EUS-guided ablation for pancreatic cystic lesions: An updated review
Jiang, Mengruo et al.
ABSTRACT
Pancreatic cystic lesions (PCLs) are a globally prevalent condition, with incidence increasing with age. The proper treatment modality for PCLs remains a controversial topic. EUS-guided ablation represents an innovative and promising minimally invasive treatment for selected PCL patients, including EUS-guided pancreatic cyst chemoablation (EUS-PCC, such as ethanol, lauromacrogol, chemotherapeutic agents, and combination therapies) and EUS-guided radiofrequency ablation (EUS-RFA). Each treatment modality varies in treatment indications, efficacy, and safety. Herein, with ongoing advancements in clinical research, we present a comprehensive, updated review of procedural techniques, patient selection, clinical outcomes, and adverse events for EUS-PCC and EUS-RFA.
INTRODUCTION
Pancreatic cystic lesions (PCLs) are a heterogeneous group of tumors with distinct biological features, characterized by a cystic cavity formed by pancreatic epithelial and/or interstitial tissues.[1] Recently, incidental PCLs in asymptomatic patients have increasingly been identified.[2] In 2024, a proportional meta-analysis of 15 studies involving 65,607 subjects showed that the global prevalence of PCLs ranges from 13% to 18%, with prevalence increasing with age.[3]
Among all PCLs, intraductal papillary mucinous neoplasms (IPMNs), mucinous cystic neoplasms (MCNs), and solid pseudopapillary neoplasms have the potential to progress into invasive carcinoma.[4,5] Over the past decades, the management of PCLs has remained a controversial topic.[1,6] Guidelines for managing PCLs recommend surgical resection for symptomatic cysts, cysts with high-risk features, and cysts with definitive malignant pathological outcomes.[7,8] However, given that these high-risk features are not entirely synonymous with malignancy and the incidence of pancreatic surgery–associated AEs is high (20%–40% for severe AEs and 1%–5% for mortality),[9,10] the difficult clinical decision between radiographic surveillance and surgical resection has been proposed. It is estimated that up to $3.6 million is spent on surveillance for each PCL-related cancer detected in the United States, with no meaningful impact on PCL-related cancer mortality.[11,12] Furthermore, ongoing radiographic surveillance is still required after surgery. Therefore, alternative treatments with a less invasive nature are urgently needed to balance the risks of surveillance and surgical resection.
Recently, EUS-guided pancreatic cyst ablation (EUS-PCA), as a derivative technique of EUS-guided fine-needle aspiration (EUS-FNA), has gradually emerged as an innovative and promising minimally invasive treatment for appropriately selected PCLs.[13–15] Recent studies on EUS-PCA have provided favorable results. In 2024, Moyer et al.[10] reported the long-term follow-up results of 2 randomized, prospective clinical trials on chemotherapy for ablation and resolution of mucinous pancreatic cysts (ChARM). The prospective study, which included 52 patients, demonstrated that the medical costs for radiological surveillance following ChARM treatment were $7200.00, compared with $19,437.44 and $12,526.52 for patients treated and monitored according to the Fukuda and ACG guidelines, respectively. Furthermore, no recurrence or development of cyst-related malignancies occurred during a 5-year follow-up, which indicated that the frequency of radiological surveillance can be reduced. Additionally, a propensity score–matched (PSM) analysis assessing the clinical benefits of EUS-PCA compared with the natural course of PCLs indicated that the surgical resection rate in the EUS-PCA group was significantly lower than that in the natural course group (4.8% vs. 26.2%; P < 0.001).[16] Furthermore, a recent comparative study by Cho et al.[17] performed 1:1 PSM for patients with unilocular or oligolocular PCLs who underwent either EUS-PCA or surgical treatment. The retrospective study, which included 620 patients, revealed that the EUS-PCA group had a lower 10-year cumulative incidence of long-term complications (1.6% vs. 33.5%; P = 0.001), readmission (1.0% vs. 15.2%; P = 0.001), and diabetes (2.2% vs. 22.8%; P = 0.001). The authors concluded that, for selected PCL patients, EUS-PCA offers superior long-term safety and pancreatic function preservation compared with surgical resection.
