advanced endoscopic management techniques for ......eus-guided fine needle injection (fni):...
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Advanced Endoscopic Management Techniques for
Pancreatic Malignancy
Harry R. Aslanian, MD, FASGE, AGAF, FACG Associate Director of Endoscopy
Director of Advanced Endoscopy Fellowship Yale University School of Medicine
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Endoscopic Management of Pancreas Cancer
- Palliation of duodenal obstruction
-Stenting, GJ - Celiac neurolysis - Fiducial placement - Fine needle Injection of anti-tumor agents - Etoh ablation of pancreas cysts -Etoh ablation of insulinoma - RFA tumor ablation
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Duodenal Obstruction: 15-20% pts Endoscopic duodenal stent vs surgery?
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Endoscopic stents (SEMS) vs. Lap or
Open Surgical Gastrojejunostomy (GJ)
STRATEGY Success* Immediate
Complication 1-Month
Complication Mortality
Cost (incremental)
SEMS 72% 6% 23% 2.1% $8,213
LGJ 69% 15% 18% 2.5% $10,340
OGJ 62% 28% 13% 4.5% $12,191
*Success defined as no major procedure related complication or long term complication for 1 month period
Conclusion: SEMS had the highest success rate, the fewest negative outcomes in terms of mortality and was the most cost-effective of the 3
treatment options evaluated
Literature Review of 33 Studies1
1Siddiqui, Dig Dis Sci, 2007
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Duodenal stent vs Surgical GJ – 39 pts: Randomized Trial – Quicker food intake with stents (5 vs 8 days) – Long term relief better with GJ (72 vs 50 days) – More re-interventions with stent (10 vs 2)
l Tissue hyperplasia obstructs stent lumen
Jeurnink Gastrointest Endosc 2010
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EUS imaging of the pancreas
via duodenum and stomach
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LAMS: Lumen Apposing Metal Stent
-Electrocautery at the catheter tip traverses wall -Appose, non-adherent adjacent structures -Allows EUS guided intervention in new areas
Itoi & Binmoeller , GIE 2012;75
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EUS guided gastrojejunostomy
Itoi GIE 2014
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LAMS: Gastrojejunostomy
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EUS Guided GJ vs Lap GJ: Perez-Miranda DDW 2017
– 29 Lap vs 25 EUS guided
l Clinical success: 90% surgery l 84% EUS l 36% of EUS cases needed 2nd salvage stent
– LAMS or FCSEMS
l 7% Surgery- Converted to open l LOS Same (9.4 vs 8.9 days) l Comp’s: 41% Surgery- leus, Anast leak, PNA
– 12% EUS- Bleeding, Peritonitis
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Afferent limb obstruction sp Whipple
2/2/18 11
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Afferent limb obstruction sp Whipple
2/2/18 12
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Therapeutic Role of EUS in Pancreatic Cancer
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EUS-guided CPN l Successful in advanced pancreatic cancer
– Decreased pain scores in (78%) at 2 and 24 weeks (45/58 pts) l No major complications
– 9%-20% transient pain, hypotension
– May also Inject directly into ganglia • Levy, Am J Gastro 2008
Gunaratnam et al., Gastrointest Endosc 2001
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EUS-guided Fiducial Marker Placement used in Image Guided Radiation Therapy
Park WG, et al. Gastrointest Endosc March 2010
50 pts with advanced panc cancer 19G needles Sterilized gold fiducials -2.5mm long -0.8mm diameter -4 to 6 per tumor
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EUS-guided Fine Needle Injection (FNI): Anti-tumor Agents
l Small trials in locally advanced pancreatic cancer – clinical efficacy uncertain – Cytoimplant1 = allogenic mixed lymphocyte culture
– ONYX-0152 = attenuated adenovirus causes replication dependent killing of cancer cells with loss of p53 function
– TNFerade3 = replication deficient adenovirus vector carrying TNF alpha gene and regulated by radiation induced promoter
-Gemcitabine4 -intratumoral injection prior to systemic tx l 4. Levy, DDW 2011
1. Chang KJ et al., Cancer 2000 2. Hecht et al., Clin Can Res 2003 3. Posner et al., ASCO AB 2007
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EUS Guided Chemoablation of Mucinous Pancreatic Cysts
Etoh and/or Paclitaxel Systematic review: Response 53% Complete resolution 27% Partial Complications: 7% abdominal pain 4% pancreatitis Kandula Indian J Gastro 2015
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EUS guided ethanol ablation of symptomatic insulinoma
l 6 pts, severe hypoglycemia l 16 mm mean tumor size l EUS guided injection of 0.75 ml etoh
– Mean of 2 treatments
l All pts had sx improvement l 1 pt abd pain, 1 self limited fluid
Levy M, GIE 2012
Endocrinol Diabetes Metab Case Rep. 2017
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EUS guided RFA pancreas tumor ablation
– Review of 42 cases l 28 ACA, 7 NET, 7 cysts l Technical success in 36
– Could not penetrate tumor in 6 (14 G needle)
l Complications: Minor in 20% • Self limited abdominal pain, bleeding
Alvarez-Sanchez World J Gastro 2016
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EUS guided pancreas tumor ablation: next steps
l Which patients may benefit from local therapy – Downstage locally advanced tumors
l Survival benefit l Technique optimization
l Etoh, brachytherapy, RFA, cryotherapy
l Safety: pancreatitis, vascular injury