) in LA- and borderline-resectable (BR) PDAC, with 6-months progression-free survival (6-PFS) rate as primary endpoint. In a phase-II randomized-controlled-trial, 33 LA/BR-PDAC patients per-arm were planned to verify 20% improved 6-PFS rate. Radiological response (Choi criteria), TV and serum CA19.9 were assessed up to 6-months. Seventeen and 20 LA/BR-PDAC patients were randomized to HTP-CT or CT. Baseline and CT-related features were balanced. At 6-months, 6-PFS rate was 41.2% and 30% in HTP-CT and CT arms (p = 0.48), respectively. A decrease ≥50% of serum CA19.9 was achieved in 75% and 64.3% of HTP-CT and CT patients (p = 0.53), respectively. TV reduced up to 6-months in 64.3% and 47.1% of HTP-CT and CT patients (p = 0.35), respectively. Resection rate, PFS-time and overall survival (OS-time) were similar. HTP-CT achieves a non-significant 11.2%, 10.7% and 17.2% improved 6-PFS, CA19.9 decrease ≥50% and TV reduction rates over CT, without any impact on resection rate, PFS-time and OS-time. As the study was underpowered, these results suggest further investigation of EUS-local ablation in selected patients with localized disease after induction CT.
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Affiliation(s)
- Sabrina Gloria Giulia Testoni
- Pancreas Translational & Clinical Research Center, Pancreato-Biliary Endoscopy & Endosonography Division, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (M.C.P.); (G.R.); (G.C.)
| | - Maria Chiara Petrone
- Pancreas Translational & Clinical Research Center, Pancreato-Biliary Endoscopy & Endosonography Division, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (M.C.P.); (G.R.); (G.C.)
| | - Michele Reni
- Pancreas Translational & Clinical Research Center, Oncology Department, San Raffaele Scientific Institute IRCCS, 20132 Milan, Italy;
| | - Gemma Rossi
- Pancreas Translational & Clinical Research Center, Pancreato-Biliary Endoscopy & Endosonography Division, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (M.C.P.); (G.R.); (G.C.)
| | - Maurizio Barbera
- Pancreas Translational & Clinical Research Center, Department of Radiology & Center for Experimental Imaging, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (M.B.); (V.N.); (S.G.); (F.D.C.)
| | - Valeria Nicoletti
- Pancreas Translational & Clinical Research Center, Department of Radiology & Center for Experimental Imaging, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (M.B.); (V.N.); (S.G.); (F.D.C.)
| | - Simone Gusmini
- Pancreas Translational & Clinical Research Center, Department of Radiology & Center for Experimental Imaging, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (M.B.); (V.N.); (S.G.); (F.D.C.)
| | - Gianpaolo Balzano
- Pancreas Translational & Clinical Research Center, Pancreatic Surgery Department, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.B.); (M.F.)
| | - Walter Linzenbold
- ERBE Research Elektromedizin GmbH, 72072 Tübingen, Germany; (W.L.); (M.E.)
| | - Markus Enderle
- ERBE Research Elektromedizin GmbH, 72072 Tübingen, Germany; (W.L.); (M.E.)
| | - Emanuel Della-Torre
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy;
| | - Francesco De Cobelli
- Pancreas Translational & Clinical Research Center, Department of Radiology & Center for Experimental Imaging, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (M.B.); (V.N.); (S.G.); (F.D.C.)
| | - Claudio Doglioni
- Pancreas Translational & Clinical Research Center, Pathology Department, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy;
| | - Massimo Falconi
- Pancreas Translational & Clinical Research Center, Pancreatic Surgery Department, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.B.); (M.F.)
| | - Gabriele Capurso
- Pancreas Translational & Clinical Research Center, Pancreato-Biliary Endoscopy & Endosonography Division, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (M.C.P.); (G.R.); (G.C.)
| | - Paolo Giorgio Arcidiacono
- Pancreas Translational & Clinical Research Center, Pancreato-Biliary Endoscopy & Endosonography Division, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (M.C.P.); (G.R.); (G.C.)
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A Multicenter Randomized Controlled Prospective Study to Assess Efficacy of Laparoscopic Electrochemotherapy in the Treatment of Locally Advanced Pancreatic Cancer. J Clin Med 2021; 10:jcm10174011. [PMID: 34501459 PMCID: PMC8432461 DOI: 10.3390/jcm10174011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/03/2021] [Accepted: 09/03/2021] [Indexed: 12/21/2022] Open
Abstract
Background: Eighty percent of patients with pancreatic adenocarcinoma present a locally advanced or metastatic disease at diagnosis and are not eligible for surgery if not with palliative intent. In cases of locally advanced disease (LAPC), the combination of chemo and radiotherapy is the only therapeutic option and correlates with a median survival of 15 months (10 months without treatment), with partial remission of disease in 50% of cases. The feasibility and safety of Electrochemotherapy (ECT) have been demonstrated in the treatment of deep tumors. Aim: The aim of the study is to evaluate the efficacy of electrochemotherapy (ECT) followed by conventional systemic treatment compared to the only conventional systemic treatment in LAPC in terms of objective response and overall survival. Patients and Methods: This study is a phase IIb prospective multicenter randomized controlled trial with two arms. The study will include 90 patients: 45 in the control group and 45 in the experimental group. Patients with LAPC in the control arm will receive conventional chemotherapy (FOLFOXIRI). Patients with LAPC in the experimental arm will be subjected to Electrochemotherapy and subsequently to FOLFOXIRI. The objective response at 30, 90, and 180 days from treatment will be based on the computed tomography (CT), magnetic resonance (MR), and positron emission tomography/CT response (PET/CT). The objective long-term treatment response will be evaluated with the modified response evaluation criteria in solid tumors (m-RECIST) criteria, which will take into account the difference in vascularization, determined by the images obtained by CT and MR of the tumor treated before and after ECT. Conclusions: Not resectable liver metastasis, pancreatic tumors, and locally advanced renal carcinomas can be treated with laparoscopic electrodes. ECT could represent an effective therapeutic option for patients not eligible for surgery susceptible to be managed only with palliative therapies.
