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Rizzo GEM, Carrozza L, Rancatore G, Binda C, Fabbri C, Anderloni A, Tarantino I. The Role of Endoscopy in the Palliation of Pancreatico-Biliary Cancers: Biliary Drainage, Management of Gastrointestinal Obstruction, and Role in Relief of Oncologic Pain. Cancers (Basel) 2023; 15:5367. [PMID: 38001627 PMCID: PMC10670525 DOI: 10.3390/cancers15225367] [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: 09/12/2023] [Revised: 10/20/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Therapeutic endoscopy permits many and various treatments for cancer palliation in patients with bilio-pancreatic cancers, enabling different options, supporting patients during their route to oncologic treatments, and trying to improve their quality of life. Therefore, both endoscopic and endoscopic ultrasound (EUS)-guided techniques are performed in this scenario. We performed a literature review focusing on the role of endoscopy in the palliation of those advanced pancreatic and biliary cancers developing malignant biliary obstruction (MBO), gastric outlet obstruction (GOO), and pain unresponsive to medical therapies. Therefore, we explored and focused on the clinical outcomes of endoscopic procedures in this scenario. In fact, the endoscopic treatment is based on achieving biliary drainage in the case of MBO through endoscopic retrograde cholangiopancreatography (ERCP) or EUS-guided biliary drainage (EUS-BD), while GOO is endoscopically treated through the deployment of an enteral stent or the creation of EUS-guided gastro-entero-anastomosis (EUS-GEA). Furthermore, untreatable chronic abdominal pain is a major issue in patients unresponsive to high doses of painkillers, so EUS-guided celiac plexus neurolysis (CPN) or celiac ganglia neurolysis (CGN) helps to reduce dosage and have better pain control. Therefore, therapeutic endoscopy in the palliative setting is an effective and safe approach for managing most of the clinical manifestations of advanced biliopancreatic tumors.
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Affiliation(s)
- Giacomo Emanuele Maria Rizzo
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
- Ph.D. Program, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, 90133 Palermo, Italy
| | - Lucio Carrozza
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
| | - Gabriele Rancatore
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 48100 Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 48100 Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy;
| | - Ilaria Tarantino
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
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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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Caceres J, Munoz-Sagastibelza M, Hossian AKMN, Paredes J, Barrera K, Mattheolabakis G, Martello LA, Vignesh S. Evaluation of the feasibility of intrapancreatic delivery of drug-loaded microparticles via EUS-guided fine needle injection using a swine model. Endosc Int Open 2019; 7:E1008-E1017. [PMID: 31404394 PMCID: PMC6687482 DOI: 10.1055/a-0953-2070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background and study aims Patients with pancreatic cancer often have locally advanced or metastatic disease and are not candidates for curative surgery. Polymer-based microparticles (MPs) represent a drug delivery system that offers sustained release of a chemotherapeutic drug after intralesional injection for local tumor management. The aim of this study was to determine the feasibility of endoscopic ultrasound-guided fine-needle injection (EUS-FNI) of drug-loaded MPs tagged with a fluorophore and fiducial markers for locating the injection site. Secondary aims were to determine the tissue-specific effects of MPs. Methods Five pigs underwent EUS with selection of an injection site within the pancreas that was marked by placing fiducial markers prior to the MPs injection. EUS-FNI of either blank microparticles (BMPs), containing no drug, or gemcitabine-loaded microparticles (GMPs) was performed. A saline flush containing Spot Endoscopic Marker was used to expel any residual MPs in the needle shaft and tattoo the injection site. Results A green fluorescent protein flashlight was used to successfully identify the site of MP injection sites in the dissected pancreas. Frozen sections of pig pancreas demonstrated a defined deposit, confirming the delivery of the MPs. Finally, fluorescence microscopy showed activation of caspase-mediated cell death in pancreases of animals that received injections of GMPs. Conclusions This pilot study demonstrated that fiducial marker placement and pancreatic EUS-FNI of MPs was successful in all pigs with no animals demonstrating pancreatitis. Further studies are needed to determine the role for intralesional injection of drug-loaded MPs in borderline resectable or unresectable pancreatic cancer.
