Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) for advanced pancreatic and periampullary adenocarcinoma

Abstract

Long term prognosis and 5-year survival for pancreatic adenocarcinoma (PDAC) remains suboptimal. Endoscopic ultrasound (EUS) guided RFA (EUS-RFA) is an emerging technology and limited data exist regarding safety and long-term outcomes. The aim of this study is to report safety-profile, feasibility and outcomes of EUS-RFA for advanced PDAC. Prospective review of patients with diagnosis of locally-advanced or metastatic PDAC undergoing EUS-RFA between October 2016 to March 2018 with long-term follow up (> 30 months). Study patients underwent a total of 1–4 RFA sessions. All patients were enrolled in longitudinal cohort study and received standard of care chemotherapy. 10 patients underwent EUS-RFA. Location of the lesions was in the head(4), neck(2), body(2), and tail(2). 22 RFA sessions were performed with a range of 1–4 sessions per patient. There were no major adverse events (bleeding, perforation, infection, pancreatitis) in immediate (up to 72 h) and short-term follow up (4 weeks). Mild worsening of existing abdominal pain was noted during post-procedure observation in 12/22 (55%) of RFA treatments. Follow-up imaging demonstrated tumor progression in 2 patients, whereas tumor regression was noted in 6 patients (> 50% reduction in size in 3 patients). Median survival for the cohort was 20.5 months (95% CI, 9.93–42.2 months). Currently, 2 patients remain alive at 61 and 81 months follow-up since initial diagnosis. One patient had 3 cm PDAC with encasement of the portal confluence, abutment of the celiac axis, common hepatic and superior mesenteric artery. This patient had significant reduction in tumor size and underwent standard pancreaticoduodenectomy. In our experience, EUS-RFA was safe, well-tolerated and could be concurrently performed with standard chemotherapy. In this select cohort, median survival was improved when compared to published survival based upon SEER database and clinical trials. Future prospective trials are needed to understand the role of EUS-RFA in overall management of PDAC.

Impact of endoscopic ultrasound-guided radiofrequency ablation in managing pancreatic malignancy

“…A recent longitudinal cohort study by Thosani et al [ 32 ] in 10 patients with pancreatic adenocarcinoma, where one to four RFA sessions per patient were performed, revealed that CA 19-9 levels decreased after 12 treatment sessions. Tumor size reduction of more than 50% was recorded in 3 patients.…”

Endoscopic ablation therapy for the pancreatic neoplasms

“…The mechanism of action of RFA is high‐frequency alternating current, generating high local temperatures that induce coagulative necrosis of the tissues 44 . This treatment approach has been proposed for pancreatic solid lesions, such as PC, NEN, SPN, and other malignant metastatic lesions; 7–21,45,46 however, only the feasibility and safety for treating for PC were assessed. Two ablation devices specifically designed for EUS are mainly used.…”

“…The other device was the Habib catheter (EMcision Ltd., London, UK). This is a monopolar electrode without a cooling system, which is inserted inside a standard EUS‐FNA needle and attached to an electrosurgical generator 19,20,45 . Different RFA needles/catheters and ablative energy settings were used in each study.…”

“…14,15 Next, mainly feasibility and safety in PC were evaluated, and in patients with advanced PCs and in those resistant to previous treatments, EUS-guided ablation therapy was indicated. [16][17][18][19][20][21] Major indications for EUSguided ablation therapy for PCNs were as follows: patients with unilocular or oligolocular cysts with a suspected or confirmed diagnosis of a mucinous pancreatic cyst, those with enlarged pancreatic cysts >2 or >3 cm in diameter, poor candidates for surgery, and those who refused to undergo surgery despite reasonable life expectancy. 22 Some studies had also treated PCNs with a diameter of <2 cm if the patients had expressed a strong desire for treatment.…”

“…This is a monopolar electrode without a cooling system, which is inserted inside a standard EUS-FNA needle and attached to an electrosurgical generator. 19,20,45 Different RFA needles/catheters and ablative energy settings were used in each study. The generator is activated to release certain wattage for a set amount of time that varies according to each RFA model.…”