EUS-guided Cyst Ablation Research Articles

S2847 Long-Term Follow-Up of Hepatic Cyst After Endoscopic Ultrasound-Guided Sclerotherapy

Introduction: Hepatic cysts can be found in up to 18% of the population. (1) In most cases they are benign, asymptomatic and do not require any intervention. For symptomatic cysts, management includes surgical unroofing or sclerotherapy. Endoscopic ultrasound (EUS)-guided sclerotherapy with ethanol has emerged as an alternative to surgical intervention and percutaneous drainage (PCD) with sclerotherapy. There is few long-term data and randomized control trials comparing the efficacy of these interventions. This case highlights the outcome of EUS-ablation with ethanol for hepatic cyst after long-term follow up. Case Description/Methods: Patient is a 47-year-old female with a history of Systemic Lupus Erythematous who initially presented with dyspnea and intermittent right upper quadrant pain then found to a large hepatic cyst on echocardiogram. Her cardiopulmonary workup was otherwise unremarkable. Liver function tests were within normal limits. She underwent liver MRI which showed a 6.9cm left lobe (segment III) unilocular hepatic cysts. Tumor markers were negative. She was referred to GI and EUS-guided cyst ablation with ethanol was performed. Analysis of cyst fluid was benign. CT 1 month after ablation showed decreased hepatic cyst to 3.5cm and patient reported significant improvement in symptoms. Two months later, a second EUS-guided ablation was done in attempt to achieve complete cyst eradication. MRI after second ablation demonstrated further decrease in size of hepatic cyst to 2.6cm. Seventeen months after initial ablation imaging showed stable reduction in size of hepatic cyst (1.8cm). Discussion: Prior to interventions for simple hepatic cysts, it is necessary to ensure that symptoms are not from alternative etiologies. The approach to management of symptomatic simple hepatic cysts depends on location, comorbidities and patient preference. EUS-guided sclerotherapy is a promising alternative to surgery and PCD with sclerotherapy. A single center retrospective study reported 100% cyst reduction at 15 month follow up in the group that received EUS guided sclerotherapy. EUS-guided ablation allows for easier access to the left, caudate and posterior segments of the liver compared to PCD and is overall safe. (2)

The efficacy and safety of endoscopic ultrasound-guided ablation of pancreatic cysts with alcohol and paclitaxel: a systematic review.

Endoscopic ultrasound (EUS)-guided pancreatic cyst ablation with alcohol lavage or paclitaxel-based regimens are investigative modalities. To evaluate the safety and efficacy of EUS-guided pancreatic cyst ablation with alcohol lavage or paclitaxel-based regimens. A systematic review of computerized bibliographic databases was carried out for studies of EUS-guided pancreatic cyst ablation with alcohol lavage or paclitaxel-based regimens from January 1980 to February 2018. EUS-guided cyst ablation-related outcomes (cyst resolution) and complications. Data were extracted from six studies (N=207 patients) for EUS-guided cyst ablation with alcohol lavage and eight studies (N=347 patients) for EUS-guided cyst ablation with paclitaxel-based regimens. The pooled proportion of patients with complete cyst resolution was 68/207 (32.8%) for EUS-guided cyst ablation with alcohol lavage and 221/347 (63.6%) for EUS-guided cyst ablation with paclitaxel. Postablation adverse events with EUS-guided ablation with alcohol lavage were 44/207 (21.7%), and those with EUS-guided ablation with paclitaxel-based regimens were 52/347 (15%). Limitations of this study are because of the variability in study design and regimens tested, paucity of randomized trials, and differences in pancreatic cyst types receiving treatment. EUS-guided cyst ablation appears to be effective and safe. The effect on pancreatic cancer incidence is unknown; EUS-guided pancreatic cyst ablation modalities require further improvement and validation to determine their role in the treatment of patients with pancreatic cystic lesions.

Long-term outcomes after endoscopic ultrasound-guided ablation of pancreatic cysts

