EUS and ERCP in Pancreatic Cancer

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EUS and ERCP in Pancreatic Cancer

• Shyam Varadarajulu, MD
• Medical Director
• Florida Hospital Center for Interventional
  Endoscopy
• Professor of Medicine, University of Central
  Florida
• Consultant, University of Alabama at Birmingham

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Tissue Acquisition in Pancreas

• Is EUS a Disruptive Innovation?

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Pancreatic Cytology from 1990-2010
EUS Instituted 07/2000
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Rise of Cytology and Fall of Histology
EUS Instituted 07/2000
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Disruptive Innovation
1990-2000 2001-2010
Sensitivity Specificity Suspicious Atypical Unsatisfactory 55 78 16 16 7 88 96 3 4 1
Non-EUS-guided FNAC 36 to 1 Needle Biopsy 29
to 9
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Is EUS a Disruptive Innovation?
YES!
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Meta-analysis EUS-FNA of Pancreas
Author No Sensitivity NA vs. EU lt100 gt100 Onsite Path Ref. standard
Hewitt1 Magee SH Puli SR 4984 3208 4766 85 90.9 86.8 85 vs. 78 N/A - 79 vs. 87 84 vs. 94 - 88 vs. 80 95 vs. 79 - 61 vs. 92 -
Experience and On-site Pathology!
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What is a good FNA?

1. One needle
2. Quick cellular sample
3. Less bloody

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Location
Sensitivity 80-85
Flexible/thin Needle
Sensitivity gt95
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Needle Selection
Author No. Lesion Needle Diagnostic Accuracy
Camellini L Fabbri C Siddiqui UD Song TH 127 50 131 117 All lesions Pancreatic Masses All lesions Pancreatic Masses 22 vs. 25G 22 vs. 25G 22 vs. 25G 22 vs. 19G 77.8 vs. 78.1 86 vs. 94 87.5 vs. 95.5 78.1 vs. 94.5 P0.01
22G 25G for FNAs
25G for Head/Uncinate Masses
19G suboptimal for pancreatic head masses
Meta-analysis Lesions 22 vs. 25G Pooled Sensitivity p
Madhoun MF 1234 799 vs. 565 0.85 (95 CI82-88) vs. 93 (95 CI-91-96) 0.0003
25G for Pancreatic Masses!!
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Algorithm for Efficient EUS-procedures
Bang JY, Varadarajulu S GI Endoscopy 2013
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Efficiency in EUS

• Phase I (2010)
• Interventions 19G FNA 22/25G
• Phase II (2011)
• Algorithm

Bang JY, Varadarajulu S GI Endoscopy 2013
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Phase I N548 Phase II N500 p
Diagnostic FNA Interventions Failure by Route Esophagus Stomach Duodenum Rectum Failure by needle 19 22 25 Technical Failures Cost/case US Diag. Adequacy 487 61 0 7.6 24.4 5 19.7 12.3 7.3 11.5 199.59 97.1 439 61 0 0.5 3.5 0 0.8 0 3.9 1.6 188.30 98.4 0.59 - lt0.001 lt0.001 1 lt0.001 lt0.001 0.124 lt0.001 0.008 0.19
It is all about efficiency
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Techniques of FNA
Does it Matter?
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FNA Technique
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RT of Standard vs. Fanning FNA
Standard n 26 Fanning n 28
First pass diagnosis
57.7
85.7
P0.03
No Needle Dysfunction
JY Bang, S Varadarajulu Endoscopy 2013
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Limitations of FNA

• Assessment for onsite diagnostic sufficiency
• Assessment for histopathology (rarely)
• Assessment for molecular markers

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What is core biopsy?

• Tissue with preserved cellular architecture

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How can core biopsy advance EUS?
Eliminating the need for an onsite
pathologist
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Pancreatic Cancer Treatment
Michl P Gut 2013
62317-326
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Targeted Therapy in Pancreatic Cancer

• Fibroblasts Promotes tumor growth
• Suppress anti-tumor
  response
• Strategy Deplete desmoplastic stroma

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Targeted Therapies in Pancreatic Cancer
Michl P Gut
2013 62317-326
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Core Biopsy Recent Developments

• ProCore Needle
• Standard 19G needle
• Flexible 19G needle

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ProCoreOne pass histological diagnosis
The bigger the better?
More passes for gt 95 accuracy
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Histology ProCore (N104) vs. FNA (N108)

