Download Advanced Endoscopic Therapy for Pancreatic Cancer

Advanced Endoscopic Therapy
for Pancreatic Cancer
Nathan Landesman, D.O.
Flint Gastroenterology Associates
February 28, 2015
Disclosures
• None
Emerging Role of Endoscopy
in 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 Endoscopic
Interventions
• Fiducial Placement
– Delineates extent of malignancy
– Quantifies respiratory-associated tumor motion
Therapeutic Endoscopic
Interventions
• 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 Endoscopic
Interventions
• 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 Endoscopic
Interventions
• 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
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Equipment malfunction
Pain (Pancreatitis)
Bleeding/Infection
Migration
Therapeutic Endoscopic
Interventions
• Fiducial Placement Safety/Efficacy
– < 7% migration rate is likely overstated
• Decompression of gastroduodenal obstruction
• Decompression of biliary obstruction
Therapeutic Endoscopic
Interventions
• 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:
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Bleeding/Infection
Diarrhea
Pain
Hypotension
Paralysis
Gastroduodenal Obstruction
in Pancreatic Cancer
• Uncovered metal prosthesis
of varying lengths
• Avoid coverage of major papilla if possible
– APC laser-assisted fenestration
• Surgical bypass
Biliary Obstruction
in 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
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Pancreatitis
Bleeding
Biliary contamination
Pancreatic fistula/leak
– Post-op complication rates did not differ
significantly.
Biliary Obstruction
in 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 Obstruction
in 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 Obstruction
in 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 Obstruction
in 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 Obstruction
in 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 Obstruction
in Pancreatic Cancer
• EUS-guided drainage for difficult cases
– Transgastric
– Transduodenal
– Rendezvous
• IR assistance