At the 20th Annual Symposium on Pancreatic Cancer, V. Raman Muthusamy, MD, MAS, a Professor of Clinical Medicine at the David Geffen School of Medicine and the Medical Director of Endoscopy for the UCLA Health System, provided an informative overview of how pancreatic cysts and tumors are diagnosed and treated using endoscopic techniques. He also emphasized the need for better predictive tools to enable more precise risk assessment for people diagnosed with pancreatic cysts.
As Dr. Muthusamy explained, pancreatic cysts are a common finding on medical imaging, and the likelihood of having a pancreatic cyst increases with age. The overall chance that any cyst is cancerous is very low. However, certain types of cysts can develop into pancreatic cancer. Pseudocysts and serous cystadenomas are generally benign, but mucinous cysts, such as mucinous cystadenomas (also called mucinous cystic neoplasms) and intraductal papillary mucinous cysts (IPMNs), carry a risk of developing into pancreatic cancer. Because of that, it’s very important to understand what type of cyst a person has.
Imaging can detect and characterize cysts, and endoscopic ultrasound (EUS) can be used to accurately diagnose the type of pancreatic cyst a patient has. These techniques include:
- EUS-FNA (endoscopic ultrasound-guided fine needle aspiration): A thin needle removes fluid from the cyst for Cyst Fluid Analysis (CFA) and measures the levels of biomarker proteins that can help determine cyst identity.
- EUS-guided biopsy: A small set of micro-forceps within a thin needle is used to sample the wall of the cyst and collect tissue for analysis.
- EUS-FNB (fine needle biopsy): a thin needle that can be used to drain the cyst and biopsy the cyst wall to collect tissue for analysis.
While most patients with cysts will be monitored over time with imaging, cysts that cannot be ruled out as malignant or that have high-risk features may be removed. While cysts can be removed surgically, there are emerging techniques using EUS for the treatment of pancreatic cysts. One such treatment involves draining the cyst, rinsing it with alcohol, and injecting a chemotherapy drug. This type of treatment has shown the ability to resolve cysts in some small-scale studies.
However, Dr. Muthusamy emphasized the need for better tools to predict which cysts will develop into pancreatic cancer. Currently, 20 to 30% of resected cysts are benign. The goal is to improve predictive capabilities to limit the number of patients who need to undergo yearly monitoring or resection surgeries to those who are genuinely at risk for pancreatic cancer.
In addition to diagnosing and treating cysts, EUS-guided techniques are also being used to treat pancreatic cancer. Multiple ablation techniques using EUS guidance have been developed and are undergoing testing, including:
- Fine needle-based techniques such as the injection of alcohol and chemotherapy
- Probe-based ablation techniques such as radiofrequency or cryoablation
One probe-based technique, Radiofrequency Ablation (RFA), is currently being evaluated in the clinical trial PANCARDINAL-1. In this protocol, patients with pancreatic cancer receive alternating neo-adjuvant chemotherapy and EUS-RFA prior to surgical resection in hopes of both shrinking the tumor and generating a longer-lasting response.
Another way EUS technology is being used for pancreatic cancer patients is to alleviate symptoms that accompany the disease. Multiple techniques are being developed and evaluated, including placing stents guided by EUS to relieve obstructions in the bile duct and duodenum. Clinicians can also use EUS-guided celiac plexus neurolysis to block abdominal pain associated with pancreatic cancer. These techniques can help avoid surgery and excessive use of painkillers, thereby increasing a patient’s quality of life.
As highlighted in Dr. Muthusamy’s presentation, endoscopic techniques are increasingly used to diagnose and treat pancreatic cysts and pancreatic cancer. Continued advancement and refinement of these techniques will enable more precise diagnosis and less invasive treatments, improving care and quality of life for people living with pancreatic cancer. Additionally, understanding which cysts are most likely to develop into pancreatic cancer requires better predictive biomarkers to limit unnecessary surveillance or treatment for people at low risk of progression to pancreatic cancer. The Hirshberg Foundation is proud to fund research that addresses both the need for translational biomarkers in pancreatic disease progression and clinical approaches to better treatment options for pancreatic cancer patients.
