Endoscopic Ultrasonography: Staging and Therapeutic Interventions

  • Girish MishraEmail author
  • Rishi Pawa


Pancreatic cancer (PC) continues to vex and frustrate clinicians largely due to their inability to impact this sinister disease, which is often metastatic upon presentation. Endoscopic ultrasound (EUS) has rapidly cemented its role in the armamentarium of diagnostic tools available for accurate staging of PC. Initial euphoria touting EUS’ superiority in staging accuracy for EUS was soon met by the stark reality that EUS was no better than the latest cross-sectional imaging available for assessing vascular invasion. Endosonographers recommend that EUS should be performed when no detectable mass lesion is identified on CT in the face of clinical suspicion of PC. Patients and clinicians should take solace when EUS fails to detect a pancreatic mass as the likelihood of a pancreatic cancer is near zero. Contrast enhancement, sonoelastography, and confocal laser endomicroscopy represent few extensions of EUS in the ongoing quest to differentiate benign from malignant masses. The unlimited therapeutic potential of EUS is just now being realized. EUS has been used to access the bile and/or pancreatic duct to help relieve malignant biliary obstruction when ERCP has been unsuccessful or in the setting of altered anatomy. Initial reports of EUS-directed fiducial placement and/or direct intratumoral injection offer hope as a combined partner to conventional treatment for attacking and dissolving tumors. Finally, EUS-guided celiac plexus neurolysis allows ablation of the ganglion to relieve the crippling pain encountered by our patients.


EUS Echoendoscope Stent FNA Contrast-enhancement Sonoelastography Confocal laser endomicroscopy nCLE Biliary drainage Pancreatography Fiducial FNI Intratumoral injection Celiac plexus neurolysis 


  1. 1.
    Shrikhande SV, Barreto SG, Goel M, Arya S. Multimodality imaging of pancreatic ductal adenocarcinoma: a review of the literature. HPB. 2012;14(10):658–68.PubMedCentralPubMedCrossRefGoogle Scholar
  2. 2.
    Mansfield SD, Scott J, Oppong K, Richardson DL, Sen G, Jaques BC, et al. Comparison of multislice computed tomography and endoscopic ultrasonography with operative and histological findings in suspected pancreatic and periampullary malignancy. Br J Surg. 2008;95(12):1512–20.PubMedCrossRefGoogle Scholar
  3. 3.
    Tierney WM, Adler DG, Chand B, Conway JD, Croffie JM, DiSario JA, et al. Echoendoscopes. Gastrointest Endosc. 2007;66(3):435–42.PubMedCrossRefGoogle Scholar
  4. 4.
    Kaul V, Adler DG, Conway JD, Farraye FA, Kantsevoy SV, Kethu SR, et al. Interventional EUS. Gastrointest Endosc. 2010;72(1):1–4.PubMedCrossRefGoogle Scholar
  5. 5.
    Michl P, Pauls S, Gress TM. Evidence-based diagnosis and staging of pancreatic cancer. Best Pract Res Clin Gastroenterol. 2006;20(2):227–51.PubMedCrossRefGoogle Scholar
  6. 6.
    Gress F, Savides T, Cummings O, Sherman S, Lehman G, Zaidi S, et al. Radial scanning and linear array endosonography for staging pancreatic cancer: a prospective randomized comparison. Gastrointest Endosc. 1997;45(2):138–42.PubMedCrossRefGoogle Scholar
  7. 7.
    Seicean A, Badea R, Mocan T, Iancu C, Pop T, Seicean R, et al. Radial endoscopic ultrasonography in the preoperative staging of pancreatic cancer. J Gastrointestin Liver Dis. 2008;17(3):273–8.PubMedGoogle Scholar
  8. 8.
    Fritscher-Ravens A, Knoefel WT, Krause C, Swain CP, Brandt L, Patel K. Three-dimensional linear endoscopic ultrasound-feasibility of a novel technique applied for the detection of vessel involvement of pancreatic masses. Am J Gastroenterol. 2005;100(6):1296–302.PubMedCrossRefGoogle Scholar
  9. 9.