Background and study aims The aim of this study was to investigate the long-term outcomes after endoscopic ultrasound (EUS)-guided pancreatic cyst ablation. Patients and methods In a single-center, prospective study, 164 patients with pancreatic cysts underwent EUS-guided cyst ablation using ethanol with paclitaxel. The inclusion criteria were as follows: unilocular or oligolocular cysts; clinically indeterminate cysts that required EUS fine-needle aspiration; and/or cysts that grew during the observation period. Treatment response was classified as complete resolution, partial resolution, or persistent cyst, with < 5 %, 5 % - 25 %, and 25 % of the original cyst volume, respectively. Results The median largest diameter of the cyst was 32 mm and the median volume was 17.1 mL. Based on cyst fluid analysis there were 71 mucinous cystic neoplasms, 16 serous cystic neoplasms, 11 intraductal papillary mucinous neoplasms, 3 pseudocysts, and 63 indeterminate cysts. Sixteen treated patients (9.8 %) had adverse events (1 severe, 4 moderate, and 11 mild). Treatment response was as follows: complete resolution in 114 (72.2 %), partial resolution in 31 (19.6 %), and persistent cysts in 13 (8.2 %). Twelve of the 13 patients with persistent cysts underwent surgery. During clinical and imaging follow-up (median 72 months, interquartile range 50 - 85 months) of the 114 patients with complete resolution, only two patients (1.7 %) showed cyst recurrence. Based on multivariate analysis, the absence of septa (odds ratio [OR] 7.12, 95 % confidence interval [CI] 2.72 - 18.67) and cyst size less than 35 mm (OR 2.39, 95 %CI 1.11 - 5.16) predicted complete resolution. Conclusion Among patients with pancreatic cysts in whom complete resolution was achieved after EUS-guided cyst ablation, 98.3 % remained in remission at 6-year follow-up. Unilocular form and small cyst size were predictive of complete resolution. This treatment approach may be an effective and durable alternative to surgery.Trial registered at ClinicalTrials.gov (NCT 00689715).

Long-term outcomes after endoscopic ultrasonography-guided ablation of pancreatic cysts

Objectives:The aim of this study was to investigate the long-term outcomes after endoscopic ultrasonography (EUS)-guided pancreatic cyst ablation.Methods:In a single-center, prospective study, 164 patients with pancreatic cysts underwent EUS-guided cyst ablation using ethanol with paclitaxel. The inclusion criteria were as follows: unilocular or oligolocular cysts, clinically indeterminate cysts that required EUS fine-needle aspiration, and/or cysts that grew during the observation period. Treatment response was classified as complete resolution (CR), partial resolution (PR), or persistent cyst, with <5%, 5%–25%, and 25% of the original cyst volume, respectively.Results:The median largest diameter of the cyst was 32 mm and the median volume was 17.1 mL. Based on cyst fluid analysis, there were 71 mucinous cystic neoplasms, 16 serous cystic neoplasms, 11 intraductal papillary mucinous neoplasms, 3 pseudocysts, and 63 indeterminate cysts. Sixteen treated patients (9.8%) had adverse events (severe 1, moderate 4, and mild 11). Treatment response was as follows: CR, 114 (72.2%); PR, 31 (19.6%); and persistent cysts, 13 (8.2%). Twelve of 13 patients with persistent cysts underwent surgery. During clinical and imaging follow-up (median 72 months, interquartile range 50–85 months) of the 114 patients with CR, only two patients (1.7%) showed cyst recurrence. Based on multivariate analysis, the absence of septa (odds ratio [OR], 7.12; 95% confidence interval [CI], 2.72–18.67) and cyst size <35 mm (OR, 2.39; 95% CI, 1.11–5.16) predicted CR.Conclusion:Among patients with pancreatic cysts who achieved CR after EUS-guided cyst ablation, 98.3% remain in remission at 6-year follow-up. Unilocular and small cyst was predictive of CR.

Endosonography in the diagnosis and management of pancreatic cysts.

Rapid advances in radiologic technology and increased cross-sectional imaging have led to a sharp rise in incidental discoveries of pancreatic cystic lesions. These cystic lesions include non-neoplastic cysts with no risk of malignancy, neoplastic non-mucinous serous cystadenomas with little or no risk of malignancy, as well as neoplastic mucinous cysts and solid pseudopapillary neoplasms both with varying risk of malignancy. Accurate diagnosis is imperative as management is guided by symptoms and risk of malignancy. Endoscopic ultrasound (EUS) allows high resolution evaluation of cyst morphology and precise guidance for fine needle aspiration (FNA) of cyst fluid for cytological, chemical and molecular analysis. Initially, clinical evaluation and radiologic imaging, preferably with magnetic resonance imaging of the pancreas and magnetic resonance cholangiopancreatography, are performed. In asymptomatic patients where diagnosis is unclear and malignant risk is indeterminate, EUS-FNA should be used to confirm the presence or absence of high-risk features, differentiate mucinous from non-mucinous lesions, and diagnose malignancy. After analyzing the cyst fluid for viscosity, cyst fluid carcinoembryonic antigen, amylase, and cyst wall cytology should be obtained. DNA analysis may add useful information in diagnosing mucinous cysts when the previous studies are indeterminate. New molecular biomarkers are being investigated to improve diagnostic capabilities and management decisions in these challenging cystic lesions. Current guidelines recommend surgical pancreatic resection as the standard of care for symptomatic cysts and those with high-risk features associated with malignancy. EUS-guided cyst ablation is a promising minimally invasive, relatively low-risk alternative to both surgery and surveillance.

