Introduction

Primary aldosteronism (PA) is a leading cause of secondary hypertension with potentially significant cardiovascular sequelae. Adrenalectomy is the standard treatment for PA caused by a unilateral aldosterone producing adenoma (APA). The often incomplete clinical resolution, procedure complexity, perioperative morbidity and patient hesitancy however, support considerations of less invasive treatment options. Endoscopic ultrasound guided Radiofrequency ablation (EUS-RFA) is an attractive alternative in which trans-gastric access enables access to the left adrenal gland, for selective ablation of unilateral APAs. We assessed the safety (procedure induced catecholamine crises, peri-adrenal and visceral complications) and efficacy of EUS-RFA as an adrenal sparing treatment alternative in a 3-centre feasibility study.

Aims & Methods

As an initial step the cohort was limited to patients unfit for surgery due to co-morbidities or an ambiguous estimation of unilateral PA. The APAs were identified by increased uptake of 11C-metomidate (MTO) on post-dexamethasone PET CT (1). Patients were subjected to α-and ß blockade two weeks before undergoing RFA, which was performed under general anaesthesia or deep sedation. Metanephrines levels were monitored before and during EUS-RFA, which was performed using a 5-10 mm19G Starmed EUSRA^TM ablation probe (Taewoong). After diagnostic fine-needle aspiration (FNA), the probe was introduced into the lesion followed by subsequent multiple, short, precise burns as the catheter was moved around the APA. The primary safety outcome was defined as the absence of perforation, haemorrhage, or infarction of major organs, as assessed by CT performed at 24-48 hours after EUS-RFA. Secondary outcomes included the PASO criteria for success (biochemical/clinical), changes in the aldosterone/renin (ARR) ratio, blood pressure and anti-hypertensive drug requirements, as well as MTO uptake on repeat PET-CT, at six months post EUS-RFA.

Results

EUS-RFA was performed in 28 patients (21 male), aged 57.9 ± 10.2 years, of whom 7 had 2 ablations. None of the expected serious adverse events occurred. A rise in metanephrines levels occurred in one patient, managed with ephedrine and metaraminol injections. Discharge delaying adverse events occurred in two patients (hypokalaemia induced atrial fibrillation, hospital acquired pneumonia) and rapidly resolved. Complete biochemical success was observed in 14 patients and partial in 3. Complete clinical success was noted in 4 patients, partial in 4. The median ARR reduction was from 3975 (IQR 2090-7475) to 880 (369-2670), p<0.001. BP remained unchanged, yet with reduced pharmacological requirements: number of antihypertensives and defined daily dose fell from 2.9 (95% CI 2.4-3.3) to 2 (95% CI 1.5-2) and 4.9 (95% CI 3.6-6.2) to 2.7 (95% CI 1.7-3.6), respectively. In 6 patients, APA MTO uptake was reduced to <50% compared to adjacent adrenal tissue (indicating complete ablation) which was unchanged or minimally reduced in all patients (i.e. preserved adrenal function). Reduction in APA diameter was noted in 21/28 patients. FNA samples analysed to date (13/28) were all positive for CYP11B2, confirming APAs as the treated lesion.

Conclusion

Transgastric EUS-RFA is a safe alternative to adrenalectomy in the treatment of left-sided APAs. A randomised controlled trial comparing EUS-RFA with surgery in 110 patients with PA is under way

References

Wu X, Senanayake R, Goodchild E, Bashari WA, Salsbury J, Cabrera CP, et al. [11C]metomidate PET-CT versus adrenal vein sampling for diagnosing surgically curable primary aldosteronism: a prospective, within-patient trial. Nat Med. 2023 Jan 16;29(1):190–202.

Disclosure

No conflict of interest

Introduction

Endoscopic ultrasound radiofrequency ablation (EUS-RFA) is a safe and effective therapeutic modality for treating pancreatic neoplasms. While robust data on technical feasibility and safety profile are available and consistent, clinical efficacy and oncological outcomes are still based on low evidence and not standardized methods.

