Ablative Therapies for Pancreatic Cystic Neoplasms

Pancreatic cystic neoplasms (PCNs) are increasingly detected incidentally with the widespread use of cross-sectional imaging. While many cysts are benign, mucinous lesions such as intraductal papillary mucinous neoplasms and mucinous cystic neoplasms carry a significant risk of malignant transformation, creating management dilemmas. Surgical resection, though curative, is associated with substantial morbidity, mortality, and long-term metabolic consequences, particularly in elderly or comorbid patients. Surveillance alone offers no therapeutic benefit and carries psychological and resource burdens. Endoscopic ultrasound (EUS)-guided ablative therapies have emerged as minimally invasive alternatives aimed at eradicating premalignant cyst epithelium while preserving pancreatic parenchyma. This chapter reviews the rationale, patient selection, technical considerations, efficacy, and safety of available EUS-guided modalities, including ethanol ablation, ethanol-based and alcohol-free chemotherapeutic injection, lauromacrogol sclerosis, and radiofrequency ablation. Among these, ethanol combined with paclitaxel and alcohol-free chemotherapeutic ablation demonstrates the highest cyst resolution rates with acceptable safety profiles.