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Laparoscopic ultrasonography-guided cryoablation of locally advanced pancreatic cancer: a preliminary report. Jpn J Radiol 2021; 40:86-93. [PMID: 34279799 DOI: 10.1007/s11604-021-01175-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/13/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To evaluate safety and feasibility of laparoscopic ultrasonography (LUS)-guided cryoablation of locally advanced pancreatic cancer (LAPC). PATIENTS AND METHODS From April 2018 to December 2018, ten patients (five women, five men; mean age 58.2 ± 9.4 years) with LAPC underwent the operation. LUS was used to guide the cryoablation. Computed tomography (CT) imaging, biochemical analysis and pain score analysis by numeric rating scale (NRS) were used to assess treatment outcomes at 1 week and 3 months after the operation. RESULTS Cryoablation was performed by the operation in all cases. Seven patients received complete ablation and the success rate of operation was 70%. Two cryoablation cycles and an average of 1.4 ± 0.5 cryoprobes were used. The average freezing time and operation time were 23.8 ± 1.0 and 110.5 ± 24.7 min, respectively. The mean blood loss was 52.0 ± 16.6 ml. No major complications were observed after the operation. The mean maximum tumor diameter determined by CT decreased from 4.9 ± 0.7 cm before the operation to 4.7 ± 1.0 cm at 1 week and 4.6 ± 1.3 cm at 3 months, with P values of 0.53 and 0.51 (relative to the preoperative values), respectively. Postoperative CT imaging results suggested tumor necrosis in cryoablation-treated areas. The mean CA19-9 levels decreased from 347.5 ± 345.7 U/mL before operation to 190.4 ± 153.8 U/mL at 1 week and 182.7 ± 165.6 U/mL at 3 months, with P values of 0.15 and 0.14 (relative to the preoperative values), respectively. The average pain scores declined from 6.9 ± 1.1 before operation to 1.3 ± 1.2 at 1 week and 2.0 ± 0.8 at 3 months, with both P values of < 0.01 (relative to the preoperative values). CONCLUSION This preliminary study suggested that LUS-assisted cryoablation was a safe and feasible treatment for LAPC.
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Abstract
Ablative therapies for locoregional treatment of pancreatic neoplastic lesions developed over the last decade to be applied during surgery are now becoming also available to be utilized under endoscopic ultrasound (EUS) guidance. The advantage of this approach is clear because of the close proximity of the EUS transducer to the target lesion, coupled with developments of specifically designed ablation devices, making the procedure minimally invasive, and potentially sparing patients from the morbidity of this method when performed surgically. EUS-guided ablative techniques that have been applied to pancreatic neoplastic cysts, pancreatic functional and non-functional neuroendocrine neoplasms and pancreatic ductal adenocarcinoma include ethanol injection, radiofrequency ablation (RFA), a combination of bipolar RFA and cryoablation, laser therapy (LT) and photodynamic therapy (PDT). Up to now, most of these procedures have been applied to patients at high surgical risk or who refused surgery. However, more studies evaluating some of these treatments also in selected patients not at surgical risk are becoming available. These studies will pave the road to apply this therapeutic approach to a more extensive number of patients, alone or in association with other therapies, such as immunomodulating drugs. The present manuscript will critically review the available evidence in the field of EUS-guided local ablative treatment of solid and cystic pancreatic neoplasms.
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Affiliation(s)
- Mihai Rimbaș
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania.,Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy - .,CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
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Timmer FE, Geboers B, Nieuwenhuizen S, Schouten EA, Dijkstra M, de Vries JJ, van den Tol MP, de Gruijl TD, Scheffer HJ, Meijerink MR. Locally Advanced Pancreatic Cancer: Percutaneous Management Using Ablation, Brachytherapy, Intra-arterial Chemotherapy, and Intra-tumoral Immunotherapy. Curr Oncol Rep 2021; 23:68. [PMID: 33864144 PMCID: PMC8052234 DOI: 10.1007/s11912-021-01057-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive neoplasms, bearing a terrible prognosis. Stage III tumors, also known as locally advanced pancreatic cancer (LAPC), are unresectable, and current palliative chemotherapy regimens have only modestly improved survival in these patients. At this stage of disease, interventional techniques may be of value and further prolong life. The aim of this review was to explore current literature on locoregional percutaneous management for LAPC. RECENT FINDINGS Locoregional percutaneous interventional techniques such as ablation, brachytherapy, and intra-arterial chemotherapy possess cytoreductive abilities and have the potential to increase survival. In addition, recent research demonstrates the immunomodulatory capacities of these treatments. This immune response may be leveraged by combining the interventional techniques with intra-tumoral immunotherapy, possibly creating a durable anti-tumor effect. This multimodality treatment approach is currently being examined in several ongoing clinical trials. The use of certain interventional techniques appears to improve survival in LAPC patients and may work synergistically when combined with immunotherapy. However, definitive conclusions can only be made when large prospective (randomized controlled) trials confirm these results.
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Affiliation(s)
- Florentine E.F. Timmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Bart Geboers
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Sanne Nieuwenhuizen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Evelien A.C. Schouten
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Madelon Dijkstra
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Jan J.J. de Vries
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - M. Petrousjka van den Tol
- Department of Surgical Oncology, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Tanja D. de Gruijl
- Department of Medical Oncology, Amsterdam UMC (location VUmc)-Cancer Center Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Hester J. Scheffer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Martijn R. Meijerink
- Department of Radiology and Nuclear Medicine, Amsterdam UMC (location VUmc), De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
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Establishing an immunocompromised porcine model of human cancer for novel therapy development with pancreatic adenocarcinoma and irreversible electroporation. Sci Rep 2021; 11:7584. [PMID: 33828203 PMCID: PMC8027815 DOI: 10.1038/s41598-021-87228-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 03/25/2021] [Indexed: 02/07/2023] Open
Abstract
New therapies to treat pancreatic cancer are direly needed. However, efficacious interventions lack a strong preclinical model that can recapitulate patients’ anatomy and physiology. Likewise, the availability of human primary malignant tissue for ex vivo studies is limited. These are significant limitations in the biomedical device field. We have developed RAG2/IL2RG deficient pigs using CRISPR/Cas9 as a large animal model with the novel application of cancer xenograft studies of human pancreatic adenocarcinoma. In this proof-of-concept study, these pigs were successfully generated using on-demand genetic modifications in embryos, circumventing the need for breeding and husbandry. Human Panc01 cells injected subcutaneously into the ears of RAG2/IL2RG deficient pigs demonstrated 100% engraftment with growth rates similar to those typically observed in mouse models. Histopathology revealed no immune cell infiltration and tumor morphology was highly consistent with the mouse models. The electrical properties and response to irreversible electroporation of the tumor tissue were found to be similar to excised human pancreatic cancer tumors. The ample tumor tissue produced enabled improved accuracy and modeling of the electrical properties of tumor tissue. Together, this suggests that this model will be useful and capable of bridging the gap of translating therapies from the bench to clinical application.
