Emory University School of Medicine Atlanta, GA, United States
Amol Koldhekar, MD1, Raj Dalsania, MD1, Ahmed Messallam, MD2, Saurabh Chawla, MD, FACG1, Vaishali Patel, MD1, Steven Keilin, MD1, Field Willingham, MD, MPH1 1Emory University School of Medicine, Atlanta, GA; 2Emory University, Atlanta, GA
Introduction: Insulinomas are the most common functional pancreatic neuroendocrine tumor (PNET). Patients present with recurrent hypoglycemic symptoms. Endoscopic ultrasound can assist in preoperative localization and biochemical sampling of suspected lesions. While medications help with symptomatic control, the standard of care for PNETs is surgical resection. However, some patients are poor surgical candidates. EUS-guided radiofrequency ablation (EUS-RFA) provides a less invasive modality for treating PNETs.
Case Description/Methods: A 90-year-old patient presented with several years of recurrent hypoglycemic episodes. The insulin and C-peptide levels were elevated. CT abdomen revealed a stable 1.7 x 1.0 cm enhancing lesion arising from the pancreatic tail. An EUS FNA found positive chromogranin and synaptophysin staining consistent with an insulinoma. The patient refused distal pancreatectomy with splenectomy due to surgical risks and elected for EUS-RFA procedure.
A 7.5MHz linear echoendoscope was used to identify the irregular mass lesion in the pancreatic tail. Doppler was used to confirm the absence of adjacent vascular structures and lack of invasion. An EUS-RFA needle was advanced through the endoscope into the lesion. The sharp tip needle incorporated a 19G tip diameter with a 10-mm distal ablation area. Eight total ablations of 30W for 20 seconds each were applied. A bubbling effect was confirmed in the tumor region. The ablation catheter was removed and the ablated areas were examined, showing no bleeding or complication. Before and during the procedure, the patient required two ampules of IV dextrose to treat hypoglycemia.
The patient was observed in the hospital after the procedure. He denied abdominal pain and tolerated a normal diet. Inpatient blood glucose monitoring showed stable serum glucose above 70 mg/dL after discontinuation of dextrose infusion. Repeat insulin and C-peptide levels normalized. The patient was discharged two days after the procedure.
Discussion: EUS radiofrequency ablation offers a less invasive option for treating pancreatic tail insulinomas. Procedures can be performed in under an hour with minimal post-procedural observation and clinically significant outcomes for patients. The goal of this procedure was to treat symptomatic hypoglycemia. The ablation may not completely ablate the tumor and so clinical observation is recommended. Long-term outcomes following ablation of insulinomas will require further monitoring.
Figure: Insulin and c-peptide levels pre- and post- EUS-guided RFA of a pancreatic tail insulinoma.
Disclosures: Amol Koldhekar indicated no relevant financial relationships. Raj Dalsania indicated no relevant financial relationships. Ahmed Messallam indicated no relevant financial relationships. Saurabh Chawla indicated no relevant financial relationships. Vaishali Patel indicated no relevant financial relationships. Steven Keilin indicated no relevant financial relationships. Field Willingham indicated no relevant financial relationships.
Amol Koldhekar, MD1, Raj Dalsania, MD1, Ahmed Messallam, MD2, Saurabh Chawla, MD, FACG1, Vaishali Patel, MD1, Steven Keilin, MD1, Field Willingham, MD, MPH1. P1753 - EUS-Guided Radiofrequency Ablation of a Pancreatic Tail Insulinoma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