    DeWitt J, Devereaux B, Chriswell M, McGreevy K, Howard T, Imperiale TF, et al. Comparison of endoscopic ultrasonography and multidetector computed tomography for detecting and staging pancreatic cancer. Ann Intern Med. 2004;141(10):753–63.PubMedCrossRefGoogle Scholar
  10. 10.
    Rosch T, Dittler HJ, Strobel K, Meining A, Schusdziarra V, Lorenz R, et al. Endoscopic ultrasound criteria for vascular invasion in the staging of cancer of the head of the pancreas: a blind reevaluation of videotapes. Gastrointest Endosc. 2000;52(4):469–77.PubMedCrossRefGoogle Scholar
  11. 11.
    Ahmad NA, Lewis JD, Ginsberg GG, Rosato EF, Morris JB, Kochman ML. EUS in preoperative staging of pancreatic cancer. Gastrointest Endosc. 2000;52(4):463–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Aslanian H, Salem R, Lee J, Andersen D, Robert M, Topazian M. EUS diagnosis of vascular invasion in pancreatic cancer: surgical and histologic correlates. Am J Gastroenterol. 2005;100(6):1381–5.PubMedCrossRefGoogle Scholar
  13. 13.
    Bao PQ, Johnson JC, Lindsey EH, Schwartz DA, Arildsen RC, Grzeszczak E, et al. Endoscopic ultrasound and computed tomography predictors of pancreatic cancer resectability. J Gastrointest Surg. 2008;12(1):10–6; discussion 16.PubMedCrossRefGoogle Scholar
  14. 14.
    Fusaroli P, Manta R, Fedeli P, Maltoni S, Grillo A, Giovannini E, et al. The influence of endoscopic biliary stents on the accuracy of endoscopic ultrasound for pancreatic head cancer staging. Endoscopy. 2007;39(9):813–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Kim JJ, Walia S, Lee SH, Patel B, Vetsa M, Zhao Y, et al. Lower yield of endoscopic ultrasound-guided fine-needle aspiration in patients with pancreatic head mass with a biliary stent. Dig Dis Sci. 2015;60(2):543–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Siddiqui AA, Fein M, Kowalski TE, Loren DE, Eloubeidi MA. Comparison of the influence of plastic and fully covered metal biliary stents on the accuracy of EUS-FNA for the diagnosis of pancreatic cancer. Dig Dis Sci. 2012;57(9):2438–45.PubMedCrossRefGoogle Scholar
  17. 17.
    Fisher JM, Gordon SR, Gardner TB. The impact of prior biliary stenting on the accuracy and complication rate of endoscopic ultrasound fine-needle aspiration for diagnosing pancreatic adenocarcinoma. Pancreas. 2011;40(1):21–4.PubMedCrossRefGoogle Scholar
  18. 18.
    Ranney N, Phadnis M, Trevino J, Ramesh J, Wilcox CM, Varadarajulu S. Impact of biliary stents on EUS-guided FNA of pancreatic mass lesions. Gastrointest Endosc. 2012;76(1):76–83.PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Shami VM, Mahajan A, Sundaram V, Davis EM, Loch MM, Kahaleh M. Endoscopic ultrasound staging is adversely affected by placement of a self-expandable metal stent: fact or fiction? Pancreas. 2008;37(4):396–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Tamm EP, Bhosale PR, Vikram R, de Almeida Marcal LP, Balachandran A. Imaging of pancreatic ductal adenocarcinoma: state of the art. World J Radiol. 2013;5(3):98–105.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Wong JC, Lu DS. Staging of pancreatic adenocarcinoma by imaging studies. Clin Gastroenterol Hepatol. 2008;6(12):1301–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Dewitt J, Devereaux BM, Lehman GA, Sherman S, Imperiale TF. Comparison of endoscopic ultrasound and computed tomography for the preoperative evaluation of pancreatic cancer: a systematic review. Clin Gastroenterol Hepatol. 2006;4(6):717–25. quiz 664.PubMedCrossRefGoogle Scholar
  23. 23.
    Nawaz H, Fan CY, Kloke J, Khalid A, McGrath K, Landsittel D, et al. Performance characteristics of endoscopic ultrasound in the staging of pancreatic cancer: a meta-analysis. JOP. 2013;14(5):484–97.PubMedCentralPubMedGoogle Scholar
  24. 24.