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Clinical Phase I/II Study: Local Disease Control and Survival in Locally Advanced Pancreatic Cancer Treated with Electrochemotherapy. J Clin Med 2021; 10:jcm10061305. [PMID: 33810058 PMCID: PMC8005134 DOI: 10.3390/jcm10061305] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 02/06/2023] Open
Abstract
Objective. To assess local disease control rates (LDCR) and overall survival (OS) in locally advanced pancreatic cancer (LAPC) treated with electrochemotherapy (ECT). Methods. Electrochemotherapy with bleomycin was performed in 25 LAPC patients who underwent baseline Magnetic Resonance Imaging (MRI) and/or Computed Tomography (CT) and Position Emission Tomography (PET) scans before ECT and 1 and 6 months post ECT. LDCR were assessed using Response Evaluation Criteria in Solid Tumors (RECIST 1.1) and Choi criteria. Needle electrodes with fixed linear (N-30-4B) or fixed hexagonal configurations (N-30-HG or I-40-HG or H-30-ST) or variable geometry (VGD1230 or VGD1240) (IGEA S.p.A., Carpi, Italy) were used to apply electric pulses. Pain evaluation was performed pre-ECT, after 1 month and after 6 months with ECT. Overall survival estimates were calculated by means of a Kaplan-Meier analysis. Results. At 1 month after ECT, 76% of patients were in partial response (PR) and 20% in stable disease (SD). Six months after ECT, 44.0% patients were still in PR and 12.0% in SD. A LDCR of 56.0% was reached six months after ECT: 13 patients treated with fixed geometry had a LDCR of 46.1%, while for the 12 patients treated with variable geometry, the LDCR was 66.7%. The overall survival median value was 11.5 months: for patients treated with fixed geometry the OS was 6 months, while for patients treated with variable geometry it was 12 months. Electrochemotherapy was well-tolerated and abdominal pain was rapidly resolved. Conclusions. Electrochemotherapy obtained good results in terms of LDCR and OS in LAPC. Multiple needle insertion in a variable geometry configuration optimized by pre-treatment planning determined an increase in LDCR and OS compared to a fixed geometry configuration.
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Yousaf MN, Ehsan H, Muneeb A, Wahab A, Sana MK, Neupane K, Chaudhary FS. Role of Radiofrequency Ablation in the Management of Unresectable Pancreatic Cancer. Front Med (Lausanne) 2021; 7:624997. [PMID: 33644089 PMCID: PMC7904870 DOI: 10.3389/fmed.2020.624997] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/11/2020] [Indexed: 12/15/2022] Open
Abstract
Pancreatic cancer is one of the most aggressive malignancies of the digestive tract and carries a poor prognosis. The majority of patients have advanced disease at the time of diagnosis. Surgical resection offers the only curative treatment, but only a small proportion of patients can undergo surgical resection. Radiofrequency ablation (RFA) is a well-known modality in the management of solid organ tumors, however, its utility in the management of pancreatic cancer is under investigation. Since the past decade, there is increasing use of RFA as it provides a feasible palliation treatment in the management of unresectable pancreatic cancer. RFA causes tumor cytoreduction through multiple mechanisms such as coagulative necrosis, protein denaturation, and activation of anticancer immunity. The safety profile of RFA is controversial because of the high risk for complications, however, small prospective and retrospective studies have shown promising results in its applicability for palliative management of unresectable pancreatic malignancies. In this review, we discuss different approaches of RFA, their indications, technical accessibility, safety, and major complications in the management of unresectable pancreatic cancer.
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Affiliation(s)
- Muhammad Nadeem Yousaf
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD, United States
- MedStar Franklin Square Medical Center, Baltimore, MD, United States
- MedStar Good Samaritan Hospital, Baltimore, MD, United States
- MedStar Harbor Hospital, Baltimore, MD, United States
| | - Hamid Ehsan
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD, United States
| | - Ahmad Muneeb
- Department of Medicine, Faisalabad Medical University, Faisalabad, Pakistan
| | - Ahsan Wahab
- Department of Medicine, Baptist Medical Center South, Montgomery, AL, United States
| | - Muhammad K. Sana
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Karun Neupane
- Department of Medicine, Manipal College of Medical Sciences, Pokhara, Nepal
| | - Fizah S. Chaudhary
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD, United States
- MedStar Franklin Square Medical Center, Baltimore, MD, United States
- MedStar Good Samaritan Hospital, Baltimore, MD, United States
- MedStar Harbor Hospital, Baltimore, MD, United States
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Larghi A, Rimbaș M, Rizzatti G, Carbone C, Gasbarrini A, Costamagna G, Alfieri S, Tortora G. Endoscopic ultrasound-guided therapies for pancreatic solid tumors: An overview. Semin Oncol 2021; 48:95-105. [PMID: 33608132 DOI: 10.1053/j.seminoncol.2021.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 01/16/2021] [Indexed: 12/14/2022]
Abstract
The close proximity of the endoscopic ultrasound (EUS) probe to the pancreas, coupled with the ease with which a needle can be inserted into a pancreatic lesion, have contributed to the development of EUS-guided therapies for both adenocarcinoma and neuroendocrine pancreatic neoplasms. EUS-guided fine needle injection of different types of drugs, implantation of fiducial markers to facilitate stereotactic body radiation therapy or of radioactive seeds to perform brachytherapy, and the use of different thermal and nonthermal ablation devices and techniques have all been tested in preliminary human studies. This manuscript will present the available evidence accumulated thus far in the field of EUS-guided oncological treatment of pancreatic solid tumors, along with a look into possible future applications.
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Affiliation(s)
- Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.