Aims & Methods

We aim to assess current practice in EUS-RFA in terms of indications, prophylaxis for adverse events, generator set-up, follow-up, and lexicon.
An online survey with 70 questions divided into 5 domains (physicians and center characteristics, indications, procedural details, post-procedural management, and proposed lexicon) was created and shared with 175 international experts at the beginning of 2025; the survey link was open for 5 months and analyzed at the end of April 2025.

Results

Domain 1. 91 physicians (52%) completed the survey; 74.4% from Europe, 13.3% North America and 12.2% Asia; 64.8% declare >10-year EUS experience from high-volume centers (83.3%). 35.6% have formal accreditation as a Center of Excellence for Neuroendocrine Tumors (NET). 41 physicians (45.1%) have performed >20 EUS-RFA procedures, while 20 (22.0%) >50 procedures.
Domain 2. 94.1% physicians perform EUS-RFA for insulinoma, 71.8% non-functioning NET, 57.7% pancreatic metastases, 54.1% other functioning NET, 37.7% pancreatic ductal adenocarcinoma, 31.8% IPMN with mural nodule; very low agreement (<25%) was reached for other indications, (solid pseudopapillary neoplasms, liver tumors, other pancreatic neoplasms, adrenal gland tumors, celiac plexus).
Domain 3. 96% of EUS-RFA are performed under deep sedation or general anesthesia, in inpatient setting (83.1%). Rectal NSAIDs and aggressive hydration are administered for post-RFA pancreatitis prophylaxis in 45.6%, while only rectal NSAIDs in 41.8%. Antibiotic prophylaxis was administered in 57.0%. 50.6% of physicians are concerned about main duct injury for lesions located ≤ 2 mm while 34.2% for lesions closer than 1 mm. In these cases, 43.0% reduce duct damage through changes in power setting, avoiding duct contact, while 24.1% perform ERCP with pancreatic duct stenting. 45.6% avoid performing EUS-RFA in case of ductal infiltration with dilation.
58.4% use the same power-setting for every procedure, and 26.6% the same probe size. 10-mm tip length probe was used by 92.2% of physicians. Low agreement (<50%) for power generator set-up was reached for any indication. 70.9% have no maximum number of applications for each EUS-RFA session and continue ablation until all tissue seems ablated. 56.4% have no maximum time for each application.
Domain 4. 52.6% test serum biochemistry the day after the procedure; 27.0% perform a routine CT scan within 2 weeks. Contrast CT scan (81.0%) and contrast EUS (46.8%) are used for follow-up. A 3-month CT scan was used as the first oncological assessment in 51.3%.
Domain 5. Technical success was defined as “achieving the presumed complete ablation at the end of the procedure” by 88.6%; clinical success as “achieving symptom control for at least 1 year for insulinoma” by 92.2%; disease recurrence as “evidence of vascularized tumor tissue following complete response”. Low consensus (< 50%) was reached on the definition of complete and partial ablation, and post-EUS-RFA pancreatitis.

Conclusion

The results of this study provide clear data on the lack of standardization of EUS-RFA procedures even among experts. An international working group on EUS-RFA methodology is required to address unanswered clinical questions and provide a consensus fostering uniformity in EUS-RFA application.

Introduction

Neuroendocrine tumors (NETs) are heterogeneous neoplasms originating from neuroendocrine cells, predominantly located in the gastrointestinal tract and pancreas. While surgical resection remains the primary curative intervention, a significant number of patients are ineligible for surgery due to comorbidities or the anatomical positioning of the tumor. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has emerged as a minimally invasive alternative; however, the extant evidence is predominantly derived from small-scale case studies.