    Yang R, Lu M, Qian X, Chen J, Li L, Wang J, et al. Diagnostic accuracy of EUS and CT of vascular invasion in pancreatic cancer: a systematic review. J Cancer Res Clin Oncol. 2014;140(12):2077–86.PubMedCrossRefGoogle Scholar
  25. 25.
    De Angelis C, Brizzi RF, Pellicano R. Endoscopic ultrasonography for pancreatic cancer: current and future perspectives. J Gastrointest Oncol. 2013;4(2):220–30.PubMedCentralPubMedGoogle Scholar
  26. 26.
    De Angelis C, Manfre SF, Pellicano R. Endoscopic ultrasonography for diagnosis and staging of pancreatic adenocarcinoma: key messages for clinicians. Minerva Med. 2014;105(2):121–8.PubMedGoogle Scholar
  27. 27.
    Klapman JB, Chang KJ, Lee JG, Nguyen P. Negative predictive value of endoscopic ultrasound in a large series of patients with a clinical suspicion of pancreatic cancer. Am J Gastroenterol. 2005;100(12):2658–61.PubMedCrossRefGoogle Scholar
  28. 28.
    Helmstaedter L, Riemann JF. Pancreatic cancer—EUS and early diagnosis. Langenbecks Arch Surg. 2008;393(6):923–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Catanzaro A, Richardson S, Veloso H, Isenberg GA, Wong RC, Sivak Jr MV, et al. Long-term follow-up of patients with clinically indeterminate suspicion of pancreatic cancer and normal EUS. Gastrointest Endosc. 2003;58(6):836–40.PubMedCrossRefGoogle Scholar
  30. 30.
    Tummala P, Munigala S, Eloubeidi MA, Agarwal B. Patients with obstructive jaundice and biliary stricture +/− mass lesion on imaging: prevalence of malignancy and potential role of EUS-FNA. J Clin Gastroenterol. 2013;47(6):532–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Sanchez MV, Varadarajulu S, Napoleon B. EUS contrast agents: what is available, how do they work, and are they effective? Gastrointest Endosc. 2009;69(2 Suppl):S71–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Jang SI, Lee DK. Contrast-enhanced endoscopic ultrasonography: advance and current status. Ultrasonography. 2014;33(3):161–9.PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Napoleon B, Alvarez-Sanchez MV, Gincoul R, Pujol B, Lefort C, Lepilliez V, et al. Contrast-enhanced harmonic endoscopic ultrasound in solid lesions of the pancreas: results of a pilot study. Endoscopy. 2010;42(7):564–70.PubMedCrossRefGoogle Scholar
  34. 34.
    Fusaroli P, Spada A, Mancino MG, Caletti G. Contrast harmonic echo-endoscopic ultrasound improves accuracy in diagnosis of solid pancreatic masses. Clin Gastroenterol Hepatol. 2010;8(7):629–34.e1-2.Google Scholar
  35. 35.
    Park JS, Kim HK, Bang BW, Kim SG, Jeong S, Lee DH. Effectiveness of contrast-enhanced harmonic endoscopic ultrasound for the evaluation of solid pancreatic masses. World J Gastroenterol. 2014;20(2):518–24.PubMedCentralPubMedCrossRefGoogle Scholar
  36. 36.
    Iglesias Garcia J, Dominguez-Munoz JE. Endoscopic ultrasound-guided biopsy for the evaluation of pancreatic tumors. Gastroenterol Hepatol. 2007;30(10):597–601.PubMedCrossRefGoogle Scholar
  37. 37.
    DeWitt J, McGreevy K, Sherman S, LeBlanc J. Utility of a repeated EUS at a tertiary-referral center. Gastrointest Endosc. 2008;67(4):610–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Varadarajulu S, Tamhane A, Eloubeidi MA. Yield of EUS-guided FNA of pancreatic masses in the presence or the absence of chronic pancreatitis. Gastrointest Endosc. 2005;62(5):728–36; quiz 51, 53.PubMedCrossRefGoogle Scholar
  39. 39.