The CHARM Trial (CHemotherapy for Ablation and Resolution of Mucinous Pancreatic Cysts): The Initial Pilot Study for the Prospective, Randomized, Double-Blind, Single-Center Clinical Trial

Introduction: Mucinous pancreatic cystic lesions carry significant potential for progression into pancreatic cancer. Currently radiographic surveillance or surgical resection is generally recommended for these cysts, both of which have significant limitations. Recently, EUS-guided cyst ablation has emerged as promising alternative treatment approach. Previous studies have shown that EUS-guided ethanol lavage of pancreatic cysts is safe and results in complete cyst resolution in roughly one-third of patients without recurrence at a follow-up of 26 months. Subsequent studies demonstrated marked increases in rates of ablation (62-78%) with infusion of paclitaxel following ethanol lavage, which raises the question of whether alcohol is necessary for effective ablation. Importantly, ethanol extravasation is felt to cause the 2 most common complications in previous trials, abdominal pain (12-16%) and pancreatitis (3-5%), and is felt to be the highest risk element of the technique. This study hypothesizes that the removal of alcohol lavage prior to chemotherapy infusion will not impair ablation rates and will decrease complication rates. A secondary aim of this study is to assess whether a custom chemoablation cocktail tailored to pancreatic neoplasia (paclitaxel+gemcitabine) will improve ablation rates overall. Methods: Patients with mucinous or indeterminate type pancreatic cysts of 1-5 cm without signs of malignancy were randomized to undergo either EUS-guided lavage with 80% alcohol or normal saline, followed by infusion of 3 mg/mL paclitaxel + 19 mg/mL gemcitabine (both arms). Patients were evaluated postop, at 72 hours, and by CT scan at 3, 6, and 12 months to assess response and complication rates. Results: The initial 13 patients of this trial (expected to have an N of 78 when complete) were randomized for this pilot study with 11 patients then able to be treated. The overall reduction in cyst surface area was 70% at 3 months and 83% at 6 months. At 3 months, size reduction was 62.5% in the alcohol infusion arm and 74% in the alcohol-free arm. Complications were mild pancreatitis (1/5) in the alcohol arm. Conclusion: The treatment of mucinous pancreatic cysts with either alcohol or saline lavage followed by gemcitabine-paclitaxel infusion is feasible and safe in this limited pilot study. Initial results indicate that alcohol-free ablation does not impair ablation efficacy. Disclosure - Dr. Moyer is a consultant for Boston Scientific Corp. This is unrelated to the current research.

Endoscopic ultrasound and pancreatic cystic lesions-diagnostic and therapeutic applications.

Pancreatic cystic lesions are being detected with an increasing frequency. Endoscopic ultrasound (EUS) provides both diagnostic and therapeutic means for pancreatic cystic lesions. Detailed imaging and EUS-guided fine-needle aspiration provide additional information on pancreatic cystic lesions. EUS-guided pseudocyst drainage has advantages over conventional drainage modalities. EUS-guided cyst ablation is a promising therapeutic modality.

Current status on the diagnosis and management of pancreatic cysts in the Asia–Pacific region: Role of endoscopic ultrasound

Endoscopic ultrasound (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) play increasingly prominent roles in the diagnosis and management of pancreatic cysts. The Asian Consortium of Endoscopic Ultrasound was recently formed to conduct collaborative research in this area. This is a review of literature on true pancreatic cysts. Due to the lack of systematic studies, there are no robust data on the true incidence of pancreatic cystic lesions in Asia and any change in over the recent decades. Certain EUS morphological features have been used to predict particular types of pancreatic cysts. Pancreatic cyst fluid viscosity, cytology, pancreatic enzymes, and tumor markers, in particular carcinoembryonic antigen, can aid in the diagnosis of pancreatic cysts. Hemorrhage and infection are the most common complications of EUS-FNA of pancreatic cysts. Pancreatic cysts can either be observed or resected depending on the benign or malignant nature, or malignant potential of the lesions. Guidelines from an international consensus did not require positive cytological findings to be present in their recommendation for resection, which included all mucinous cystic neoplasms, all main-duct intraductal papillary mucinous neoplasms (IPMN), all mixed IPMN, symptomatic side-branch IPMN, and side-branch IPMN larger than 3 cm. In patients with poor surgical risks, EUS-guided cyst ablation of mucinous pancreatic cysts is an alternative. As long-term prospective data on pancreatic cysts are still not available in Asia, management strategies are largely based on risk stratification by surgical risk and malignant potential. Gene expression profiling of pancreatic cyst fluid and confocal laser endomicroscopic examination of pancreatic cysts are novel techniques currently being studied.