Advanced Endoscopic Ultrasound Management Techniques for Preneoplastic Pancreatic Cystic Lesions

Abstract

Pancreatic cystic lesions can be benign, premalignant or malignant. The recent increase in detection and tremendous clinical variability of pancreatic cysts has presented a significant therapeutic challenge to physicians. Mucinous cystic neoplasms are of particular interest given their known malignant potential. This review article provides a brief but comprehensive review of premalignant pancreatic cystic lesions with advanced endoscopic ultrasound (EUS) management approaches. A comprehensive literature search was performed using PubMed, Cochrane, OVID and EMBASE databases. Preneoplastic pancreatic cystic lesions include mucinous cystadenoma and intraductal papillary mucinous neoplasm. The 2012 International Sendai Guidelines guide physicians in their management of pancreatic cystic lesions. Some of the advanced EUS management techniques include ethanol ablation, chemotherapeutic (paclitaxel) ablation, radiofrequency ablation and cryotherapy. In future, EUS-guided injections of drug-eluting beads and neodymium:yttrium aluminum agent laser ablation is predicted to be an integral part of EUS-guided management techniques. In summary, International Sendai Consensus Guidelines should be used to make a decision regarding management of pancreatic cystic lesions. Advanced EUS techniques are proving extremely beneficial in management, especially in those patients who are at high surgical risk.

New treatment of the pancreatic cystic neoplasm: Endoscopic ultrasonography-guided radiofrequency ablation combined with lauromacrogol ablation

“…Under EUS guidance, RFA allows targeted delivery of heat energy and causes sustained thermal damage to the epithelium and septation of the cyst (2,11,12). However, for the irregular cystic lesions, the RFA destruction of the cystic wall may be variable due to the influence of distance between the RFA active electrode tip and the lesion.…”

“…However, the efficacy of ethanol lavage (EL) remains controversial and reports of patients undergoing surgery after EL showed a low rate of epithelial ablation (8,9). The septation in the PCNs also reduces the efficacy of EL (2,10). Then EUS-guided RFA, the other type of EUS-guided ablation, was investigated in the treatment of PCNs.…”

“…The EUS-guided ablation for PCNs has received an increasing attention due to minimal invasion and possible direct imaging of the lesions (2). One of the EUS-guided ablations of PCNs is ethanol lavage with or without an injection of anti-tumoral agents.…”

“…The prevalence and clinical variability of PCNs have presented a significant treatment challenge for physicians (2,3). Surgical resection and surveillance are the standard management approaches at present.…”

“…Surgical resection and surveillance are the standard management approaches at present. Surgical resection has substantial perioperative morbidity and mortality; surveillance increases economic and psychological burden of the patients, and it may also lead to delayed treatment because the current differential diagnosis is still limited (2,4). Meantime, a substantial portion of PCNs remains indeterminate even after comprehensive evaluation (5).…”