Efficacy and safety of endoscopic ultrasonography-guided interventional treatment for refractory malignant left-sided liver tumors: a case series of 26 patients

Endoscopic ultrasound for the diagnosis and treatment of primary hepatocellular carcinoma

Chronic liver disease has emerged as a significant global concern, with primary hepatocellular carcinoma (HCC) representing a critical consequence of this disease. However, early detection of HCC remains challenging in clinical practice. Recently, there has been a growing interest in applying endoscopic ultrasound (EUS) as a diagnostic tool for gastrointestinal diseases. Nevertheless, using EUS to diagnose and treat HCC is uncommon. In this review we described the diagnostic and therapeutic applications of EUS in primary HCC and evaluated its clinical significance. The diagnostic procedures primarily involve EUS-guided fine-needle biopsy or aspiration, assessment of metastatic lymph nodes and portal vein thrombosis, portal pressure monitoring, and portal vein blood collection. Treatment mainly includes EUS-guided tumor ablation, brachytherapy, injectable chemotherapy, and managing variceal hemorrhage related to portal hypertension.

Diagnostic and therapeutic role of endoscopic ultrasound in liver diseases: A systematic review and meta-analysis

BACKGROUND

In hepatology, the clinical use of endoscopic ultrasound (EUS) has experienced a notable increase in recent times. These applications range from the diagnosis to the treatment of various liver diseases. Therefore, this systematic review summarizes the evidence for the diagnostic and therapeutic roles of EUS in liver diseases.

AIM

To examine and summarize the current available evidence of the possible roles of the EUS in making a suitable diagnosis in liver diseases as well as the therapeutic accuracy and efficacy.

METHODS

PubMed, Medline, Cochrane Library, Web of Science, and Google Scholar databases were extensively searched until October 2023. The methodological quality of the eligible articles was assessed using the Newcastle-Ottawa scale or Cochrane Risk of Bias tool. In addition, statistical analyses were performed using the Comprehensive Meta-Analysis software.

RESULTS

Overall, 45 articles on EUS were included (28 on diagnostic role and 17 on therapeutic role). Pooled analysis demonstrated that EUS diagnostic tests had an accuracy of 92.4% for focal liver lesions (FLL) and 96.6% for parenchymal liver diseases. EUS-guided liver biopsies with either fine needle aspiration or fine needle biopsy had low complication rates when sampling FLL and parenchymal liver diseases (3.1% and 8.7%, respectively). Analysis of data from four studies showed that EUS-guided liver abscess had high clinical (90.7%) and technical success (90.7%) without significant complications. Similarly, EUS-guided interventions for the treatment of gastric varices (GV) have high technical success (98%) and GV obliteration rate (84%) with few complications (15%) and rebleeding events (17%).

CONCLUSION

EUS in liver diseases is a promising technique with the potential to be considered a first-line therapeutic and diagnostic option in selected cases.

Endohepatology: The endoscopic armamentarium in the hand of the hepatologist

ABSTRACT

Recent advances in the field of hepatology include new and effective treatments for viral hepatitis. Further effort is now being directed to other disease entities, such as non-alcoholic fatty liver disease, with an increased need for assessment of liver function and histology. In fact, with the evolving nomenclature of fat-associated liver disease and the emergence of the term "metabolic-associated fatty liver disease" (MAFLD), new diagnostic challenges have emerged as patients with histologic absence of steatosis can still be classified under the umbrella of MAFLD. Currently, there is a growing number of endoscopic procedures that are pertinent to patients with liver disease. Indeed, interventional radiologists mostly perform interventional procedures such as percutaneous and intravascular procedures, whereas endoscopists focus on screening for and treatment of esophageal and gastric varices. EUS has proven to be of value in many areas within the realm of hepatology, including liver biopsy, assessment of liver fibrosis, measurement of portal pressure, managing variceal bleeding, and EUS-guided paracentesis. In this review article, we will address the endoscopic applications that are used to manage patients with chronic liver disease.

Interventional Endoscopic Ultrasound: Current Status and Future Frontiers

Interventional endoscopic ultrasound has fueled remarkable advancements in the field of therapeutic procedures, revolutionizing minimally invasive interventions for a diverse range of conditions. This review highlights the latest breakthroughs and advancements in therapeutic endoscopic ultrasound, showcasing its potential to transform patient care.

Efficacy and Safety of Endoscopic Ultrasound-Guided Radiofrequency Ablation for Pancreatic Neuroendocrine Tumors: A Systematic Review and Metanalysis

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.

Peritumoral abnormalities on dynamic-enhanced CT after brachytherapy for hepatic malignancies: local progression or benign changes?

