Endoscopy in the Management of Malignant Obstructive Jaundice

Endoscopic Palliation of Pancreatic Cancer

OPINION STATEMENT

Pancreas cancer is a fourth-leading cause of cancer death in the USA and its incidence is rising as the population is aging. The majority of patients present at an advanced stage due to the silent nature of the disease and treatment have focused more on palliation than curative intent. Gastroenterologists have become integral in the multidisciplinary care of these patients with a focus on providing endoscopic palliation of pancreas cancer. The three most common areas that gastroenterologists palliate endoscopically are biliary obstruction, cancer-related pain, and gastric outlet obstruction. To palliate biliary obstruction, the procedure of choice is to perform endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement. We tend to place covered self-expandable metal stents (SEMS) due to their longer patency and removability unless the patient has resectable disease. Pancreas cancer pain is a result of tumor infiltration of the celiac plexus and can be severe and poorly responsive to narcotics. To improve pain control, neurolysis of the celiac plexus has been performed for decades. Since 1996, neurolysis of the celiac area has been performed endoscopically by Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis. This has proven to be as safe and effective as traditional non-endoscopic methods and has allowed the patients to decrease their narcotic use and improve their pain control. This should be done early on in the course of the disease to have maximal effect. Gastric outlet obstruction (GOO) occurs in approximately 15-20% of patients with pancreas cancer. Endoscopic palliation of GOO can be performed by placing uncovered metal enteral stents across the obstruction. This procedure has proven to be very effective in patients who have a short life expectancy (less than two to 6 months) while surgical bypass should be considered for patients with longer life expectancies because it offers better long-term symptom relief. This chapter will review the current literature, latest advancements, and optimal techniques for endoscopic palliation of pancreatic cancer.

Endoscopic palliation for pancreatic cancer

Pancreatic cancer is devastating due to its poor prognosis. Patients require a multidisciplinary approach to guide available options, mostly palliative because of advanced disease at presentation. Palliation including relief of biliary obstruction, gastric outlet obstruction, and cancer-related pain has become the focus in patients whose cancer is determined to be unresectable. Endoscopic stenting for biliary obstruction is an option for drainage to avoid the complications including jaundice, pruritus, infection, liver dysfunction and eventually failure. Enteral stents can relieve gastric obstruction and allow patients to resume oral intake. Pain is difficult to treat in cancer patients and endoscopic procedures such as pancreatic stenting and celiac plexus neurolysis can provide relief. The objective of endoscopic palliation is to primarily address symptoms as well improve quality of life.

Positive expression of L1-CAM is associated with perineural invasion and poor outcome in pancreatic ductal adenocarcinoma

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) frequently invades and migrates along neural tissue, which results in local tumor recurrences, distant metastases, and poor prognosis. We evaluated whether L1 cell adhesion molecule (L1-CAM) and glial cell line-derived neurotrophic factor (GDNF) expression in PDAC correlated with neural invasion and overall survival on a large cohort of previously untreated patients.

METHODS

L1-CAM and GDNF were examined by immunohistochemistry in pancreatic cancer tissue samples of 94 cases with PDAC on a tissue microarray. The molecular findings were correlated with pain, clinicopathologic characteristics, and overall survival in these patients.

RESULTS

L1-CAM and GDNF were overexpressed in pancreatic cancer tissues compared with the adjacent normal tissues of pancreas. Positive L1-CAM expression was associated with node involvement (P = 0.007), vascular invasion (P = 0.012), perineural invasion (P = 0.001), and higher degree of pain (P = 0.005). In univariate analysis, tissue expression of L1-CAM was associated with poor survival (hazard ratio, 2.508; 95% confidence interval, 1.551-4.053; P < 0.001), and this was also significant in multivariate analysis (hazard ratio, 2.046; 95% confidence interval, 1.200-3.488; P = 0.009). Positive staining of GDNF, neural invasion, and vascular invasion were all statistically significantly related to unfavorable prognosis.

CONCLUSIONS

Enhanced expression of L1-CAM may contribute to the pain syndrome and perineural invasion and may correlate with poor overall survival in human pancreatic cancer.

Preoperative diagnosis of extrapancreatic neural invasion in pancreatic cancer

BACKGROUND & AIMS

Pancreatic cancer recurs in most patients after resection with curative intent. Recurrence is particularly common in patients with extrapancreatic neural invasion (EPNI), the presence of which correlates with poor prognosis. Macroscopic EPNI may be detected with conventional noninvasive imaging and endoscopic ultrasound (EUS) imaging, but microscopic EPNI has required postoperative pathologic examination of surgical specimens. We report the preoperative diagnosis of cancer infiltration into celiac ganglia. We hypothesized that microscopic pancreatic cancer metastasis to neural ganglia can be detected by EUS-guided biopsy examination.

METHODS

We performed a retrospective review of patients with pancreatic cancer undergoing EUS in whom celiac ganglia were sampled to exclude malignant infiltration.

RESULTS

Six patients with pancreatic cancer underwent EUS-guided fine-needle aspiration or trucut biopsy examination of presumed celiac ganglia. Metastatic cancer was found in ganglia of 2 patients. Specimen review identified adenocarcinoma and neural tissue in the absence of lymphocytes. At laparoscopy, 1 of the 2 patients with positive celiac biopsy specimens also had several unexpected peritoneal metastatic deposits. The other patient was considered to have locally advanced unresectable disease. Both patients are receiving supportive care.

CONCLUSIONS

EPNI may be shown preoperatively in patients with pancreatic cancer using EUS-guided sampling of celiac ganglia. A preoperative diagnosis of EPNI has the potential to improve staging accuracy and patient outcomes.

Pancreatic neoplasms

Patients who present with signs and symptoms suggesting a pancreatic neoplasm typically undergo initial imaging with transabdominal ultrasound or CT. When a pancreatic mass or fullness is identified, it may represent an inflammatory mass, benign process, or malignancy. Endoscopic ultrasound (EUS) is performed commonly to further characterize the lesion, obtain a tissue diagnosis, and for staging. This article reviews the role of EUS for the diagnosis and staging of pancreatic tumors.

EUS with EUS-guided fine-needle aspiration as the first endoscopic test for the evaluation of obstructive jaundice

BACKGROUND

This study assesses the cost savings associated with using endoscopic ultrasound (EUS) before endoscopic retrograde cholangiopancreatography (ERCP) for evaluating patients with suspected obstructive jaundice.

METHODS

One hundred forty-seven patients with obstructive jaundice of unknown or possibly neoplastic origin had EUS as their first endoscopic procedure. With knowledge of the final diagnosis and actual management for each patient, their probable evaluation and outcomes and their additional costs were reassessed assuming that ERCP would have been performed as the first endoscopic procedure. Also calculated were the additional costs incurred if EUS were unavailable for use after ERCP and had to be replaced by computed tomography or other procedures.

RESULTS

The final diagnoses in these patients included malignancies (65%), choledocholithiasis or cholecystitis (18%), "medical jaundice" (11%), and miscellaneous benign conditions (6%). Fifty-four percent had EUS-guided fine-needle aspiration but only 53% required ERCP after EUS. An EUS-first approach saved an estimated $1007 to $1313/patient, but the cost was $2200 more if EUS was unavailable for use after ERCP. Significant savings persisted through sensitivity analysis.

CONCLUSIONS

Performing EUS with EUS-guided fine-needle aspiration as the first endoscopic procedure in patients suspected to have obstructive jaundice can obviate the need for about 50% of ERCPs, helps direct subsequent therapeutic ERCP, and can substantially reduce costs in these patients.