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Review
. 2016 Apr 10;8(7):319-29.
doi: 10.4253/wjge.v8.i7.319.

What are the current and potential future roles for endoscopic ultrasound in the treatment of pancreatic cancer?

Stephen Y Oh  1 , Shayan Irani  1 , Richard A Kozarek  1
Affiliations
Review

What are the current and potential future roles for endoscopic ultrasound in the treatment of pancreatic cancer?

Stephen Y Oh et al. World J Gastrointest Endosc. .

Abstract

Pancreatic adenocarcinoma is the fourth leading cause of cancer-related death in the United States. Due to the aggressive tumor biology and late manifestations of the disease, long-term survival is extremely uncommon and the current 5-year survival rate is 7%. Over the last two decades, endoscopic ultrasound (EUS) has evolved from a diagnostic modality to a minimally invasive therapeutic alternative to radiologic procedures and surgery for pancreatic diseases. EUS-guided celiac plexus intervention is a useful adjunct to conventional analgesia for patients with pancreatic cancer. EUS-guided biliary drainage has emerged as a viable option in patients who have failed endoscopic retrograde cholangiopancreatography. Recently, the use of lumen-apposing metal stent to create gastrojejunal anastomosis under EUS and fluoroscopic guidance in patients with malignant gastric outlet obstruction has been reported. On the other hand, anti-tumor therapies delivered by EUS, such as the injection of anti-tumor agents, brachytherapy and ablations are still in the experimental stage without clear survival benefit. In this article, we provide updates on well-established EUS-guided interventions as well as novel techniques relevant to pancreatic cancer.

Keywords: Endoscopic ultrasound; Endoscopic ultrasound-guided ablation; Endoscopic ultrasound-guided anti-tumor therapy; Endoscopic ultrasound-guided biliary drainage; Endoscopic ultrasound-guided celiac plexus neurolysis and block; Endoscopic ultrasound-guided fiducial placement; Endoscopic ultrasound-guided gastrojejunal anastomosis; Palliation; Pancreatic cancer.

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Figures

Figure 1
Figure 1
Endoscopic ultrasound-guided injection into the celiac ganglion. A: Celiac ganglion visualized by linear endoscopic ultrasound as a hypoechoic structure anterior to the aorta (arrow); B: 19-gauge needle puncture into the celiac ganglia for neurolysis.
Figure 2
Figure 2
A 84 years old male with duodenal adenocarcinoma causing biliary obstruction underwent endoscopic ultrasound-guided choledochoduodenostomy following unsuccessful endoscopic retrograde cholangiopancreatography. A: Tumor involving the major papilla; B: Endoscopic ultrasound-guided puncture of the common bile duct through the duodenum with a 19-gauge needle; C: Guidewire insertion and balloon dilation of a choledochoduodenal fistula; D: Followed by the placement of a 10 mm × 10 mm lumen-apposing metal stent to create a choledochoduodenostomy; E and F: Endoscopic (E) and flouroscopic (F) view after the placement of a 7 Fr × 3 cm double pigtail stent into the common hepatic duct.
Figure 3
Figure 3
A 66 years old female with metastatic cholangiocarcinoma and gastric outlet obstruction undergoing endoscopic ultrasound-guided gastrojejunostomy. A: Tumor ingrowth into two previously placed duodenal stents; B: Endoscopic ultrasound visualization of a 20 mm balloon inflated in the proximal jejunum followed by a 19-gauge needle puncture (arrow); C and D: Balloon dilation of the gastrojejunal fistula over a 0.035 inch guidewire; E and F: Endoscopic (E) and fluoroscopic (F) demonstration of contrast flow across 10 mm × 15 mm lumen-apposing metal stent (arrow) into the jejunum.
Figure 4
Figure 4
Magnetic anastomosis device to create endoscopic gastrojejunostomy (Images courtesy of Cook Medical). A: Gastric magnent marked with an endoscopy clip; B: Mating of gastric and proximal jejunal magnets under fluoroscopic guidance to create a gastrojejunal fistula; C: Placement of a fully covered stent within the fistula with a proximal flanged edge positioned in the gastric lumen; D: The stent within the fistula functions as a gastrojejunostomy.
Figure 5
Figure 5
Images courtesy of Sanders et al[74]. A: Fiducial loaded into 19-gauge needle with sterile forceps; B: Fiducial within tip of needle; C: Sealing fiducial with sterile bonewax; D: Loaded fiducial ready for advancement down operating channel; E and F: Needle delivering fiducial into pancreatic mass (arrow).
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