Objectives

To determine if dynamic CT can differentiate local progression from radioactive seed-induced peritumoral reaction (RSIPR) after brachytherapy with iodine-125 radioactive seeds (BIRS) for advanced hepatic malignancies.

Methods

Enhanced CT images of seed-implanted lesions between 2006 and 2018 were retrospectively evaluated. Hounsfield units of peritumoral parenchyma were measured and assessed quantitatively. The classification, conversion, consequences, and serological indicators during follow-up were recorded and quantified. Statistical differences were analyzed using a Pearson χ² test.

Results

RSIPR was observed in 201 of 290 (69.3%) lesions (161 patients; median age, 55 years; range, 26–79 years), while local progression occurred in 53 lesions. The low density of local progression was much lower than that of RSIPR (p < 0.001), and the former did not exhibit iso-/high density in the portal or equilibrium phase. Ring-like enhancement in progressive lesions was also quite different from RSIPR. Local progression rate was lower for lesions with RSIPR than for those without RSIPR (14.9% vs 25.8%; p = 0.03), and their doses were different (397.2 Gy vs 120.3 Gy, p < 0.001).

Conclusions

Radioactive seed-induced peritumoral reaction has characteristic manifestations on CT images, which is associated with a higher dose of lesions and lower local progression rate. Notably, the enhancement pattern of local progression was distinct from RSIPR and was clearly distinguishable on dynamic-enhanced CT.

Key Points

• Radioactive seed-induced peritumoral reaction after brachytherapy with¹²⁵I seeds for liver malignancies has characteristic manifestations on CT images, which is associated with a higher dose of lesions (397.2 Gy vs 120.3 Gy, p < 0.001), as a focal radiation injury.

• Lesions with RSIPR were less likely to develop local progression, while those without RSIPR had a higher rate of local progression (14.9% vs 25.8%; p = 0.03).

• The enhancement pattern of local progression after brachytherapy was distinct from radioactive seed-induced peritumoral reaction and was clearly distinguishable on dynamic-enhanced CT.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-022-09074-x.

A state-of-the-art comprehensive review summarizing the emerging data on endoscopic ultrasound-guided liver diseases management

Liver diseases are among the most common diseases worldwide accounting for substantial morbidity and mortality. Most liver diseases necessitate radiological evaluation or accurate diagnosis and recently for management as well. In the last decade, the application of therapeutic endoscopic ultrasound (EUS) procedure has been increasingly utilized for the management of various liver diseases. In this comprehensive narrative review article, we provide systematic overview on EUS-guided therapeutic interventions in various liver diseases summarizing most updated data regarding technical success, outcomes and safety profiles. Overall, 35 articles have reported on the use of EUS in the treatment of liver diseases with excellent technical success, favorable radiological response and high safety profiles for EUS-guided treatment of solid and cystic liver lesion and for EUS-guided angiotherapy for gastric varices, except for EUS-guided cyanoacrylate glue injection which was associated with life-threatening fatal systemic embolization adverse events. This suggests that EUS-guided intervention is a new promising therapeutic intervention for the treatment of various liver diseases with durable effect and a limited potential for adverse events.

Role of endoscopic ultrasound in the field of hepatology: Recent advances and future trends

The role of endoscopic ultrasound (EUS) as a diagnostic and therapeutic modality for the management of various gastrointestinal diseases has been expanding. The imaging or intervention for various liver diseases has primarily been the domain of radiologists. With the advances in EUS, the domain of endosonologists is rapidly expanding in the field of hepatology. The ability to combine endoscopy and sonography in one hybrid device is a unique property of EUS, together with the ability to bring its probe/transducer near the liver, the area of interest. Its excellent spatial resolution and ability to provide real-time images coupled with several enhancement techniques, such as contrast-enhanced (CE) EUS, have facilitated the growth of EUS. The concept of “Endo-hepatology” encompasses the wide range of diagnostic and therapeutic procedures that are now gradually becoming feasible for managing various liver diseases. Diagnostic advancements can enable a wide array of techniques from elastography and liver biopsy for liver parenchymal diseases, to CE-EUS for focal liver lesions to portal pressure measurements for managing various liver conditions. Similarly, therapeutic advancements range from EUS-guided eradication of varices, drainage of bilomas and abscesses to various EUS-guided modalities of liver tumor management. We provide a comprehensive review of all the different diagnostic and therapeutic EUS modalities available for the management of various liver diseases. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.

Role of Endoscopic Ultrasound in Liver Disease: Where Do We Stand?