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Affiliation(s)
- Jennifer Caceres
- Medicine Digestive and Liver Diseases, Columbia University Medical Center, New York, New York, United States
| | - Maria Munoz-Sagastibelza
- SUNY Downstate Medical Center, Department of Medicine, Division of Gastroenterology & Hepatology, Brooklyn, New York, United States
| | | | - Jenny Paredes
- SUNY Downstate Medical Center, Department of Medicine, Division of Gastroenterology & Hepatology, Brooklyn, New York, United States
| | - Kaylene Barrera
- SUNY Downstate Medical Center, Department of Surgery, Brooklyn, New York, United States
| | - George Mattheolabakis
- University of Louisiana at Monroe, College of Pharmacy, Monroe, Louisiana, United States
| | - Laura A. Martello
- SUNY Downstate Medical Center, Department of Medicine, Division of Gastroenterology & Hepatology, Brooklyn, New York, United States
| | - Shivakumar Vignesh
- SUNY Downstate Medical Center, Department of Medicine, Division of Gastroenterology & Hepatology, Brooklyn, New York, United States,Corresponding author Shivakumar Vignesh, MD SUNY Downstate Medical Center450 Clarkson AvenueMSC 1196Brooklyn, NY 11203USA718-270-7201
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Targeting Ligand Specificity Linked to Tumor Tissue Topological Heterogeneity via Single-Cell Micro-Pharmacological Modeling. Sci Rep 2018; 8:3638. [PMID: 29483578 PMCID: PMC5827036 DOI: 10.1038/s41598-018-21883-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 02/13/2018] [Indexed: 02/07/2023] Open
Abstract
Targeted therapy has held promise to be a successful anticancer treatment due to its specificity towards tumor cells that express the target receptors. However, not all targeting drugs used in the clinic are equally effective in tumor eradication. To examine which biochemical and biophysical properties of targeted agents are pivotal for their effective distribution inside the tumor and their efficient cellular uptake, we combine mathematical micro-pharmacological modeling with in vivo imaging of targeted human xenograft tumors in SCID mice. The mathematical model calibrated to experimental data was used to explore properties of the targeting ligand (diffusion and affinity) and ligand release schemes (rates and concentrations) with a goal to identify the properties of cells and ligands that enable high receptor saturation. By accounting for heterogeneities typical of in vivo tumors, our model was able to identify cell- and tissue-level barriers to efficient drug uptake. This work provides a base for utilizing experimentally measurable properties of a ligand-targeted agent and patient-specific attributes of the tumor tissue to support the development of novel targeted imaging agents and for improvement in their delivery to individual tumor cells.
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The Emerging Role of Endoscopists in Treating Unresectable Pancreatic Cancer. Pancreas 2017; 46:839-849. [PMID: 28697122 DOI: 10.1097/mpa.0000000000000862] [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: 12/10/2022]
Abstract
Pancreatic adenocarcinoma is the eighth leading cause of cancer deaths worldwide in men and ninth leading cause in women. Surgical resection offers the only chance of potential cure; however, only 9.4% of patients present at the localized, resectable stage, whereas the rest present at the locally advanced or metastatic, unresectable stages. Because of the guarded outcomes following systemic chemoradiation and the associated systemic toxicities, locoregional therapies have recently gained popularity. Various endoscopic techniques (endoscopic ultrasound [EUS]-guided ablative therapies, fine-needle instillation of antitumor agents, stereotactic body radiation therapy with EUS-guided fiducial marker placement, and EUS-guided brachytherapy) have been explored over the past several years. Endoscopic therapy plays a role in the treatment of unresectable pancreatic adenocarcinoma. Its minimal invasiveness and increased precision of delivering oncologic treatments under EUS guidance render it as a favorable option for patients who do not benefit from surgical resection. New endoscopic therapies are currently under investigation, and the emerging role of the endoscopist in the treatment of unresectable pancreatic cancer continues to grow.
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Luthra AK, Mishra G. Novel diagnostic and therapeutic modalities using endoscopic ultrasound in pancreatic disease. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Anjuli Kristin Luthra
- Section on General Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Girish Mishra
- Department of Gastroenterology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Coronel E, Waxman I. State-of-the-art endoscopic procedures for pancreatic cancer. Future Oncol 2016; 12:2037-47. [DOI: 10.2217/fon-2016-0123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Pancreatic cancer is the twelfth most common cancer worldwide, taking the fourth place in cancer-related mortality in western countries. Despite significant efforts in understanding the tumor biology of pancreatic cancer and introducing new technologies and therapies to improve the detection, staging and treatment of this disease, pancreatic cancer continues to have a high and almost unchanged mortality. In the last few decades, the development of techniques such as endoscopic retrograde cholangio pancreatography and endoscopic ultrasound have allowed us to directly access the pancreaticobiliary system and fight pancreatic cancer and its complications from different fronts. Our goal with this review is to discuss the most cutting-edge endoscopic techniques available in our armamentarium to diagnose, stage and treat pancreatic cancer.
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Affiliation(s)
- Emmanuel Coronel
- University of Chicago Medicine, Gastroenterology, Hepatology & Nutrition, Chicago, IL, USA
| | - Irving Waxman
- University of Chicago Medicine, Center for Endoscopic Research & Therapeutics, Chicago IL, USA
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Abstract
AbstractPancreatic cancer has long been a leading cause of cancer death. Few patients are suitable for surgery and for those who are not, the response to treatment is generally poor. No more than about 10% survive for more than a year. Recent research has focused on focal treatment for local disease control. This review covers the development of one of the most promising options, photodynamic therapy (PDT).This review covers pre-clinical and clinical studies. Laboratory work was designed to understand the effect of PDT on the normal pancreas and surrounding tissues and on transplanted cancers in the hamster pancreas to ensure safety prior to clinical application. Essentially all clinical studies have been undertaken in University College Hospital, London. Phase-I studies used the photosensitisers mTHPC and verteporfin in patients with localised but inoperable cancers.Laboratory results showed that normal pancreas, bile duct, liver, stomach and major blood vessels could tolerate PDT without any unacceptable effects on the structure and function of these organs. Necrosis that healed safely was documented in transplanted cancers. The clinical trials showed that focal necrosis could be produced in inoperable cancers with acceptable levels of complications, but considerable refinements of treatment delivery and monitoring are required before the technique will be ready for assessment in controlled clinical trials.PDT is showing promise for the minimally invasive treatment of localised pancreatic cancers, but it is still at an early stage of development. Much more work will be necessary to optimise techniques for applying PDT to these cancers and for combining it with other therapeutic options such as chemotherapy.
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