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      Technical advances in endoscopic ultrasound-guided fiducial placement for the treatment of pancreatic cancer

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          Abstract

          Radiation therapy has an important role in the treatment of locally advanced or metastatic pancreatic cancer and can be used alone or in conjunction with surgery and/or systemic chemotherapy. Because of the challenge of delivering an accurate and optimal radiation dose, image-guided radiation therapy can be used to improve targeting. Fiducial markers can be placed in the tumor and used for localization in patients undergoing image-guided radiation therapy. The safety and feasibility of endoscopic ultrasound (EUS)-guided placement of fiducials has been assessed and reported for the management of pancreatic cancer. We herein review the technique, efficacy, and safety profile of EUS-guided fiducial placement. In addition, we highlight recent advances and technological upgrades in EUS-guided fiducial delivery systems for pancreatic cancer most relevant to practicing gastroenterologists and interventional endoscopists.

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          Stereotactic radiotherapy for unresectable adenocarcinoma of the pancreas.

          John Shen, Jeffrey Chang, Terry Desser … (2009)
          The authors report on the local control and toxicity of stereotactic body radiotherapy (SBRT) for patients with unresectable pancreatic adenocarcinoma. Seventy-seven patients with unresectable adenocarcinoma of the pancreas received 25 gray (Gy) in 1 fraction. Forty-five patients (58%) had locally advanced disease, 11 patients (14%) had medically inoperable disease, 15 patients (19%) had metastatic disease, and 6 patients (8%) had locally recurrent disease. Nine patients (12%) had received prior chemoradiotherapy. Sixteen patients (21%) received between 45 to 54 Gy of fractionated radiotherapy and SBRT. Various gemcitabine-based chemotherapy regimens were received by 74 patients (96%), but 3 patients (4%) did not receive chemotherapy until they had distant failure. The median follow-up was 6 months (range, 3-31 months) and, among surviving patients, it was 12 months (range, 3-31 months). The overall rates of freedom from local progression (FFLP) at 6 months and 12 months were 91% and 84%, respectively. The 6- and 12-month isolated local recurrence rates were 5% and 5%, respectively. There was no difference in the 12-month FFLP rate based on tumor location (head/uncinate, 91% vs body/tail, 86%; P = .52). The progression-free survival (PFS) rates at 6 months and 12 months were 26% and 9%, respectively. The PFS rate at 6 months was superior for patients who had nonmetastatic disease versus patients who had metastatic disease (28% vs 15%; P = .05). The overall survival (OS) rates at 6 months and 12 months from SBRT were 56% and 21%, respectively. Four patients (5%) experienced grade > or = 2 acute toxicity. Three patients (4%) experienced grade 2 late toxicity, and 7 patients (9%) experienced grade > or = 3 late toxicity. At 6 months and 12 months, the rates of grade > or = 2 late toxicity were 11% and 25%, respectively. SBRT for pancreatic adenocarcinoma was effective for local control with associated risk of toxicity and should be used with rigorous attention to quality assurance. Efforts to reduce complications are warranted. Distant metastases account for the vast majority of disease-related mortality. (c) 2008 American Cancer Society.
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            Systematic review, including meta-analyses, on the management of locally advanced pancreatic cancer using radiation/combined modality therapy

            Shaik Sultana, C Tudur-Smith, D. A. Cunningham … (2007)
            There is no consensus on the management of locally advanced pancreatic cancer, with either chemotherapy or combined modality approaches being employed (Maheshwari and Moser, 2005). No published meta-analysis (Fung et al, 2003; Banu et al, 2005; Liang, 2005; Bria et al, 2006; Milella et al, 2006) has included randomised controlled trials employing radiation therapy. The aim of this systematic review was to compare the following: (i) chemoradiation followed by chemotherapy (combined modality therapy) vs best supportive care (ii) radiotherapy vs chemoradiation (iii) radiotherapy vs combined modality therapy (iv) chemotherapy vs combined modality therapy (v) 5FU-based combined modality treatment vs another-agent-based combined modality therapy. Relevant randomised controlled trials were identified by searching databases, trial registers and conference proceedings. The primary end point was overall survival and secondary end points were progression-free survival/time-to-progression, response rate and adverse events. Survival data were summarised using hazard ratio (HR) and response-rate/adverse-event data with relative risk. Eleven trials involving 794 patients met the inclusion criteria. Length of survival with chemoradiation was increased compared with radiotherapy alone (two trials, 168 patients, HR 0.69; 95% confidence interval (CI) 0.51–0.94), but chemoradiation followed by chemotherapy did not lead to a survival advantage over chemotherapy alone (two trials, 134 patients, HR 0.79; CI 0.32–1.95). Meta-analyses could not be performed for the other comparisons. A survival benefit was demonstrated for chemoradiation over radiotherapy alone. Chemoradiation followed by chemotherapy did not demonstrate any survival advantage over chemotherapy alone, but important clinical differences cannot be ruled out due to the wide CI.
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              Locally advanced pancreatic cancer.

              Brian Czito, Johanna C. Bendell, Eric Ryan … (2005)
              Of the 32,180 patients diagnosed with pancreatic carcinoma in the United States this year, approximately 40% will present with locally advanced disease. Radiotherapeutic approaches are often employed because these patients have unresectable tumors by virtue of local invasion into the retroperitoneal vessels in the absence of clinically detectable metastases. These treatments include external-beam irradiation with and without fluorouracil-based chemotherapy, intraoperative irradiation, and, more recently, external-beam irradiation with new systemic targeted agents.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Endosc Int Open
                Journal ID (iso-abbrev): Endosc Int Open
                Journal ID (publisher-id): 10.1055/s-0034-1377934
                Title: Endoscopy International Open
                Publisher: © Georg Thieme Verlag KG (Stuttgart · New York )
                ISSN (Print): 2364-3722
                ISSN (Electronic): 2196-9736
                Publication date (Print): August 2015
                Publication date (Electronic): 21 July 2015
                Volume: 3
                Issue: 4
                Pages: E373-E377
                Affiliations
                [1 ]Division of Gastroenterology, University of Florida, Gainesville, Florida, United States
                [2 ]Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York, United States
                [3 ]Department of Gastroenterology, University Medical Center Utrecht, The Netherlands
                Author notes
                Corresponding author Mihir S. Wagh, MD, FACG, FASGE Interventional Endoscopy, Division of Gastroenterology, University of Florida 1329 SW 16th Street, Suite 5251Gainesville, Florida 32608United States+1-352-627-9002 mihir.wagh@ 123456medicine.ufl.edu
                Article
                DOI: 10.1055/s-0034-1392274
                PMC ID: 4554510
                PubMed ID: 26355267
                SO-VID: bc49f90f-3684-4bc3-98bc-563a96289312
                Copyright © © Thieme Medical Publishers
                History
                Date received : 20 December 2014
                Date accepted : 26 February 2015
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                Subject: Article

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