As the burden of liver disease in the general populace steadily increases, so does the need for both advanced diagnostic and treatment options. Endoscopic ultrasound is a reliable diagnostic and therapeutic method that has an established role, foremost in pancreatobiliary pathology. This paper aims to summarize the growing role of endoscopic ultrasound in hepatology based on the search of the current literature. A number of applications of endoscopic ultrasound are reviewed, including both noninvasive methods and tissue acquisition in focal and diffuse liver disease, portal hypertension measurement, detection and management of gastric and esophageal varices, treatment of focal liver lesions and staging of pancreatobiliary malignancies, treatment of cystic and solid liver lesions, as well as liver abscess drainage. Both hepatologists and endoscopists should be aware of the evolving role of endoscopic ultrasound in liver disease. The inherent invasive nature of endoscopic examination limits its use to a targeted population identified using noninvasive methods. Endoscopic ultrasound is one the most versatile methods in gastroenterology, allowing immediate access with detection, sampling, and treatment of digestive tract pathology. Further expansion of its use in hepatology is immanent.

The Role of Interventional Endoscopic Ultrasound in Liver Diseases: What Have We Learnt?

Chronic liver disease (CLD) is still a major problem, where the disease progression will lead to liver cirrhosis (LC) or hepatocellular carcinoma (HCC). Portal hypertension (PH) management and loco-regional therapy for HCC have become the cornerstones in advanced liver disease management. Recently, there are studies looking at the potential role of interventional endoscopic ultrasound (EUS) in liver diseases. EUS may be useful in vascular changes of the digestive wall evaluation, performing dynamic assessment of hemodynamic changes, predicting variceal bleeding and rebleeding risk, and assessing the pharmacological effects. In PH management, EUS-guided vascular therapy-which revolves around glue injection, endovascular coil placement/embolization, and combination of both-has shown promising results. As a diagnostic modality for liver cancer, the implementation of EUS in liver diseases is currently not only limited to liver biopsy (EUS-LB) but also in shear-wave elastography (SWE) and portal pressure gradient measurement, as well as portal vein sampling. The application of EUS-guided radiofrequency ablation (EUS-RFA) and tumor injection can also overcome the limitations shown by both modalities without EUS. Nevertheless, establishing EUS as a firm diagnostic and therapeutic modality is still challenging since the performance of interventional EUS requires high expertise and adequate facilities.

Endoscopic Ultrasound for Detection of Liver Metastasis: Hope or Hype?

Transabdominal ultrasonography, contrast-enhanced computed tomography, and magnetic resonance imaging (MRI) are the common diagnostic tests for the detection of hepatic lesions. Use of enhanced and advanced MRI technique, that is, diffusion weighted MRI and hepatocyte-specific contrast agents, has further improved the accuracy of detection of metastatic liver lesions ≤10 mm in diameter. However, even with these advanced imaging modalities sensitivity is low for lesions smaller than 10 mm when compared with standard intraoperative ultrasound. Endoscopic ultrasound (EUS) is an emerging imaging modality with resolution sufficient to detect and sample lesions as small as 5 mm in diameter. In this news and views, we have discussed the role of standard and enhanced EUS for the detection of metastatic liver lesions.

The Evolving Role of Advanced Endoscopic Techniques in Hepatology

The role of advanced endoscopy in the field of hepatology has evolved rapidly over the last decade. Several novel diagnostic and therapeutic interventions can now be accomplished endoscopically both easily and safely in patients with liver disease; these include endoscopic ultrasound (EUS)-guided liver biopsy, EUS-guided measurement of the portal pressure gradient, EUS-guided therapy for gastric varices, and EUS elastography. This article highlights advances in endoscopic tools and techniques that can be applied in the field of hepatology.

Endoscopic ultrasound guided hepatic interventions

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.

A Comprehensive Narrative Review on the Evolving Role of Endoscopic Ultrasound in Focal Solid Liver Lesions Diagnosis and Management

The implications of endoscopic ultrasound (EUS) have expanded considerably in recent years to cover more fields in invasive gastroenterology practice, as both an investigative and therapeutic modality. The utility of EUS in the diagnosis and management of focal liver lesions has gained a special attractiveness recently. The EUS probe proximity to the liver and its excellent spatial resolution enables real-time images coupled with several enhancement techniques, such as contrast-enhanced (CE) EUS. Aside from its notable capability to execute targeted biopsies and therapeutic interventions, EUS has developed into a hopeful therapeutic tool for the management of solid liver lesions. Herein, we provide a comprehensive state-of-the-art review on the efficacy and safety of EUS in the diagnosis and management of focal solid liver lesions. Medline/PubMed and Embase database searches were conducted by two separate authors (T.K. and W.S.), all relevant studies were assessed, and relevant data was extracted and fully reported. EUS-guided diagnosis of focal liver lesions by sonographic morphologic appearance and cytological and histopathological finding of biopsies obtained via fine needle aspiration/biopsy have been shown to significantly improve the diagnosis of solid liver lesions compared with traditional imaging tools. Similarly, EUS-guided treatment has been shown to consistently have excellent technical success, high efficacy, and minor adverse events. The evolving valuable evidences of EUS utility might satisfy the unmet need of optimizing management of focal solid liver lesions.

