Post on 21-Dec-2015
Advanced Endoscopic Therapyfor Pancreatic Cancer
Nathan Landesman, D.O.
Flint Gastroenterology Associates
February 28, 2015
Disclosures
• None
Emerging Role of Endoscopyin Pancreatic Cancer
• Therapeutic– Fiducial Placement– Fine Needle Injection (FNI)
• Palliative– Celiac Plexus Neurolysis (CPN)– Relief of Obstruction
• Gastroduodenal• Biliary
• Shifting emphasis from ERCP-based approach to EUS-guided modalities
Therapeutic EndoscopicInterventions
• Fiducial Placement– Delineates extent of malignancy
– Quantifies respiratory-associated tumor motion
Therapeutic EndoscopicInterventions
• Fiducial Placement Technique– 19 or 22 gauge delivery system
– Loaded retrograde after stylet withdrawal
– Needle tip sealed with sterile bone wax
– Lesion accessed and fiducial deployed by stylet or sterile water injection
Therapeutic EndoscopicInterventions
• Fiducial Placement Technique
– Placement of at least 3 markers is preferred to “triangulate” the malignancy
– > 4 markers to “box-in” the lesion is ideal
Therapeutic EndoscopicInterventions
• Fiducial Placement Safety/Efficacy– Prior studies reported technical failure with 19
gauge delivery system in the pancreatic head and/or altered anatomy
– Newer trials report 88-97% success with only minor complications
• Equipment malfunction• Pain (Pancreatitis)• Bleeding/Infection• Migration
Therapeutic EndoscopicInterventions
• Fiducial Placement Safety/Efficacy
– < 7% migration rate is likely overstated
• Decompression of gastroduodenal obstruction
• Decompression of biliary obstruction
Therapeutic EndoscopicInterventions
• Fine Needle Injection (FNI)
– Activated lymphocytes/Oncolytic viruses
– Viral vectors (“Gene Therapy”)
– Ink marking of small lesions
Gene Therapy
• Delivery Vector– Viral vs Non-viral
• Delivery Route– Intravascular vs Intratumoral
• Tumor Targeting– Gene Mutation/Transcriptional/Transductional
• Therapeutic Systems– Virotherapy/Suicide Genes/Correction
Celiac Plexus Neurolysis (CPN)• Bupivacaine and absolute alcohol• 74-88% effective
– Head lesions may respond more favorably– Single/Multiple Sites +/- Fenestrated needles
• Side Effects:– Bleeding/Infection– Diarrhea– Pain– Hypotension– Paralysis
Gastroduodenal Obstructionin Pancreatic Cancer
• Uncovered metal prosthesis of varying lengths
• Avoid coverage of major papilla if possible– APC laser-assisted fenestration
• Surgical bypass
Biliary Obstructionin Pancreatic Cancer
• Role of pre-operative biliary decompression in resectable pancreatic head tumors– van der Gaag NEJM 1/14/10 reported “serious
complication” rate of 39% and 74% in 2 arms from biliary intervention
• Pancreatitis
• Bleeding
• Biliary contamination
• Pancreatic fistula/leak
– Post-op complication rates did not differ significantly.
Biliary Obstructionin Pancreatic Cancer
• Is plastic stenting for pancreatic cancer still relevant in 2015? GIE review (Wang)– Plastic stents 15-40x cheaper than metal
– Historically there was believed to be a cost advantage in using plastic stents if:
• Diagnosis of malignancy was not established
• Patients expected to live < 3-6 months
• Patients undergoing operative resection < 3 months
Biliary Obstructionin Pancreatic Cancer
• Is plastic stenting for pancreatic cancer still relevant in 2015?
– Patency of 10 French plastic biliary stents becomes an issue after 8 weeks with larger caliber stents failing to increase patency duration
– Plastic stents > 7 cm length are associated with higher occlusion (and migration) rates.
Biliary Obstructionin Pancreatic Cancer
• Multiple studies have demonstrated superior patency of metal stents, which overrides cost savings of plastic stenting
– More frequent ERCPs
– More frequent hospitalizations for occluded stents
– Possible sequelae of migrated plastic stents
Biliary Obstructionin Pancreatic Cancer
• 2014 NCCN Guidelines on Pancreatic Adenocarcinoma
– Short metal stent should be considered effective first-line therapy for palliation (uncovered) or bridge to surgery (covered) in borderline resectable, non-metastatic patients assigned to neoadjuvant therapy.
Biliary Obstructionin Pancreatic Cancer
• Covered vs Uncovered metal biliary stents
– Comparable patency
– Higher migration risk of covered stents
– Higher cholecystitis and sludge risks of covered stents
– Fragmentation risk with covered stent removal
Biliary Obstructionin Pancreatic Cancer
• EUS-guided drainage for difficult cases
– Transgastric
– Transduodenal
– Rendezvous• IR assistance