| | - Mihai Rimbaș
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Gastroenterology Division, Fondazione Policlinico Universitario A. Gemelli, Catholic University, IRCCS, Rome, Italy
| | - Carmine Carbone
- Oncological Division, Fondazione Policlinico Universitario A. Gemelli, Catholic University, IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Gastroenterology Division, Fondazione Policlinico Universitario A. Gemelli, Catholic University, IRCCS, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy; IHU-USIAS, University of Strasbourg, Strasbourg, France
| | - Sergio Alfieri
- Digestive Surgery, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy
| | - Giampaolo Tortora
- Oncological Division, Fondazione Policlinico Universitario A. Gemelli, Catholic University, IRCCS, Rome, Italy
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DeWitt JM, Arain M, Chang KJ, Sharaiha R, Komanduri S, Muthusamy VR, Hwang JH. Interventional Endoscopic Ultrasound: Current Status and Future Directions. Clin Gastroenterol Hepatol 2021; 19:24-40. [PMID: 32950747 DOI: 10.1016/j.cgh.2020.09.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/11/2020] [Accepted: 09/15/2020] [Indexed: 02/06/2023]
Abstract
The evolution of endoscopic ultrasound (EUS) from a diagnostic to a therapeutic procedure has resulted in a paradigm shift toward endoscopic management of disease states that previously required percutaneous or surgical approaches. The past few years have seen additional techniques and devices that have enabled endoscopists to expand its diagnostic and therapeutic capabilities. Some of these techniques initially were reported more than a decade ago; however, with further device development and refinement in techniques there is potential for expanding the application of these techniques and new technologies to a broader group of interventional gastroenterologists. Lack of formalized training, devices, and prospective data regarding their use in addition to a scarcity of guidelines on implementation of these technologies into clinical practice are contributing factors impeding the growth of the field of interventional EUS. In April 2019, the American Gastroenterological Association's Center for Gastrointestinal Innovation and Technology conducted its annual Tech Summit and a key session focused on interventional EUS. This article is a White Paper generated from the conference, discusses the published literature pertaining to the topic of interventional EUS, and outlines a proposed framework for the implementation of interventional EUS techniques into clinical practice. Three primary areas of interventional EUS are addressed: (1) EUS-guided access; (2) EUS-guided tumor ablation; and (3) endohepatology. There was general agreement among participants on several key components. The introduction of these novel interventions requires better tools, more data on safety/outcomes, and improved training for endoscopists. Participants also agreed that widespread implementation and use of these techniques will require support from Gastrointestinal Societies and other key stakeholders including payers. Continued work by the Gastrointestinal Societies and manufacturers to provide training programs, appropriate equipment/work environments, and policies that motivate endoscopists to adopt new techniques is essential for growing the field of interventional EUS.
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Affiliation(s)
- John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana
| | - Mustafa Arain
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California
| | - Kenneth J Chang
- H. H. Chao Comprehensive Digestive Disease Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California, Irvine, California
| | - Reem Sharaiha
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Weill Cornell Medicine, New York, New York
| | - Sri Komanduri
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, California.
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Hashimoto R, Chang KJ. Endoscopic ultrasound guided hepatic interventions. Dig Endosc 2021; 33:54-65. [PMID: 32145117 DOI: 10.1111/den.13661] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 03/03/2020] [Indexed: 02/08/2023]
Abstract
Intervention for liver disease has predominantly been performed through the percutaneous approach. However, as endoscopic ultrasound (EUS) applications have expanded, there have emerged various EUS-guided interventions for liver disease, a space we call "Endo-Hepatology". EUS-guided liver biopsy can be considered the "forerunner" of Endo-Hepatology and has become a clinical option for patients requiring histologic diagnosis and staging of their liver disease. EUS also enables direct access to the portal vein. Subsequently, many procedures are being explored, such as angiography, measurement of the portosystemic pressure gradient, portal vein sampling to detect cancer cell or DNA, and EUS-guided transhepatic intrahepatic portosystemic shunt creation. Since the transducer is close to the liver, especially the left and caudate lobes, EUS can be used as a rescue when the percutaneous approach is not favorable and EUS-guided treatments of liver tumor, cyst and abscess have been reported. This review summarizes the available studies of EUS-guided intervention in the liver.
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Affiliation(s)
- Rintaro Hashimoto
- H. H. Chao Comprehensive Digestive Center, University of California Irvine Medical Center, Orange, USA
| | - Kenneth J Chang
- H. H. Chao Comprehensive Digestive Center, University of California Irvine Medical Center, Orange, USA
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Rimbaş M, Horumbă M, Rizzatti G, Crinò SF, Gasbarrini A, Costamagna G, Larghi A. Interventional endoscopic ultrasound for pancreatic neuroendocrine neoplasms. Dig Endosc 2020; 32:1031-1041. [PMID: 31995848 DOI: 10.1111/den.13635] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 12/25/2019] [Accepted: 01/22/2020] [Indexed: 02/06/2023]
Abstract
The proximity of the endoscopic ultrasound (EUS) transducer to the pancreas and the possibility to place needles or other accessories into a target located adjacent to the wall of the GI tract have encouraged researchers to develop various EUS-guided local treatments directed towards pancreatic neuroendocrine neoplasms (PanNENs). The use of pre-operative EUS-guided tattooing or fiducial marker placement to facilitate intraoperative tumor localization has proven effective in reducing operative time of laparoscopic surgeries. To reduce the mortality and morbidity rates of surgical resection, which is presently the mainstay treatment of PanNENs. EUS-guided loco-regional treatments, such as injection of alcohol and radiofrequency ablation have been proposed and results are hitherto promising. The present paper summarizes currently available data in the field of EUS-guided interventions to pancreatic neuroendocrine tumors, as well as possible future applications.
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Affiliation(s)
- Mihai Rimbaş
- Digestive Endoscopy Unit, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy.,Gastroenterology and Internal Medicine Departments, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Mihaela Horumbă
- Gastroenterology and Internal Medicine Departments, Colentina Clinical Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Stefano Francesco Crinò
- Gastroenterology and Digestive Endoscopy Unit, Pancreas Institute, University Hospital of Verona, Verona, Italy
| | - Antonio Gasbarrini
- Gastroenterology Division, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy
| | - Guido Costamagna
- and, Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University, Rome, Italy.,IHU-USIAS, University of Strasbourg, Strasbourg, France
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy.,CERTT, Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
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Cho JH, Jang SI, Lee DK. Recent developments in endoscopic ultrasound-guided radiofrequency ablation for pancreatic lesions. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Jae Hee Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Testoni SGG, Capurso G, Petrone MC, Barbera M, Linzenbold W, Enderle M, Gusmini S, Nicoletti R, Della Torre E, Mariani A, Rossi G, Archibugi L, De Cobelli F, Reni M, Falconi M, Arcidiacono PG. Necrosis volume and Choi criteria predict the response to endoscopic ultrasonography-guided HybridTherm ablation of locally advanced pancreatic cancer. Endosc Int Open 2020; 8:E1511-E1519. [PMID: 33043122 PMCID: PMC7541180 DOI: 10.1055/a-1221-9879] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/25/2020] [Indexed: 12/16/2022] Open
Abstract
Background and study aims Endoscopic ultrasound (EUS)-guided ablation of pancreatic ductal adenocarcinoma (PDAC) with HybridTherm-Probe (EUS-HTP) is feasible and safe, but the radiological response and ideal tool to measure it have not been investigated yet. The aims of this study were to: 1) assess the radiological response to EUS-HTP evaluating the vital tumor volume reduction rate, Response Evaluation Criteria in Solid Tumors (RECIST1.1) and Choi criteria; 2) determine the prognostic predictive yield of these criteria. Patients and methods A retrospective analysis was performed of patients with locally advanced PDAC after primary treatment or unfit for chemotherapy prospectively treated by EUS-HTP. Computed tomography scan was performed 1 month after EUS-HTP to evaluate: 1) vital tumor volume reduction rate (VTVRR) by measuring necrosis and tumor volumes through a computer-aided detection system; and 2) RECIST1.1 and Choi criteria. Results EUS-HTP was feasible in 22 of 31 patients (71 %), with no severe adverse events. Median post-HTP survival was 7 months (1 - 35). Compared to pre-HTP tumor volume, a significant 1-month VTVRR (mean 21.4 %) was observed after EUS-HTP ( P = 0.005). We identified through ROC analysis a VTVRR > 11.46 % as the best cut-off to determine post-HTP 6-month survival outcome (AUC = 0.733; sensitivity = 70.0 %, specificity = 83.3 %). This cut-off was significantly associated with longer overall survival (HR = 0.372; P = 0.039). According to RECIST1.1 and Choi criteria, good responders to EUS-HTP were 60 % and 46.7 %, respectively. Good responders according to Choi, but not to RECIST1.1, had longer survival (HR = 0.407; P = 0.04). Conclusions EUS-HTP induces a significant 1-month VTVRR. This effect is assessed accurately by evaluation of necrosis and tumor volumes. Use of VTVRR and Choi criteria, but not RECIST 1.1 criteria, might identify patients who could benefit clinically from EUS-HTP.