Aims & Methods

This multicenter study aims to comprehensively evaluate the efficacy, safety, and technical considerations of EUS-RFA in the management of NETs. A retrospective analysis was conducted on 45 patients with histologically confirmed neuroendocrine tumors (NETs) from five countries: Costa Rica, Egypt, India, Palestine, and Romania. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) was performed using a standardized 19-gauge RFA needle equipped with a 1 cm active-tip electrode. The primary outcomes assessed were treatment success, categorized as complete, partial, or failure. Secondary outcomes included the evaluation of complications and their correlations with tumor characteristics (such as grade, location, and histology), technical parameters (including power settings and ablation duration), and clinical factors. Statistical analyses were conducted using SPSS, employing Chi-square and Kruskal-Wallis tests.

Results

The cohort consisted of 53.3% females, with a mean age of 47.87 years. The overall complete ablation rate was 75.6%, with higher success rates observed for higher-grade tumors (G2/G3: 100% vs. G1: 80.8%). Tumor location significantly influenced outcomes, with pancreatic tail/neck lesions achieving 100% complete ablation compared to 58.8% for head lesions. Power settings of 35W, 40W, and 60W yielded 100% success, whereas 50W and 30W demonstrated lower efficacy (72.2% and 62.5%, respectively). Ablation duration tended to be longer in successful cases (mean 16.36 seconds) compared to failures (4.50 seconds). Insulinomas exhibited an 89.7% complete ablation rate, surpassing non-functioning NETs (50%). Complications were minimal, underscoring the procedure's safety.

Conclusion

Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) represents a safe and efficacious minimally invasive approach for the treatment of neuroendocrine tumors (NETs), particularly in patients who present a high surgical risk. The success of this technique is contingent upon the biological characteristics of the tumor, anatomical considerations, and the precision of the procedure. Future research should aim to standardize protocols, integrate advanced imaging techniques, and investigate combination therapies to further enhance this promising intervention.

References

1. Oronsky B, Ma PC, Morgensztern D, Carter CA. Nothing But NET: A Review of Neuroendocrine Tumors and Carcinomas. Neoplasia 2017; 19: 991–1002. [DOI: 10.1016/j.neo.2017.09.002]
2. Verma SK, Khare R, Singh D. Current perspectives on neuroendocrine tumors. hLife 2024; 2: 563–575. [DOI: 10.1016/j.hlife.2024.07.006]
3. Modlin IM, Oberg K, Chung DC, Jensen RT, de Herder WW, Thakker RV, Caplin M, Delle Fave G, Kaltsas GA, Krenning EP, Moss SF, Nilsson O, Rindi G, Salazar R, Ruszniewski P, Sundin A. Gastroenteropancreatic neuroendocrine tumours. The Lancet Oncology 2008; 9: 61–72. [DOI: 10.1016/S1470-2045(07)70410-2]

Introduction

Mucinous cysts of the pancreas are known precursors of pancreatic ductal adenocarcinoma. International guidelines for management and surveillance of pancreatic cysts advise surgical resection of high-risk lesions - mucinous cystic neoplasms (MCNs) and main duct intraductal papillary neoplasms (IPMNs), especially in those with worrisome clinicopathological stigmata. For low-risk cysts, lifelong radiographic surveillance is the standard approach, which can be psychologically distressing for patients and burdensome for healthcare systems. Endoscopic ultrasound (EUS)-guided radiofrequency ablation (RFA) of high-risk cystic lesions of the pancreas is increasingly being used as a minimally invasive alternative in patients who are unfit for or who decline surgery (1). We assessed the safety and efficacy of EUS-guided RFA in the management of low-risk cystic lesions of the pancreas.

Aims & Methods

68 patients (29M, 39F; mean age 63, range 33-82 years) with low-risk mucinous cystic neoplasms of the pancreas (branch-duct IPMN/mucinous cystadenomas, 0.7-4cm in size) were recruited for treatment by EUS-RFA. The primary endpoint was change in size of the pancreatic cyst on cross-sectional imaging (MRI) at one year after treatment (efficacy). Secondary endpoints included progression following treatment, procedure related morbidity and local complication rate (safety).

