EUS-Guided Pancreatic Cyst Ablation: a Clinical and Technical Review

Abstract

Purpose of review: Pancreatic cystic lesions represent a growing public health dilemma, particularly as our population ages and cross-sectional imaging becomes more sensitive. Mucinous cysts carry a clinically significant risk of developing pancreatic cancer, which carries an extremely poor prognosis. Determining which cysts will develop cancer may be challenging, and surgical resection of the pancreas carries significant morbidity. The goal of this paper is to review the rationale for cyst ablation and discuss prior and current research on cyst ablation techniques and efficacy. Indications, contraindications, and factors related to optimal patient selection are outlined.

Recent findings: Endoscopic ultrasound-guided chemoablation of pancreatic cysts has been performed in neoplastic cysts, with varying levels of efficacy. Safety concerns arose due to the risk of pancreatitis in alcohol-based treatments; however, the most recent data using a non-alcohol chemoablation cocktail suggests that ablation is effective without the need for alcohol, resulting in a significantly more favorable adverse event profile. Endoscopic ultrasound-guided chemoablation of neoplastic pancreatic cysts is a promising, minimally invasive approach for treatment of cysts, with recent significant advances in safety and efficacy, suggesting that it should play a role in the treatment algorithm.

Keywords: Pancreatic cancer prevention; Pancreatic cyst ablation; Pancreatic cyst treatment.

Fig. 1

The EUS-guided cyst ablation process: The FNA needle is introduced into the center of the cystic lesion. Following near complete aspiration of mucinous fluid from all compartments, the cyst is then repeatedly filled and aspirated with the lavage solution, always leaving a small rim of fluid around the needle tip to prevent damaging the cyst wall. This is followed by near complete aspiration of the lavage agent with subsequent filling with the chemoablation agent(s) using the same volume as was originally aspirated. If an alcohol-free ablation technique is used, there is the option to skip the lavage step and simply aspirate the mucinous fluid to near total collapse, subsequently filling the cyst with an equal volume of chemotherapy ablation agent(s)

Fig. 2

a MRI-MRCP imaging of an 83-year-old male with a 2.7-cm intraductal mucinous pancreatic neoplasm (white arrow) prior to EUS-guided chemoablation. b Follow-up MRI-MCRP imaging reveals no evidence of residual cyst at 6 month follow-up evaluation