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Affiliation(s)
- Sabrina Gloria Giulia Testoni
- Pancreatico-Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Gabriele Capurso
- Pancreatico-Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Chiara Petrone
- Pancreatico-Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Maurizio Barbera
- Department of Radiology & Center for Experimental Imaging, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | | | | | - Simone Gusmini
- Department of Radiology & Center for Experimental Imaging, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Nicoletti
- Department of Radiology & Center for Experimental Imaging, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Emanuel Della Torre
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases. Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Mariani
- Pancreatico-Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Gemma Rossi
- Pancreatico-Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Livia Archibugi
- Pancreatico-Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco De Cobelli
- Department of Radiology & Center for Experimental Imaging, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Michele Reni
- Oncology Department, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Department, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Paolo Giorgio Arcidiacono
- Pancreatico-Biliary Endoscopy & Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
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Abstract
(1) Background: Preclinical and clinical data about a novel radiofrequency ablation (RFA) system (STARmed Co, Ltd.; Koyang, Korea) designed to be used under endoscopic ultrasound (EUS) control for pancreatic lesion ablation, are limited, obtained with non-standardized procedures and heterogeneous results. The aim of this study is to standardize the RFA procedure of this system in order to define the optimal ablation power and time. (2) Methods: RFA was performed on an ex-vivo porcine liver at different powers (40, 30, 20, 10 Watts (W)) and times (1, 3, 5, 7, 15 min) with a 1-centimeter monopolar electrode (perfused by chilled solution) positioned on the distal tip of a 19-Gauge needle. A blinded expert pathologist histologically analyzed each ablation area. (3) Results: The size of the total macroscopic ablated area was negatively correlated with ablation power (R −0.74): the largest was obtained at 10 W (p = 4.7 × 10−4) for longer times (R 0.92; p = 8.9 × 10−8). Central histologic coagulative necrosis did not differ among ablation settings (mean size 3.25 mm). External “parenchymal hypochromia” or “diaphanization” resulted the widest at 10 W, for longer times (R 0.8, p = 3.6 × 10−4). (4) Conclusions: The RFA system can produce small sizes of coagulative necrosis, regardless of the setting. Larger areas of diaphanization surrounding the necrosis can be produced at lower powers for longer times.
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Zhang L, Tan S, Huang S, Zhong C, Lü M, Peng Y, Tang X. The safety and efficacy of endoscopic ultrasound-guided ablation therapy for solid pancreatic tumors: a systematic review. Scand J Gastroenterol 2020; 55:1121-1131. [PMID: 32730715 DOI: 10.1080/00365521.2020.1797870] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Recently, endoscopic ultrasound (EUS)-guided ablation therapy, as a minimally invasive technique, has shown its potential to substitute surgery in treating solid pancreatic tumors, such as small potential malignant pancreatic tumors, small insulinomas and locally advanced pancreatic ductal adenocarcinoma (LAPDAC). Therefore, we conducted this systematic review to assess the safety and efficacy of EUS-guided ablation therapy for solid pancreatic tumors. METHODS We conducted a comprehensive search of PubMed, Embase, Cochrane library and Web of Science databases from inception to February 2020. The endpoints were clinical success and complications rates. The pooled event rate was calculated using Comprehensive Meta Analysis software. RESULTS Fourteen studies with a total of 158 patients were included in our final analysis. The major types of solid pancreatic tumors were nonfunction pancreatic neuroendocrine tumors (n = 78, 49.4%), LAPDAC (n = 48, 30.4%) and insulinomas (n = 26, 16.5%). Overall, the pooled clinical success rate was 85.9% (95% confidence interval (CI): 75.4-92.4%, I 2 = 25.18%), pooled complications rate was 29.1% (95% CI: 18.6-42.3%, I 2 = 50.40%). Subgroup analysis was performed based on ablation methods, which showed clinical success rate for radiofrequency ablation (RFA) was 83.5% (95% CI: 67.9-92.4%), and 87.9% (95% CI: 66.2-96.4%) for ethanol ablation (EA). In terms of complications rate, it was 32.2% (95% CI: 19.4-48.4%) for RFA, and 21.2% (95% CI: 6.8-49.9%) for EA. CONCLUSIONS EUS-guided ablation therapy is a promising alternative treatment for solid pancreatic tumors, especially for p-NETs and insulinomas < 2 cm, with rarely severe complications. Further prospective studies with long-term follow-up are warranted in future.
