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Radiofrequency ablation of pancreatic serous cystic neoplasms: feasibility, but for the wrong indication
We read with interest the recent study of Oh et al. , which reported the use of endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) of proven pancreatic serous cystic neoplasms (SCNs) in 13 patients. As shown in a large international series, SCNs are usually non-evolving cystic tumors that are associated with an extremely low risk of malignancy (0.1 %) and specific symptoms are rare, even during a long period of follow-up . The inclusion criteria of this study were: symptomatic SCNs or SCNs that were increasing in size. However, an isolated increase in size should not be a criterion for considering an ablative treatment   . Furthermore, 10 patients (77 %) presented with abdominal pain/discomfort, which is questionable as a symptom relating to SCN. The remaining three patients (23 %) had main pancreatic duct dilatation with acute pancreatitis. Resection or endoscopic emptying of SCNs is recommended only in rare patients with symptoms of adjacent organ compression (e. g. bile duct, stomach, duodenum, or portal vein) . Guidelines state that no follow-up or surgery are recommended if the diagnosis is certain  .
The SCNs in this study had a median size of 50 mm (range 34 – 52.5) and were of microcystic type  . Knowing that the action of RFA takes place within 2 cm around the needle in solid tumors and given the impossibility of emptying an SCN made of thousands of microcysts, one might wonder if RFA is an appropriate technique here. Indeed, the effectiveness of RFA on the size of the SCNs was limited (0 % complete response, 62 % partial response). No precise information about improvement in the so-called symptoms that led to RFA was available. Pancreatic RFA is an attractive ablative technique; however, the adverse event rate (acute pancreatitis, stenosis of main pancreatic duct, and pain) is around 10 % .
Even if RFA seems feasible for SCNs, the selection of patients needs to be more rigorous. Its effectiveness should be assessed on specific symptoms and not on the lesion size. To assess that a procedure is feasible when the indication is wrong broadcasts an undesirable message.
26 May 2021 (online)
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- 1 Oh D, Ko SW, Seo D-W. et al. Endoscopic ultrasound-guided radiofrequency ablation of pancreatic microcystic serous cystic neoplasms: a retrospective study. Endoscopy 2020; DOI: 10.1055/a-1250-7786.
- 2 Jais B, Rebours V, Malleo G. et al. Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas). Gut 2016; 65: 305-312
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- 4 European Study Group on Cystic Tumours of the Pancreas. European evidence-based guidelines on pancreatic cystic neoplasms. Gut 2018; 67: 789-804
- 5 Barthet M, Giovannini M, Lesavre N. et al. Endoscopic ultrasound-guided radiofrequency ablation for pancreatic neuroendocrine tumors and pancreatic cystic neoplasms: a prospective multicenter study. Endoscopy 2019; 51: 836-842