    Giovannini M, Hookey LC, Bories E, Pesenti C, Monges G, Delpero JR. Endoscopic ultrasound elastography: the first step towards virtual biopsy? Preliminary results in 49 patients. Endoscopy. 2006;38(4):344–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Dawwas MF, Taha H, Leeds JS, Nayar MK, Oppong KW. Diagnostic accuracy of quantitative EUS elastography for discriminating malignant from benign solid pancreatic masses: a prospective, single-center study. Gastrointest Endosc. 2012;76(5):953–61.PubMedCrossRefGoogle Scholar
  41. 41.
    Figueiredo FA, da Silva PM, Monges G, Bories E, Pesenti C, Caillol F, et al. Yield of contrast-enhanced power doppler endoscopic ultrasonography and strain ratio obtained by EUS-elastography in the diagnosis of focal pancreatic solid lesions. Endosc Ultrasound. 2012;1(3):143–9.PubMedCentralPubMedCrossRefGoogle Scholar
  42. 42.
    Iglesias-Garcia J, Larino-Noia J, Abdulkader I, Forteza J, Dominguez-Munoz JE. Quantitative endoscopic ultrasound elastography: an accurate method for the differentiation of solid pancreatic masses. Gastroenterology. 2010;139(4):1172–80.PubMedCrossRefGoogle Scholar
  43. 43.
    Li X, Xu W, Shi J, Lin Y, Zeng X. Endoscopic ultrasound elastography for differentiating between pancreatic adenocarcinoma and inflammatory masses: a meta-analysis. World J Gastroenterol. 2013;19(37):6284–91.PubMedCentralPubMedCrossRefGoogle Scholar
  44. 44.
    Pei Q, Zou X, Zhang X, Chen M, Guo Y, Luo H. Diagnostic value of EUS elastography in differentiation of benign and malignant solid pancreatic masses: a meta-analysis. Pancreatology. 2012;12(5):402–8.PubMedCrossRefGoogle Scholar
  45. 45.
    Ussui VM, Wallace MB. Confocal endomicroscopy of colorectal polyps. Gastroenterol Res Pract. 2012;2012:545679.PubMedCentralPubMedCrossRefGoogle Scholar
  46. 46.
    Technology Committee ASGE. Confocal laser endomicroscopy. Gastrointest Endosc. 2014;80(6):928–38.CrossRefGoogle Scholar
  47. 47.
    Kiesslich R, Goetz M, Vieth M, Galle PR, Neurath MF. Confocal laser endomicroscopy. Gastrointest Endosc Clin N Am. 2005;15(4):715–31.PubMedCrossRefGoogle Scholar
  48. 48.
    Kiesslich R, Gossner L, Goetz M, Dahlmann A, Vieth M, Stolte M, et al. In vivo histology of Barrett’s esophagus and associated neoplasia by confocal laser endomicroscopy. Clin Gastroenterol Hepatol. 2006;4(8):979–87.PubMedCrossRefGoogle Scholar
  49. 49.
    Leung KK, Maru D, Abraham S, Hofstetter WL, Mehran R, Anandasabapathy S. Optical EMR: confocal endomicroscopy-targeted EMR of focal high-grade dysplasia in Barrett’s esophagus. Gastrointest Endosc. 2009;69(1):170–2.PubMedCrossRefGoogle Scholar
  50. 50.
    Canto MI, Anandasabapathy S, Brugge W, Falk GW, Dunbar KB, Zhang Z, et al. In vivo endomicroscopy improves detection of Barrett’s esophagus-related neoplasia: a multicenter international randomized controlled trial (with video). Gastrointest Endosc. 2014;79(2):211–21.PubMedCentralPubMedCrossRefGoogle Scholar
  51. 51.
    Buchner AM, Wallace MB. In-vivo microscopy in the diagnosis of intestinal neoplasia and inflammatory conditions. Histopathology. 2015;66(1):137–46.PubMedCrossRefGoogle Scholar
  52. 52.
    Wallace MB, Fockens P. Probe-based confocal laser endomicroscopy. Gastroenterology. 2009;136(5):1509–13.PubMedCrossRefGoogle Scholar
  53. 53.
    Kahaleh M, Turner BG, Bezak K, Sharaiha RZ, Sarkaria S, Lieberman M, et al. Probe-based confocal laser endomicroscopy in the pancreatic duct provides direct visualization of ductal structures and aids in clinical management. Dig Liver Dis. 2014;47:202–4.PubMedCrossRefGoogle Scholar
  54. 54.
