Sa1449 Endoscopic Ultrasound Guided Pancreatic Cyst Ablation With Ethanol and Paclitaxel: Will It Also Work in the Western Hemisphere?

Abstract

Follow-up imaging after EUS-guided pancreatic cyst ablation with ethanol alone leads to resolution in about 1/3 of patients. Experience at a single Korean hospital reports that the addition of paclitaxel to ethanol (EUS-EP) increases resolution to 60-70% but this has not been confirmed elsewhere. To report initial results and complications from EUS-EP in a Western population. In a single center prospective cohort study, consecutive patients with a 1-5 cm pancreatic cyst and ≤5 septations (regardless of main pancreatic duct [PD] communication) were enrolled. Exclusion criteria: active pancreatitis, pancreatic necrosis, portal hypertension, ascites, coagulopathy or dilated PD. Baseline evaluation: CT or MRI, EUS imaging, cyst fluid cytology, CEA and DNA analysis (PathFinderTG®, RedPath IP, Inc; Pittsburgh PA). At initial ablation (EUS-EP1), cysts were lavaged for 3-5 minutes with 99% ethanol, re-aspirated and then injected with an equal volume of 2mg/mL paclitaxel (Bedford Laboratories; Bedford, OH) which was left in place. Three months later, repeat EUS and cyst ablation (EUS-EP2) was performed if cyst size was ≥10mm. Repeat ablation was considered on a case-by-case basis for patients with preceding ablation-induced pancreatitis. Three months after EUS-EP-2, pancreas protocol CT was performed at our hospital. Baseline imaging and post-ablation 3D volume CT images were interpreted by a single radiologist. Complete response (CR), partial response (PR) and a persistent cyst were defined using CT criteria: <5% of the original volume (OV), 5-25% of OV, and >25% of OV respectively. 18 patients (13F, median 65 yrs) with cysts located in the uncinate in 3, head in 5, neck 2, body in 5, and tail 3 were enrolled. Baseline median CT or MRI cyst diameter: 2.7 cm (1.5-4.6) and 3D volume: 6.4 cm3 (1.1-38). Median cyst CEA was 1307 ng/mL (range: 0.2-75508). Clinical diagnoses were: IPMN in 11, MCN in 6 and SCN 1. EUS-EP1 (n=18) was complicated by acute pancreatitis (AP) in 3 and abdominal pain in 2. EUS-EP2 was not done in two who refused follow up EUS (n=1) or had surgery (n=1). The remaining 16 returned for EUS- EP2, but injection was not done in 7 with cysts measuring <10 mm (n=5) or in patients with previous AP (n=2). In the 9 injected, abdominal pain without pancreatitis occurred in 2. Follow up CT (available in 12/16 to date) showed: a CR in 5/12 (42%), PR in 5/12 (42%) and persistent cyst in 2/12 (16%). In our initial ongoing experience, EUS-guided pancreatic cyst ablation with ethanol and paclitaxel led to a CT-defined CR in 5/12 (42%), PR in 5/12 (42%) and a persistent cyst in 2/12 (16%). Complication rates encountered were acute pancreatitis in 3/27 (11%) injections and self-limited abdominal pain in 4/27 (15%).