• All Solid Masses

• Pancreatic Masses

No difference!
FNA 66.5 (95CI 41.7-91.3) vs. PC67.1 (95CI
43.4-90.8)
FNA 72.6 (95CI 0-100) vs. PC74.1 (95CI 0-100)
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19G (Flexible) Needle
Trans-duodenal FNA YES
Cytology YES
Histology YES
Interventions YES
Combination (Cytology Histology) still needed
for close to 100
Varadarajulu GIE 2012
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FNA Trends
Right Direction!
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EUS-FNA/FNB
Technique Present Future
Needle Anything Algorithm
Suction Yes/No No
Stylet Yes/No No
FNA Standard Fanning
Core Biopsy Dedicated Access. 19G
19G needle Not comfortable Get used to it
Cytology N/A Learn
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Endoscopic Management of Distal Biliary
Strictures

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Meta-analysis of Plastic vs. SEMS
Biliary Occlusion
Complications
SEMS superior on all fronts!
Stent Occlusion
30-day Mortality
Moss AC. Eur J Gastroenterol Hepatol 2007
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Meta-analysis of Covered vs. Uncovered Stents
CSEMS prolonged patency
Similar rates of stent dysfunction
Saleem A GI Endosc 2011
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Fully Covered vs. Partially Covered SEMS
No difference
Telford JJ GI Endosc 2010
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Management of Malignant Strictures

• Think more of the clinical setting
• Think less of the product (stent)
• Make your choice

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Overview Stenting of Malignant Strictures

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Preoperative Biliary Decompression

• Van der Gaag NA RT of surgery vs. stent
  surgery
• ERCP cohort 26 cholangitis
• 30 preoperative reinterventions
• 33 unresectable at surgery

• Limitations
• Plastic stents, unclear size
• Six weeks wait period

Van der Gaag NA. NEJM 2010
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Preoperative Biliary Decompression without XRT
SEMS Plastic
Number of Patients 11 18
Time to surgery (days) 17 (12-33) 24 (10-30)
Stent exchanges 0 7 (39)
EUS-FNA 2 1
Go Metal?
Varadarajulu Surg Endosc 2011
p 0.02
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Preoperative Biliary Decompression by SEMS with
XRT
Author Total No. No. Surgery Surgery (weeks) Stent Dysfunction
Lawrence 100 5 5 0
Aadam 55 27 15 11
Few patients eventually undergo surgery
SEMS benefits both operable and inoperable
patients
Lawrence C GI Endosc 2006 Aadam
AA GI Endosc 2012
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Overview Stenting of Malignant Strictures

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Algorithmic Approach to Biliary Stenting

Wilcox CM, Varadarajulu S DDW 2011
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Algorithmic Approach to Biliary Stenting
N 104 patients Plastic (10Fr) 64 SEMS40
MEAN RESTENTING
MEDIAN SURVIVAL TIME
Plastic 4.9 months SEMS 13.2 months
Plastic 6 months SEMS 16.7 months
Wilcox CM, Varadarajulu S DDW 2011
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Conclusion

• No need for stenting operable patients
• SEMS for locally advanced disease AND good
  functional status
• Plastic stents for poor functional status and/or
  metastatic disease

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EUS to the rescue of ERCP
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Biliary Ductal Drainage
Failed ERCP (5-10 in adv. cancer)
Hepato-gastrostomy
Rendezvous
Trans-duodenal
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Issues

• Precut papillotomy vs. EUS-drainage
• Accessible papilla Rendezvous
• Inaccessible papilla Trans-luminal
• Extra vs. Intra-hepatic
• Percutaneous vs. EUS-drainage

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Biliary Drainage
Trans-luminal
Rendezvous
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EUS-Rendezvous vs. Precut Papillotomy
Precut Rendezvous p
First-time success Overall success Complications 90.3 95.8 6.9 98.3 98.3 3.4 0.38 0.35 0.27
Rendezvous is effective and safe
Dhir V GI Endoscopy 2012
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Trans-luminal route Intra vs. Extra-hepatic

• N 35 patients
• Extra-hepatic 18, Intra-hepatic 17
• Complications 3, Intra-hepatic
• Bile leak,
  Perforation, Pain
• LOS gt for Intra-hepatic

Spare the liver?
Dhir V DDW 2012
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