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Affiliation(s)
- Lu Zhang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shali Tan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shu Huang
- Department of Gastroenterology, The People's Hospital of Lianshui, Huaian, China
| | - Chunyu Zhong
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
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Hwang JS, Joo HD, Song TJ. Endoscopic Ultrasound-Guided Local Therapy for Pancreatic Neoplasms. Clin Endosc 2020; 53:535-540. [PMID: 33027583 PMCID: PMC7548142 DOI: 10.5946/ce.2020.181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/07/2020] [Accepted: 09/17/2020] [Indexed: 12/18/2022] Open
Abstract
Surgical resection is considered the only treatment option for pancreatic cancer and other pancreatic neoplasms with malignant potential, such as neuroendocrine tumors, mucinous cystic neoplasms, and intraductal papillary mucinous neoplasms. However, only 10%-20% of all patients with pancreatic cancer present with resectable forms of the disease as the symptoms are rarely manifested during the early stages, and the disease tends to progress rapidly. Furthermore, pancreatic surgery is associated with high rates of morbidity and mortality. The development of linear-array endoscopic ultrasound (EUS) techniques has increased the indications of EUS-guided local therapy for pancreatic neoplasms. We assessed the studies that investigated various treatment modalities, such as fine-needle injection, radiofrequency ablation, irreversible electroporation, and radiotherapy, under EUS guidance to better understand the usefulness of these techniques with respect to the efficacy and associated complications.
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Affiliation(s)
- Jun Seong Hwang
- Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hyun Don Joo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Jun Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Flak RV, Stender MT, Stenholt L, Thorlacius-Ussing O, Petersen LJ. Imaging response evaluation after local ablative treatments in locally advanced pancreatic cancer: an expedited systematic review. HPB (Oxford) 2020; 22:1083-1091. [PMID: 32451236 DOI: 10.1016/j.hpb.2020.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Several local ablative modalities have been introduced for the treatment of locally advanced pancreatic cancer (LAPC). However, there is no consensus on how to evaluate the imaging response after treatment. A systematic review was performed regarding the use of imaging for response assessment in LAPC. METHODS A systematic literature search was conducted in PubMed. Studies reporting imaging outcomes were included in the review. Studies were excluded if the imaging outcomes could not be differentiated between different disease stages, tumor histology or surgical approaches. RESULTS Thirty-four studies were included in the analysis. Fourteen studies used standardized response criteria, while six studies did not report the response evaluation method. The rest used self-determined criteria, absolute size comparisons or similar methods. One study found a correlation between early systemic progression (<6 months) and overall survival. CONCLUSION There was notable variation in the use of imaging for response assessment in LAPC. This significantly hinders cross-comparison of results among studies. There is currently only sparse evidence of an association between imaging responses and overall survival. The field calls for standardized recommendations regarding the choice of response assessment method, timing of scans, target definition and reporting of outcomes.
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Affiliation(s)
- R V Flak
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Denmark; Department of Clinical Science, Aalborg University, Denmark.
| | - Mogens T Stender
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Denmark; Department of Clinical Science, Aalborg University, Denmark
| | | | - Ole Thorlacius-Ussing
- Department of Gastrointestinal Surgery, Aalborg University Hospital, Denmark; Department of Clinical Science, Aalborg University, Denmark; Clinical Cancer Research Center, Aalborg University Hospital, Denmark
| | - Lars J Petersen
- Department of Clinical Science, Aalborg University, Denmark; Clinical Cancer Research Center, Aalborg University Hospital, Denmark; Department of Nuclear Medicine, Aalborg University Hospital, Denmark
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Vanella G, Capurso G, Arcidiacono PG. Endosonography-guided Radiofrequency Ablation in Pancreatic Diseases: Time to Fill the Gap Between Evidence and Enthusiasm. J Clin Gastroenterol 2020; 54:591-601. [PMID: 32482951 DOI: 10.1097/mcg.0000000000001370] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Over the past 20 years, endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has generated interest as a novel minimally invasive tool in the multimodal treatment of pancreatic malignant and premalignant lesions. However, although optimization of probes and settings has made EUS-RFA relatively safe, questions on the ideal positioning of this treatment in a multimodal strategy remain unanswered. This review will summarize the technical aspects of EUS-RFA and available clinical experiences for each pancreatic indication (pancreatic cancer, neuroendocrine neoplasms, cystic lesions, and celiac ganglia neurolysis). Established indications will be discussed along those requiring additional clinical data or even proof-of-concept studies. A dedicated session will further discuss evidence expected to emerge from ongoing registered trials, together with issues that must be addressed in future research, including the possible combination with immunotherapy, and the personalization of this treatment on the basis of genetic profiling. Despite the great clinical enthusiasm and scientific fervor, while evidence-based answers are produced, EUS-RFA must be centralized in high-volume centers of recognized expertise, where multidisciplinary discussions of indications and actively recruiting research protocols are available.
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Affiliation(s)
- Giuseppe Vanella
- Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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Testoni SGG, Healey AJ, Dietrich CF, Arcidiacono PG. Systematic review of endoscopy ultrasound-guided thermal ablation treatment for pancreatic cancer. Endosc Ultrasound 2020; 9:83-100. [PMID: 32295966 PMCID: PMC7279078 DOI: 10.4103/eus.eus_74_19] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The development of curvilinear-array EUS and EUS-guided fine-needle aspiration (EUS-FNA) has led these approaches to become interventional procedures rather than purely diagnostic, as a minimally invasive antitumor therapeutic alternative to radiological and surgical treatments. The possibility to accurately position needle devices and to reach a deep target like the pancreas gland under real-time imaging guidance has expanded the use of EUS to ablate tumors. Currently, a variety of probes specifically designed for EUS ablation are available, including radiofrequency, hybrid cryothermal ablation (combining radiofrequency with cryotechnology), photodynamic therapy, and laser ablation. To date, several studies have demonstrated the safety and feasibility of these ablation techniques in the pancreatic setting, but only a few small series on pancreatic thermal ablation under EUS guidance are available. EUS-guided thermal ablation is primarily used for pancreatic cancer. It is well suited to this disease because of its superior anatomical access compared with other imaging modalities and the dismal prognosis despite improvements in chemoradiotherapy and surgery in the management of pancreatic cancer. Other targets are pancreatic neuroendocrine tumors and pancreatic cystic neoplasms, which are curable by surgical resection, but some patients are poor surgical candidates or prefer conservative management. This is a literature review of previously published clinical studies on EUS-guided thermal ablative therapies. Data on the long-term efficacy of EUS-guided antitumor thermal ablation therapy and large prospective randomized studies are still needed to confirm the real clinical benefits of these techniques for the management of pancreatic neoplasms.
