Simple Summary Pancreatic cystic lesions are diagnosed with an increasing frequency, thus comprising a significant routine condition in clinical practice. In addition to the current approaches, which include surgery and surveillance, endoscopic ultrasound (EUS) provides the potential of an additional therapeutic tool. This review collected the existing literature regarding EUS-guided ablation techniques for pancreatic cystic lesions and assessed its efficacy and safety. The cumulative effect in treating pancreatic cysts was 44% (95%CI: 31–57), with the highest rate achieved when a combination of ethanol and paclitaxel was injected into the cysts (70%; 95%CI: 64–76). Considering safety, most adverse events were mild and occurred after ethanol injection. EUS-guided pancreatic cyst ablation seems to be an acceptable and safe procedure, with promising results in appropriately selected patients. Abstract Background: Pancreatic cystic lesions (PCL) represent an increasingly diagnosed condition with significant burden to patients’ lives and medical resources. Endoscopic ultrasound (EUS) ablation techniques have been utilized to treat focal pancreatic lesions. This systematic review with meta-analysis aims to assess the efficacy of EUS ablation on PCL in terms of complete or partial response and safety. Methods: A systematic search in Medline, Cochrane and Scopus databases was performed in April 2023 for studies assessing the performance of the various EUS ablation techniques. The primary outcome was complete cyst resolution, defined as cyst disappearance in follow-up imaging. Secondary outcomes included partial resolution (reduction in PCL size), and adverse events rate. A subgroup analysis was planned to evaluate the impact of the available ablation techniques (ethanol, ethanol/paclitaxel, radiofrequency ablation (RFA), and lauromacrogol) on the results. Meta-analyses using a random effects model were conducted and the results were reported as percentages with 95% confidence intervals (95%CI). Results: Fifteen studies (840 patients) were eligible for analysis. Complete cyst resolution after EUS ablation was achieved in 44% of cases (95%CI: 31–57; 352/767; I2 = 93.7%), and the respective partial response rate was 30% (95%CI: 20–39; 206/767; I2 = 86.1%). Adverse events were recorded in 14% (95%CI: 8–20; 164/840; I2 = 87.2%) of cases, rated as mild in 10% (95%CI: 5–15; 128/840; I2 = 86.7%), and severe in 4% (95%CI: 3–5; 36/840; I2 = 0%). The subgroup analysis for the primary outcome revealed rates of 70% (95%CI: 64–76; I2 = 42.3%) for ethanol/paclitaxel, 44% (95%CI: 33–54; I2= 0%) for lauromacrogol, 32% (95%CI: 27–36; I2 = 88.4%) for ethanol, and 13% (95%CI: 4–22; I2 = 95.8%) for RFA. Considering adverse events, the ethanol-based subgroup rated the highest percentage (16%; 95%CI: 13–20; I2 = 91.0%). Conclusion: EUS ablation of pancreatic cysts provides acceptable rates of complete resolution and a low incidence of severe adverse events, with chemoablative agents yielding higher performance rates.

/pdf/performance-and-safety-of-eus-ablation-techniques-for-22nogpfl.pdf

Performance and Safety of EUS Ablation Techniques for Pancreatic Cystic Lesions: A Systematic Review and Meta-Analysis

Simple Summary In endocrinology, endoscopic ultrasound is a useful and reliable diagnostic technique in the assessment of multiple endocrine neoplasia type 1, localizing insulinomas, and identifying aldosterone-producing adenomas. Abstract In endocrinology, endoscopic ultrasound (EUS) may be used to image the adrenals, the endocrine pancreas, and other organs where endocrine neoplasms may occur. During the recent decades, EUS has been established predominantly to assess multiple endocrine neoplasia type 1, to localize insulinomas, and to identify aldosterone-producing adenomas. EUS in endocrinology requires special skills and individual experience in order to provide reliable diagnostic information.

/pdf/relevance-of-endoscopic-ultrasound-in-endocrinology-today-2e6mu8lo.pdf

Relevance of Endoscopic Ultrasound in Endocrinology Today: Multiple Endocrine Neoplasia Type 1, Insulinoma, Primary Aldosteronism—An Expert’s Perspective Based on Three Decades of Scientific and Clinical Experience