    Giovannini M, Bories E, Monges G, Pesenti C, Caillol F, Delpero JR. Results of a phase I–II study on intraductal confocal microscopy (IDCM) in patients with common bile duct (CBD) stenosis. Surg Endosc. 2011;25(7):2247–53.PubMedCrossRefGoogle Scholar
  55. 55.
    Becker V, Wallace MB, Fockens P, von Delius S, Woodward TA, Raimondo M, et al. Needle-based confocal endomicroscopy for in vivo histology of intra-abdominal organs: first results in a porcine model (with videos). Gastrointest Endosc. 2010;71(7):1260–6.PubMedCrossRefGoogle Scholar
  56. 56.
    Konda VJ, Aslanian HR, Wallace MB, Siddiqui UD, Hart J, Waxman I. First assessment of needle-based confocal laser endomicroscopy during EUS-FNA procedures of the pancreas (with videos). Gastrointest Endosc. 2011;74(5):1049–60.PubMedCrossRefGoogle Scholar
  57. 57.
    Konda VJ, Meining A, Jamil LH, Giovannini M, Hwang JH, Wallace MB, et al. A pilot study of in vivo identification of pancreatic cystic neoplasms with needle-based confocal laser endomicroscopy under endosonographic guidance. Endoscopy. 2013;45(12):1006–13.PubMedCrossRefGoogle Scholar
  58. 58.
    Voegeli DR, Crummy AB, Weese JL. Percutaneous transhepatic cholangiography, drainage, and biopsy in patients with malignant biliary obstruction. An alternative to surgery. Am J Surg. 1985;150(2):243–7.PubMedCrossRefGoogle Scholar
  59. 59.
    Artifon EL, Sakai P, Cunha JE, Dupont A, Filho FM, Hondo FY, et al. Surgery or endoscopy for palliation of biliary obstruction due to metastatic pancreatic cancer. Am J Gastroenterol. 2006;101(9):2031–7.PubMedCrossRefGoogle Scholar
  60. 60.
    Artifon EL, Aparicio D, Paione JB, Lo SK, Bordini A, Rabello C, et al. Biliary drainage in patients with unresectable, malignant obstruction where ERCP fails: endoscopic ultrasonography-guided choledochoduodenostomy versus percutaneous drainage. J Clin Gastroenterol. 2012;46(9):768–74.PubMedCrossRefGoogle Scholar
  61. 61.
    Sarkaria S, Lee HS, Gaidhane M, Kahaleh M. Advances in endoscopic ultrasound-guided biliary drainage: a comprehensive review. Gut Liver. 2013;7(2):129–36.PubMedCentralPubMedCrossRefGoogle Scholar
  62. 62.
    Khashab MA, Valeshabad AK, Modayil R, Widmer J, Saxena P, Idrees M, et al. EUS-guided biliary drainage by using a standardized approach for malignant biliary obstruction: rendezvous versus direct transluminal techniques (with videos). Gastrointest Endosc. 2013;78(5):734–41.PubMedCrossRefGoogle Scholar
  63. 63.
    Kahaleh M, Hernandez AJ, Tokar J, Adams RB, Shami VM, Yeaton P. Interventional EUS-guided cholangiography: evaluation of a technique in evolution. Gastrointest Endosc. 2006;64(1):52–9.PubMedCrossRefGoogle Scholar
  64. 64.
    Savides TJ, Varadarajulu S, Palazzo L. EUS 2008 Working Group document: evaluation of EUS-guided hepaticogastrostomy. Gastrointest Endosc. 2009;69(2 Suppl):S3–7.PubMedCrossRefGoogle Scholar
  65. 65.
    Wiersema MJ, Sandusky D, Carr R, Wiersema LM, Erdel WC, Frederick PK. Endosonography-guided cholangiopancreatography. Gastrointest Endosc. 1996;43(2 Pt 1):102–6.PubMedCrossRefGoogle Scholar
  66. 66.