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Affiliation(s)
- Sabrina Gloria Giulia Testoni
- Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
| | - Andrew James Healey
- Department of Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, Scotland
| | - Christoph F Dietrich
- Department of Internal Medicine, Hirslanden Hospitals Berne Beau Site, Salem and Permanence, Berne, Switzerland
| | - Paolo Giorgio Arcidiacono
- Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Vita-Salute San Raffaele University, Milan, Italy
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Shangguan A, Shang N, Figini M, Pan L, Yang J, Ma Q, Hu S, Eresen A, Sun C, Wang B, Velichko Y, Yaghmai V, Zhang Z. Prophylactic dendritic cell vaccination controls pancreatic cancer growth in a mouse model. Cytotherapy 2020; 22:6-15. [PMID: 32005355 DOI: 10.1016/j.jcyt.2019.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 11/29/2019] [Accepted: 12/01/2019] [Indexed: 12/18/2022]
Abstract
PURPOSE Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of cancer-related deaths with high recurrence after surgery due to a paucity of effective post-surgical adjuvant treatments. DC vaccines can activate multiple anti-tumor immune responses but have not been explored for post-surgery PDAC recurrence. Intraperitoneal (IP) delivery may allow increased DC vaccine dosage and migration to lymph nodes. Here, we investigated the role of prophylactic DC vaccination controlling PDAC tumor growth with IP delivery as an administration route for DC vaccination. METHODS DC vaccines were generated using ex vivo differentiation and maturation of bone marrow-derived precursors. Twenty mice were divided into four groups (n = 5) and treated with DC vaccines, unpulsed mature DCs, Panc02 lysates or no treatment. After tumor induction, mice underwent three magnetic resonance imaging scans to track tumor growth. Apparent diffusion coefficient (ADC), a quantitative magnetic resonance imaging measurement of tumor microstructure, was calculated. Survival was tracked. Tumor tissue was collected after death and stained with hematoxylin and eosin, Masson's trichrome, terminal deoxynucleotidyl transferase dUTP nick end labeling and anti-CD8 stains for histology. RESULTS DC-vaccinated mice demonstrated stronger anti-tumor cytotoxicity compared with control groups on lactate dehydrogenase assay. DC vaccine mice also demonstrated decreased tumor volume, prolonged survival and increased ΔADC compared with control groups. On histology, the DC vaccine group had increased apoptosis, increased CD8+ T cells and decreased collagen. ΔADC negatively correlated with % collagen in tumor tissues. DISCUSSION Prophylactic DC vaccination may inhibit PDAC tumor growth during recurrence and prolong survival. ΔADC may be a potential imaging biomarker that correlates with tumor histological features.
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Affiliation(s)
- Anna Shangguan
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA; Medical Student Training Program, Northwestern University, Chicago, Illinois, USA
| | - Na Shang
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Matteo Figini
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Liang Pan
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA; Department of Radiology, The Third Affiliated Hospital of Suzhou University, Changzhou, Jiangsu, China
| | - Jia Yang
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Quanhong Ma
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Su Hu
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA; Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Aydin Eresen
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Chong Sun
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA; Department of Orthopaedics, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Bin Wang
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA; Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangdong Provincial Engineering Technology Research Center of Minimally Invasive Surgery, Guangzhou, China
| | - Yuri Velichko
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA; Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
| | - Vahid Yaghmai
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA; Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
| | - Zhuoli Zhang
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA; Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA.
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Armellini E. Endosonography guided ethanol ablation for pancreatic cystic lesions: Current status. Hepatobiliary Pancreat Dis Int 2019; 18:503-504. [PMID: 31706858 DOI: 10.1016/j.hbpd.2019.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 10/23/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Elia Armellini
- "Maggiore della Carità" University-Hospital, Largo Mazzini 18, Novara, Italy.
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Moutinho-Ribeiro P, Liberal R, Macedo G. Endoscopic ultrasound in pancreatic cancer treatment: Facts and hopes. Clin Res Hepatol Gastroenterol 2019; 43:513-521. [PMID: 30935904 DOI: 10.1016/j.clinre.2019.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 02/12/2019] [Accepted: 02/16/2019] [Indexed: 02/04/2023]
Abstract
Pancreatic ductal adenocarcinoma is one of the most common causes of cancer-related deaths. Since most patients present with advanced disease, its prognosis is dismal. New and more effective therapeutic strategies are needed. Endoscopic ultrasound is currently an indispensable tool for the diagnosis and staging of pancreatic ductal adenocarcinoma. In recent years, endoscopic ultrasound has evolved to become also a therapeutic procedure. On one hand, the role of endoscopic ultrasound in the management of pancreatic cancer-related symptoms (pain, obstructive jaundice, and gastric outlet obstruction) is now well established. On the other hand, its use as a mean to the delivery of anti-tumor therapies (injecting anti-tumor agents, assisting in radiotherapy, and guiding ablative therapies) is still mostly experimental, despite growing evidence supporting its feasibility, safety and efficacy.
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Affiliation(s)
- Pedro Moutinho-Ribeiro
- Gastroenterology and Hepatology Department, Centro Hospitalar Sao Joao and World Gastroenterology Organisation (WGO) Porto Training Center, Porto, Portugal.
| | - Rodrigo Liberal
- Gastroenterology and Hepatology Department, Centro Hospitalar Sao Joao and World Gastroenterology Organisation (WGO) Porto Training Center, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology and Hepatology Department, Centro Hospitalar Sao Joao and World Gastroenterology Organisation (WGO) Porto Training Center, Porto, Portugal
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Barthet M. Endoscopic ultrasound-guided radiofrequency ablation for pancreatic neuroendocrine tumor. ANNALES D'ENDOCRINOLOGIE 2019; 80:182-184. [PMID: 31053252 DOI: 10.1016/j.ando.2019.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Marc Barthet
- Service de gastro-entérologie, hôpital Nord, chemin des Bourrely, 13915 Marseille cedex 20, France.
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Abstract
"Endoscopic ultrasound (EUS)-guided ablative therapies have advanced significantly and have led to experimental applications in locations that have been difficult to image and/or reach with percutaneous approaches, such as the caudate and left lobe of the liver. EUS-guided treatments of the liver are under development. The literature has shown that many percutaneous ablative techniques are readily adaptable for EUS. In this review, the authors discuss the current developments on EUS-guided ablation of liver tumors, including injection of sclerosants, thermal therapy, and EUS-guided portal injection of chemotherapy."
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Affiliation(s)
- Tiffany Chua
- Division of Gastroenterology and Hepatology, Mayo Clinic Phoenix, Phoeniz, AZ, USA
| | - Douglas O Faigel
- Division of Gastroenterology and Hepatology, Mayo Clinic Phoenix, Phoeniz, AZ, USA.