Results

68 patients were recruited of whom 55 completed RFA ablation of their cyst. Anatomical concerns (i.e., blood vessel, main duct proximity) precluded RFA in 12 patients. 18/55 patients (33%) underwent a second ablation. Follow up imaging data were available for 46 (84%) patients and showed a <20% reduction in cyst size in 18 patients, 20-49% in 4 patients, 50-79% in 5 and 80-100% size reduction in 18 patients. For one patient, doubling in cyst size was recorded at the 12-month follow-up. Excluding one case of scope-induced small bowel perforation (Clavien-Dindo; ClvD grade 3), other adverse events were mild (ClvD 0-2) and expected (transient abdominal pain, bloating, sore throat, nausea/vomiting). One patient experienced a self-limiting, post procedure grand mal seizure on a background of epilepsy.

Conclusion

​EUS-RFA was well tolerated in most cases. Our data indicate that the procedure is relatively safe. The response ranged from a <20% reduction in size to complete cyst resolution.

References

1. Papaefthymiou A, Johnson GJ, Maida M, Gkolfakis P, Ramai D, Facciorusso A, Arvanitakis M, Ney A, Fusai GK, Saftoiu A, Tabacelia D, Phillpotts S, Chapman MH, Webster GJ, Pereira SP. Performance and safety of EUS-ablation techniques for pancreatic cystic lesions: a systematic review and meta-analysis. Cancers 2023 [in press].

Disclosure

No conflict of interest

Introduction

Insulinomas are rare, functioning pancreatic neuroendocrine neoplasms (pNEN), whose gold standard therapy is surgical resection. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has emerged as a minimally invasive therapeutic option for pancreatic lesions. This study aims at describing a series of patients with pancreatic insulinoma treated with EUS-RFA.

Aims & Methods

This single-center, retrospective study includes all consecutive patients with pancreatic insulinoma undergoing EUS-RFA because unfit for surgery or refusing surgery. EUS-RFA was performed by using a 19G RFA needle, and a dedicated current generator system with a RFA energy of 20 to 50W. Technical success (i.e., the achievement of complete ablation), adverse events rate, and radiologic response within 3 months after EUS-RFA (i.e., complete tumor necrosis) were evaluated. Follow-up was assessed by clinical monitoring and blood test evaluation at least every 6 months for the first year after the procedure. A descriptive statistical analysis was performed for all the variables.

Results

From March 2017 to September 2022, 10 patients (mean age: 67.1 ± 10.1 years; F:M 7:3) were included. The mean size of insulinomas was 11.9 ± 3.3mm. The median number of passes was 6 (1-14) with a median ablation duration of 15 (6-20) seconds per pass. Technical success, immediate post-procedural euglycemia, and complete radiological response by abdominal CT scan were achieved in all cases (100%). Mild procedure-related early adverse are shown in Table 1. Persistent euglycemia was assessed at 6 and 12 months for each treated patient.

Conclusion

Data from this case series suggest that EUS-RFA is a feasible and safe therapeutic approach for pancreatic insulinomas with mid-term efficacy.

References

Waung, J.A.; Todd, J.F.; Keane, M.G.; Pereira, S.P. Successful management of a sporadic pancreatic insulinoma by endoscopic ultrasound-guided radiofrequency ablation. Endoscopy 2016, 48 (Suppl. S1), E144–E145
Goldberg SN, Mallery S, Gazelle GS, Brugge WR. EUS-guided radiofrequency ablation in the pancreas: results in a porcine model. Gastrointest Endosc. 1999 Sep;50(3):392-401. doi: 10.1053/ge.1999.v50.98847.
Tsoli M, Chatzellis E, Koumarianou A, Kolomodi D, Kaltsas G. Current best practice in the management of neuroendocrine tumors. Ther Adv Endocrinol Metab. 2018 Oct 31;10:2042018818804698. doi: 10.1177/2042018818804698.