    Giovannini M, Dotti M, Bories E, Moutardier V, Pesenti C, Danisi C, et al. Hepaticogastrostomy by echo-endoscopy as a palliative treatment in a patient with metastatic biliary obstruction. Endoscopy. 2003;35(12):1076–8.PubMedCrossRefGoogle Scholar
  67. 67.
    Kahaleh M, Artifon EL, Perez-Miranda M, Gupta K, Itoi T, Binmoeller KF, et al. Endoscopic ultrasonography guided biliary drainage: summary of consortium meeting, May 7th, 2011, Chicago. World J Gastroenterol. 2013;19(9):1372–9.PubMedCentralPubMedCrossRefGoogle Scholar
  68. 68.
    Kumta NA, Kedia P, Kahaleh M. Endoscopic ultrasound-guided biliary drainage: an update. Curr Treat Options Gastroenterol. 2014;12(2):154–68.PubMedCrossRefGoogle Scholar
  69. 69.
    Khashab MA, Valeshabad AK, Afghani E, Singh VK, Kumbhari V, Messallam A, et al. A comparative evaluation of EUS-guided biliary drainage and percutaneous drainage in patients with distal malignant biliary obstruction and failed ERCP. Dig Dis Sci. 2015;60(2):557–65.PubMedCrossRefGoogle Scholar
  70. 70.
    Goldstein SD, Ford EC, Duhon M, McNutt T, Wong J, Herman JM. Use of respiratory-correlated four-dimensional computed tomography to determine acceptable treatment margins for locally advanced pancreatic adenocarcinoma. Int J Radiat Oncol Biol Phys. 2010;76(2):597–602.PubMedCrossRefGoogle Scholar
  71. 71.
    Olender D. Fiducials for target localization. In: Heilbrun MP, editor. CyberKnife radiosurgery: a practical guide. Sunnyvale: CyberKnife Society; 2003. p. 80Y94.Google Scholar
  72. 72.
    Park WG, Yan BM, Schellenberg D, Kim J, Chang DT, Koong A, et al. EUS-guided gold fiducial insertion for image-guided radiation therapy of pancreatic cancer: 50 successful cases without fluoroscopy. Gastrointest Endosc. 2010;71(3):513–8.PubMedCrossRefGoogle Scholar
  73. 73.
    Sanders MK, Moser AJ, Khalid A, Fasanella KE, Zeh HJ, Burton S, et al. EUS-guided fiducial placement for stereotactic body radiotherapy in locally advanced and recurrent pancreatic cancer. Gastrointest Endosc. 2010;71(7):1178–84.PubMedCrossRefGoogle Scholar
  74. 74.
    Ammar T, Cote GA, Creach KM, Kohlmeier C, Parikh PJ, Azar RR. Fiducial placement for stereotactic radiation by using EUS: feasibility when using a marker compatible with a standard 22-gauge needle. Gastrointest Endosc. 2010;71(3):630–3.PubMedCrossRefGoogle Scholar
  75. 75.
    Wallace MB, Sabbagh LC. EUS 2008 Working Group document: evaluation of EUS-guided tumor ablation. Gastrointest Endosc. 2009;69(2 Suppl):S59–63.PubMedCrossRefGoogle Scholar
  76. 76.
    Chang KJ, Nguyen PT, Thompson JA, Kurosaki TT, Casey LR, Leung EC, et al. Phase I clinical trial of allogeneic mixed lymphocyte culture (cytoimplant) delivered by endoscopic ultrasound-guided fine-needle injection in patients with advanced pancreatic carcinoma. Cancer. 2000;88(6):1325–35.PubMedCrossRefGoogle Scholar
  77. 77.
    Hecht JR, Bedford R, Abbruzzese JL, Lahoti S, Reid TR, Soetikno RM, et al. A phase I/II trial of intratumoral endoscopic ultrasound injection of ONYX-015 with intravenous gemcitabine in unresectable pancreatic carcinoma. Clin Cancer Res. 2003;9(2):555–61.PubMedGoogle Scholar
  78. 78.
    Hecht JR, Farrell JJ, Senzer N, Nemunaitis J, Rosemurgy A, Chung T, et al. EUS or percutaneously guided intratumoral TNFerade biologic with 5-fluorouracil and radiotherapy for first-line treatment of locally advanced pancreatic cancer: a phase I/II study. Gastrointest Endosc. 2012;75(2):332–8.PubMedCentralPubMedCrossRefGoogle Scholar
  79. 79.