Simple Summary Neuroendocrine tumors (NET) arise from cells throughout the diffuse endocrine system. They are primarily sporadic but can also occur in the context of genetic syndromes like multiple endocrine neoplasia. They are most commonly seen in the gastrointestinal tract, pancreas, and lungs. Data show that the incidence of NETs is increasing, partly contributed to by improving diagnostic modalities and their increasing use. The management of larger (>2 cm) NETs and those with evidence of local or metastatic involvement is relatively well defined and involves surgery, chemotherapy, or a combination. Endoscopic evaluation is pivotal in diagnosing, staging, and grading NETs. Furthermore, advanced endoscopic techniques like resection and ablation can now successfully treat NETs, particularly those less than 2 cm, potentially reducing the adverse events and healthcare costs associated with surgical management. This article discusses the latest advances in the endoscopic evaluation and management of this rare condition. Abstract Neuroendocrine neoplasms (NENs), also called neuroendocrine tumors (NETs), are relatively uncommon, heterogenous tumors primarily originating in the gastrointestinal tract. With the improvement in technology and increasing use of cross-sectional imaging and endoscopy, they are being discovered with increasing frequency. Although traditionally considered indolent tumors with good prognoses, some NENs exhibit aggressive behavior. Timely diagnosis, risk stratification, and management can often be a challenge. In general, small NENs without local invasion or lymphovascular involvement can often be managed using minimally invasive advanced endoscopic techniques, while larger lesions and those with evidence of lymphovascular invasion require surgery, systemic therapy, or a combination thereof. Ideal management requires a comprehensive and accurate understanding of the stage and grade of the tumor. With the recent advancements, a therapeutic advanced endoscopist can play a pivotal role in diagnosing, staging, and managing this rare condition. High-definition white light imaging and digital image enhancing technologies like narrow band imaging (NBI) in the newer endoscopes have improved the diagnostic accuracy of traditional endoscopy. The refinement of endoscopic ultrasound (EUS) over the past decade has revolutionized the role of endoscopy in diagnosing and managing various pathologies, including NENs. In addition to EUS-directed diagnostic biopsies, it also offers the ability to precisely assess the depth of invasion and lymphovascular involvement and thus stage NENs accurately. EUS-directed locoregional ablative therapies are increasingly recognized as highly effective, minimally invasive treatment modalities for NENs, particularly pancreatic NENs. Advanced endoscopic resection techniques like endoscopic submucosal dissection (ESD), endoscopic submucosal resection (EMR), and endoscopic full-thickness resection (EFTR) have been increasingly used over the past decade with excellent results in achieving curative resection of various early-stage gastrointestinal luminal lesions including NENs. In this article, we aim to delineate NENs of the different segments of the gastrointestinal (GI) tract (esophagus, gastric, pancreatic, and small and large intestine) and their management with emphasis on the endoscopic management of these tumors.

Role of Advanced Gastrointestinal Endoscopy in the Comprehensive Management of Neuroendocrine Neoplasms

Pancreatic neuroendocrine neoplasms (PanNENs) are rare and heterogeneous diseases that account for less than 2% of all cases of pancreatic cancer and only 30% of digestive neuroendocrine neoplasia, even if their incidence and prevalence continue to rise globally [...]

When Should We Adopt EUS-Guided Radiofrequency Ablation in Pancreatic Neuroendocrine Tumors?

Simple Summary Pancreatic cancer is a highly aggressive disease associated with poor clinical outcomes. It is the seventh leading cause of cancer-related death worldwide. Due to the lack of obvious signs and symptoms until advanced disease, establishing an early diagnosis is often difficult. EUS is the imaging modality of choice to establish a diagnosis of pancreatic cancer. However, over the years, EUS has evolved to have therapeutic applications in the management of pancreatic cancer. EUS-guided fine needle injection of anti-tumoral agents, EUS-guided radiotherapy, and EUS-guided ablation techniques have become vital tools for endoscopic oncologists, especially in the management of locally advanced pancreatic cancer. These EUS-guided techniques offer high efficacy and demonstrate an excellent safety profile. However, they have not yet become routine practice due to the lack of long-term efficacy outcomes. Hence, additional studies are needed to investigate the long-term clinical outcomes and establish standardized procedural protocols for these techniques. Abstract Pancreatic cancer is a highly lethal disease with an aggressive clinical course. Patients with pancreatic cancer are usually asymptomatic until significant progression of their disease. Additionally, there are no effective screening guidelines for pancreatic cancer in the general population. This leads to a delay in diagnosis and treatment, resulting in poor clinical outcomes and low survival rates. Endoscopic Ultrasound (EUS) is an indispensable tool for the diagnosis and staging of pancreatic cancer. In the modern era, with exponential advancements in technology and device innovation, EUS is also being increasingly used in a variety of therapeutic interventions. In the context of pancreatic cancer where therapies are limited due to the advanced stage of the disease at diagnosis, EUS-guided interventions offer new and innovative options. Moreover, due to their minimally invasive nature and ability to provide real-time images for tumor localization and therapy, they are associated with fewer complication rates compared to conventional open and laparoscopic approaches. In this article, we detail the most current and important therapeutic applications of EUS for pancreatic cancer, namely EUS-guided Fine Needle Injections, EUS-guided Radiotherapy, and EUS-guided Ablations. Furthermore, we also discuss the feasibility and safety profile of each intervention in patients with pancreatic cancer to provide gastrointestinal medical oncologists, radiation and surgical oncologists, and therapeutic endoscopists with valuable information to facilitate patient discussions and aid in the complex decision-making process.

/pdf/role-of-therapeutic-endoscopic-ultrasound-in-management-of-1ccbl5ab.pdf

Role of Therapeutic Endoscopic Ultrasound in Management of Pancreatic Cancer: An Endoscopic Oncologist Perspective

Pc.01.6 endoscopic ultrasound-guided radiofrequency ablation versus surgical resection for treatment of pancreatic insulinoma: a multicenter propensity scorematched study

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Pc.01.6 endoscopic ultrasound-guided radiofrequency ablation versus surgical resection for treatment of pancreatic insulinoma: a multicenter propensity scorematched study