Introduction

Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has emerged as a promising minimally invasive technique for the management of unresectable pancreatic adenocarcinoma. Despite its potential, the practical outcomes and overall survival implications of this technique require thorough assessment in real-world settings.

Aims & Methods

This prospective study aimed to evaluate the feasibility, safety, and efficacy of EUS-RFA in patients with locally advanced or metastatic pancreatic adenocarcinoma. For the procedure, an RFA 19-g needle with an electrode active tip length of 10 mm was introduced into the tumor through the working channel of the echoendoscope. The generator settings were set at 35 W, and energy was applied from the distal to the proximal margin of the tumor until the entire lesion was treated. (video 1 EUS RFA PADC.mp4) The primary endpoints were technical success, complication rate, and overall survival.

Results

Twenty consecutive patients (58% female; average age 60 +/- 11.5 years; average tumor diameter, 37 +/- 16.7 mm) underwent EUS-RFA combined with subsequent chemotherapy. Sixteen patients (80%) were diagnosed with locally advanced adenocarcinoma, while four (20%) had metastatic disease. Technical success was achieved in 100% of the cases. The median overall survival was 15 +/- 2.2 months. No adverse events were reported. It should be noted that a patient with locally advanced adenocarcinoma downstaged after multimodal therapy and underwent surgical resection.

Conclusion

EUS-RFA is a feasible and safe treatment modality for patients with unresectable pancreatic adenocarcinoma, with high technical success and low complication rates. Future studies with larger cohorts are needed to confirm these findings and optimize treatment protocols.

Introduction

The sensitivity and accuracy of diagnosis for extrahepatic cholangiocarcinoma (EHCC) can be greatly improved by Spyglass DS choledochoscope, which can realize direct observation and biopsy . Studies have shown that endoscopic radiofrequency ablation (RFA) could prolong stent patency and survival in patients with unresectable extrahepatic cholangiocarcinoma (EHCC) . However, there are few reports about Spyglass DS choledochoscopy and endoscopic RFA therapy in the same stage of diagnosis and treatmen for unresectable EHCC.

Aims & Methods

Aim: To investigate the feasibility and safety of Spyglass DS combined with endoscopic RFA)for unresectable EHCC on the same stage.
Methods A total of 90 patients with extrahepatic bile duct obstruction treated in Hangzhou First People's Hospital from January 2013 to January 2022 were divided into two groups according to the diagnosis and treatment process: conventional group: ERCP + cytobrush/ Spyglass DS cholangioscopy first, and ERCP + RFA again when the pathological results were positive; simultaneous group: ERCP was performed via Spyglass DS cholangioscopy to examine the bile duct and biopsy the lesion under direct vision, and RFA was performed on the same stage for patients identified as malignant tumor. The success rate of procedure, recovery of liver function, the number of ERCPs and the incidence of postoperative adverse events were compared between the two groups.

Results

The sensitivity of Spyglass DS choledochoscope biopsy for EHCC was 87.5% (35/40) significantly higher than that of the cell brush group (38.9% (14/36), and the difference was statistically significant (P<0.05); All patients in both groups successfully completed endoscopic RFA with a 100% of procedure success rate; there was no statistically significant difference in the improvement of bilirubin between the two groups (P>0.05); the mean number of ERCPs in simultaneous group was significantly less than that in conventional group (1.00 vs. 2.59, P<0.001), which was statistically different; the incidence of postoperative adverse events between the two groups was 14.7% (5/34) vs. 14.3% (5/35), with no statistical significance (P=0.889).

Conclusion

Spyglass direct vision diagnosis + biopsy combined with RFA for unresectable extrahepatic cholangiocarcinoma can significantly improve the diagnostic sensitivity, reduce the number of ERCPs, and not increase the incidence of postoperative adverse events, which is a safe and effective diagnosis and treatment method with a high cost-benefit ratio.

Disclosure

NO