    Hanna N, Ohana P, Konikoff FM, Leichtmann G, Hubert A, Appelbaum L, et al. Phase 1/2a, dose-escalation, safety, pharmacokinetic and preliminary efficacy study of intratumoral administration of BC-819 in patients with unresectable pancreatic cancer. Cancer Gene Ther. 2012;19(6):374–81.PubMedCrossRefGoogle Scholar
  80. 80.
    Irisawa A, Takagi T, Kanazawa M, Ogata T, Sato Y, Takenoshita S, et al. Endoscopic ultrasound-guided fine-needle injection of immature dendritic cells into advanced pancreatic cancer refractory to gemcitabine: a pilot study. Pancreas. 2007;35(2):189–90.PubMedCrossRefGoogle Scholar
  81. 81.
    Herman JM, Wild AT, Wang H, Tran PT, Chang KJ, Taylor GE, et al. Randomized phase III multi-institutional study of TNFerade biologic with fluorouracil and radiotherapy for locally advanced pancreatic cancer: final results. J Clin Oncol. 2013;31(7):886–94.PubMedCrossRefGoogle Scholar
  82. 82.
    Collins D, Penman I, Mishra G, Draganov P. EUS-guided celiac block and neurolysis. Endoscopy. 2006;38(9):935–9.PubMedCrossRefGoogle Scholar
  83. 83.
    Santosh D, Lakhtakia S, Gupta R, Reddy DN, Rao GV, Tandan M, et al. Clinical trial: a randomized trial comparing fluoroscopy guided percutaneous technique vs. endoscopic ultrasound guided technique of coeliac plexus block for treatment of pain in chronic pancreatitis. Aliment Pharmacol Ther. 2009;29(9):979–84.PubMedCrossRefGoogle Scholar
  84. 84.
    Gunaratnam NT, Sarma AV, Norton ID, Wiersema MJ. A prospective study of EUS-guided celiac plexus neurolysis for pancreatic cancer pain. Gastrointest Endosc. 2001;54(3):316–24.PubMedCrossRefGoogle Scholar
  85. 85.
    Penman ID, Rosch T. EUS 2008 Working Group document: evaluation of EUS-guided celiac plexus neurolysis/block (with video). Gastrointest Endosc. 2009;69(2 Suppl):S28–31.PubMedCrossRefGoogle Scholar
  86. 86.
    Wyse JM, Carone M, Paquin SC, Usatii M, Sahai AV. Randomized, double-blind, controlled trial of early endoscopic ultrasound-guided celiac plexus neurolysis to prevent pain progression in patients with newly diagnosed, painful, inoperable pancreatic cancer. J Clin Oncol. 2011;29(26):3541–6.PubMedCrossRefGoogle Scholar
  87. 87.
    Arcidiacono PG, Calori G, Carrara S, McNicol ED, Testoni PA. Celiac plexus block for pancreatic cancer pain in adults. Cochrane Database Syst Rev. 2011;(3):Cd007519.Google Scholar
  88. 88.
    Ascunce G, Ribeiro A, Reis I, Rocha-Lima C, Sleeman D, Merchan J, et al. EUS visualization and direct celiac ganglia neurolysis predicts better pain relief in patients with pancreatic malignancy (with video). Gastrointest Endosc. 2011;73(2):267–74.PubMedCrossRefGoogle Scholar
  89. 89.
    Levy MJ, Topazian MD, Wiersema MJ, Clain JE, Rajan E, Wang KK, et al. Initial evaluation of the efficacy and safety of endoscopic ultrasound-guided direct Ganglia neurolysis and block. Am J Gastroenterol. 2008;103(1):98–103.PubMedCrossRefGoogle Scholar
  90. 90.
    O’Toole TM, Schmulewitz N. Complication rates of EUS-guided celiac plexus blockade and neurolysis: results of a large case series. Endoscopy. 2009;41(7):593–7.PubMedCrossRefGoogle Scholar

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© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Internal Medicine-Section on GastroenterologyWake Forest School of Medicine, Medical Center Boulevard, Winston-SalemWinston-SalemUSA

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