pISSN 2636-0004eISSN 2636-0012
pISSN 2636-0004Summary of the Position Statement on EUS-Guided Pancreatic Cyst Ablation
| Question | Statement |
|---|---|
| Indications for the procedure | |
| When should we perform pancreatic cyst ablation? | Patients who are not surgical candidates or refuse surgery with a reasonable life expectancy and suffering from either: - Unilocular or oligolocular cyst with a presumed or confirmed diagnosis of a mucinous cyst - Enlarging PCLs with a diameter of > 2 cm or PCLs with diameter of > 3 cm |
| Which pancreatic cysts respond best to ablation? | - PCLs with ≤ 6 locules - PCLs 2 to 6 cm in diameter |
| What are the contraindications to the procedure? | Absolute contraindications - Pregnancy - Irreversible coagulopathy - Signs of pancreatic malignancy - Active pancreatitis or pancreatic necrosis - Short life expectancy Relative contraindications - PCLs with enhancing mural nodules - Cyst with no or low malignant potential - Dilated main pancreatic duct > 5 mm in size - Clear open communication with the main pancreatic duct - > 6 locules comprising the cyst - Thick walls or septations - Main pancreatic duct stricture with pancreatic tail atrophy - Significant solid components - Past medical history of acute pancreatitis |
| What level of certainty of diagnosis is required before the procedure? | The treating physician should be reasonably certain that the cyst is not a benign asymptomatic pancreatic cyst with no or low malignant potential |
| Procedural preparations | |
| What investigational modalities are required before EUS cyst ablation is performed? | CT (pancreatic protocol), MRI with MRCP (enhancement) ± EUS ± FNA |
| Are prophylactic antibiotics required? | Fluoroquinolones or beta-lactamase are recommended |
| How long do antibiotics need to be continued if given? | 3 to 5 days |
| Procedural considerations | |
| Should the fluid be aspirated completely or not before ablation? | Leave a small rim of fluid around the tip of the needle within the cyst after the initial aspiration |
| What should be done if the cyst fluid is too viscous to be aspirated out during EUS-FNA? | - Use a 19-gauge needle under high suction pressure - Viscosity can then be lowered by injection of normal saline or alcohol that were aspirated out |
| What are the available agents for the procedure? | - Ethanol lavage only - Ethanol lavage followed by the infusion of paclitaxel - Alcohol-free saline lavage followed by an admixture of paclitaxel-gemcitabine - Lauromacrogol |
| Is ethanol required for effective pancreatic cyst ablation? | - Ethanol is the traditional agent used for ablation - Ethanol is not required when a chemotherapeutic agent is used |
| What is the difference between aspiration, lavage, and retention? Are there any differences between the practices? | - Aspiration: removal of cyst fluid by the aspiration needle - Lavage: repetitive aspiration and reinjection of the lavage agent for 3 to 5 minutes - Retention: retain the injected ethanol for 20 to 40 minutes while rotating the patient’s position, and the injected ethanol is aspirated completely - Infusion: replacement of the cyst content with an ablation agent, which is then left in place |
| Outcomes of EUS-guided pancreatic cyst ablation | |
| How should response to therapy be defined after the procedure? | Completeness of response: defined by the amount of reduction in the volume of the cyst as measured by the radius of primary imaging modality at initial and 6-month follow-up - Complete response: 95% or greater reduction in volume - Partial response: 75% to 95% reduction in volume - Non-response: < 75% reduction in volume |
| What are the results of pancreatic cyst ablation? | - Ethanol alone: CR in 30% of treated PCLs - Ethanol + paclitaxel: CR in 60%–79% of treated PCLs |
| What are the effects of ablation on the cyst epithelium? | - Surgery is rarely performed after cyst ablation - Reported histologic epithelial ablation rates are generally 50%–100% |
| What are the cytological and genetic changes after the procedure? | - Limited data suggesting that genetic changes revert to normal after cyst ablation |
| Follow-up and monitoring | |
| How should these patients be followed up and monitored? | - Followed non-operatively - Cross-sectional imaging at 6-month intervals for the first year - Annually until no longer warranted due to patient age and medical conditions |
| Potential adverse events and management | |
| What are the potential adverse events of the procedure? | - The baseline risks of standard EUS-FNA procedures, which are considered safe and rarely associated with adverse events - Specific adverse events associated with the ablation itself include self-limiting abdominal pain, acute pancreatitis, and VTE |
| Are there systemic effects from the chemotherapeutic agent during and after the procedure? | - Paclitaxel in doses used for pancreatic cyst ablation has been shown without identifiable blood levels of the agent post-procedure |
This table was revised from the position statement on EUS-guided ablation of pancreatic cystic neoplasms from an international expert panel.30
EUS, endoscopic ultrasound; PCL, pancreatic cystic lesion; CT, computed tomography; MRI, magnetic resonance imaging; MRCP, magnetic resonance cholangiopancreatography; FNA, fine-needle aspiration; VTE, venous thromboembolism.