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Barret M, Leblanc S, Rouquette A, Chaussade S, Terris B, Prat F. EUS-guided pancreatic radiofrequency ablation: preclinical comparison of two currently available devices in a pig model. Endosc Int Open 2019; 7:E138-E143. [PMID: 30705944 PMCID: PMC6336466 DOI: 10.1055/a-0668-5653] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 04/13/2018] [Indexed: 02/08/2023] Open
Abstract
Introduction Two devices are currently available to perform pancreatic radiofrequency ablation (P-RFA). Potential clinical indications might extend from the treatment of pancreatic cystic lesions to ablation of small pancreatic solid lesions or cytoreduction of advanced pancreatic adenocarcinomas, but more preclinical data from animal models are needed to optimize P-RFA operation. Methods P-RFA was performed under laparotomy and under endoscopic ultrasonographic guidance on the liver and pancreatic parenchyma of four live swine using the Habib EUS RFA (EMcision Ltd, London, UK) probe and the EUS-RA needle (Taewoong Medical, Gyeonggi-do, South Korea). Animals were sacrificed 2 hours after the procedure. Influence of tuning ablation time and power on tissue ablation were studied by histopathological assessment of the maximal depth of tissue damage on representative slides for each P-RFA shot. Results The Habib probe in the liver parenchyma resulted in tissue necrosis increasing within the range of 1.9 ± 0.5 mm (Power = 8 W, Time = 120 s) to 2.5 ± 1 mm (Power = 10 W, Time = 120 s). In the pancreatic parenchyma, tissue damage ranged from 3.1 ± 0.4 mm (Power = 8 W, Time = 120 s) to 2.3 ± 0.1 mm (12 W, 120 s) in depth. EUS RFA ablation of the liver parenchyma resulted in tissue damage ranging from 1.6 ± 0.2 mm (Power = 30 W, Time = 11 s) to 1.5 ± 0.1 mm (Power = 70 W, Time = 9 s); in the pancreas, ablation depth ranged from 3.6 ± 0.5 mm (Power = 30 W, Time = 15 s) to 3.8 ± 0.4 mm (Power = 70 W, Time = 11 s). Conclusion Both devices allow for effective ablation of pancreatic tissue within 1.5 to 3.8 mm around the RFA electrode, with a modest influence of tuning power settings. Specific settings are recommended for each of the devices studied. Ablation of larger lesions may require more repeat P-RFA shots in different locations rather than a simple modulation of ablation parameters.
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Affiliation(s)
- Maximilien Barret
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France,Paris-Descartes University, Paris, France
| | - Sarah Leblanc
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France,Paris-Descartes University, Paris, France
| | | | - Stanislas Chaussade
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France,Paris-Descartes University, Paris, France
| | - Benoit Terris
- Paris-Descartes University, Paris, France,Department of Pathology, Cochin Hospital, Paris, France
| | - Frédéric Prat
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France,Paris-Descartes University, Paris, France,Corresponding author Frédéric Prat Department of GastroenterologyCochin Hospital27 rue du Faubourg St Jacques75014 Paris+33-1-58411965
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DeWitt JM, Sandrasegaran K, O'Neil B, House MG, Zyromski NJ, Sehdev A, Perkins SM, Flynn J, McCranor L, Shahda S. Phase 1 study of EUS-guided photodynamic therapy for locally advanced pancreatic cancer. Gastrointest Endosc 2019; 89:390-398. [PMID: 30222972 DOI: 10.1016/j.gie.2018.09.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 09/07/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Locally advanced pancreatic cancer (LAPC) has a poor prognosis. There are limited data describing the use of photodynamic therapy (PDT) for pancreatic cancer in humans. We hypothesized that EUS-guided PDT for LAPC is safe, technically feasible, and produces a dose- and time-dependent increasing degree of image-defined tumor necrosis. METHODS In a single-center, prospective, dose-escalation phase 1 study, patients with treatment-naïve LAPC received intravenous porfimer sodium (Concordia Laboratories Inc, St Michael, Barbados) followed 2 days later by EUS-PDT. EUS-PDT was performed by puncture with a 19-gauge needle and insertion of a 1.0-cm light diffuser (Pioneer Optics, Bloomfield, Conn) and illumination with a 630-nm light (Diomed Inc, Andover, Mass). A CT scan 18 days after PDT was done to assess for change in pancreatic necrosis. Nab-paclitaxel (125 mg/ m2 intravenously) and gemcitabine (1000 mg /m2 intravenously) were initiated 7 days after CT and given weekly for 3 of 4 weeks (1 cycle) until disease progression or unacceptable toxicity. RESULTS Twelve patients (mean age, 67 ± 6 years; 8 male) with tumors (mean diameter, 45.2 ± 12.9 mm) in the head and/or neck (8) or body and/or tail (4) underwent EUS-PDT. Compared with baseline imaging, increased volume and percentage of tumor necrosis were observed in 6 of 12 patients (50%) after EUS-PDT. The mean overall increases in volume and percentage necrosis were 10 ± 26 cm3 (P = .20) and 18% ± 22% (P = .016), respectively. After a median follow-up of 10.5 months (range, 1.0-37.4 months), median progression-free (PFS) and overall survival (OS) were 2.6 months (95% confidence interval, 0.7, not estimable) and 11.5 months (95% confidence interval, 1.1, 16.9), respectively. Surgical resection was attempted in 2 patients, and pathology showed a complete response (n = 1) and residual 2-mm tumor (n = 1). There were 8 serious adverse events and none related to EUS or EUS-PDT. CONCLUSION EUS-PDT for LAPC appears to be safe and produces measurable imaged-defined tumor necrosis. Phase 2 studies are warranted. (Clinical trial registration number: NCT01770132.).
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Affiliation(s)
- John M DeWitt
- Department of Gastroenterology, Indiana University Health Medical Center, Indianapolis, Indiana, USA
| | - Kumar Sandrasegaran
- Department of Radiology, Indiana University Health Medical Center, Indianapolis, Indiana, USA
| | - Bert O'Neil
- Department of Oncology, Indiana University Health Medical Center, Indianapolis, Indiana, USA
| | - Michael G House
- Department of Surgery, Indiana University Health Medical Center, Indianapolis, Indiana, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University Health Medical Center, Indianapolis, Indiana, USA
| | - Amikar Sehdev
- Department of Oncology, Indiana University Health Medical Center, Indianapolis, Indiana, USA
| | - Susan M Perkins
- Department of Statistics, Indiana University Health Medical Center, Indianapolis, Indiana, USA
| | - Janet Flynn
- Department of Oncology, Indiana University Health Medical Center, Indianapolis, Indiana, USA
| | - Lynne McCranor
- Department of Oncology, Indiana University Health Medical Center, Indianapolis, Indiana, USA
| | - Safi Shahda
- Department of Oncology, Indiana University Health Medical Center, Indianapolis, Indiana, USA
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