The role of EUS in diagnosis and treatment of liver disorders

Background and aim  Transabdominal ultrasound (US), computed tomographic scanning (CT) and magnetic resonance imaging (MRI) are established diagnostic tools for liver diseases. Percutaneous transhepatic cholangiography is used to perform hepatic interventional procedures including biopsy, biliary drainage procedures, and radiofrequency ablation. Despite their widespread use, these techniques have limitations. Endoscopic ultrasound (EUS), a tool that has proven useful for evaluating the mediastinum, esophagus, stomach, pancreas, and biliary tract, has an expanding role in the field of hepatology complementing the traditional investigational modalities. This review aimed to assess the current scientific evidence regarding diagnostic and therapeutic applications of EUS for hepatic diseases.

Treatment response and preliminary efficacy of hepatic tumour laser ablation under the guidance of percutaneous and endoscopic ultrasonography

Background

Studies focusing on the treatment effectiveness of endoscopic ultrasonography (EUS)-guided laser ablation (LA) for hepatic tumours or the technical differences from percutaneous ultrasonography (US)-guided LA are lacking. The objective of this study was to evaluate the treatment response and preliminary efficacy of US- and EUS-guided LA for hepatic tumours.

Methods

We performed a prospective analysis of treatment response and preliminary efficacy in 92 consecutive patients who underwent US-LA and EUS-LA from January 2015 to June 2017. The primary endpoint was complete tumour ablation (CTA). The secondary endpoint was 12-month local tumour progression (LTP).

Results

Among a total of 120 hepatic lesions, 20 lesions were ablated under the guidance of EUS. The application of the multi-fibre technique (0, 0% vs. 69, 69.0%, p < 0.01), tumours located in the left lobe (18, 90.0% vs. 28, 28.0%, p < 0.01) and multi-session ablation (4, 20.0% vs. 4, 4.0%, p = 0.009) were factors found to be significantly different between the EUS-LA and US-LA groups. The CTA was achieved in 94% of patients in the US-LA group and 100% of patients in the EUS-LA group (p = 0.261). Twelve-month LTP was observed in 8.5% of the patients in the US-LA group and 15.0% of the patients in the EUS-LA group with no significant difference between the two groups (p = 0.372). The multivariate analysis identified that the tumour diagnosis (p = 0.004; 95% CI, 0.039–0.547) was the only independent risk factor associated with 12-month LTP.

Conclusions

Patients in the EUS-LA and US-LA groups shared as similar treatment response and preliminary efficacy in the treatment of hepatic tumours. A hybrid LA approach to nonsurgical hepatic tumours appeared to be reasonable.

Endoscopic ultrasonography (EUS)-guided laser ablation (LA) of adrenal metastasis from pancreatic adenocarcinoma

Endoscopic ultrasonography (EUS)-guided laser ablation (LA) is potentially applicable to tumours in the left lobe of the liver and pancreas. This report seeks to introduce the novel use of EUS-guided LA for left adrenal metastases from pancreatic adenocarcinoma. A 70-year-old female was referred to our hospital for dull abdominal pain and tiredness for 1 month. Computed tomography (CT) discovered a 1.0 × 1.7 cm mass in the area of the left adrenal gland. The lesion was highly suspicious for metastasis due to her history of pancreatic adenocarcinoma 1 year ago, which was removed through radical surgery. Intraoperative frozen-section pathology revealed a tumour invading the left adrenal gland. The left adrenal mass was clearly visualised on EUS and exhibited irregular hyper-enhancement during contrast. The tumour was successfully treated by four sessions of EUS-guided LA. After the procedure, symptomatic relief was achieved and remained. At the 4-month follow-up, contrast-enhanced CT revealed that the volume of the target was significantly decreased. Here, we introduced a new method for left adrenal metastasis using thermal ablation through EUS. As a potential alternative access to the percutaneous approach, EUS-guided LA may provide a minimally invasive treatment to relieve the tumour burdens and symptoms when applied accurately.