Endoscopic ultrasound radiofrequency ablation of pancreatic insulinoma in elderly patients: Three case reports

Abstract

Background: Endoscopic ultrasound (EUS)-guided radiofrequency ablation (RFA) has recently been proposed as a local treatment for functional pancreatic neuroendocrine neoplasms in patients unfit for surgery, in order to obtain clinical syndrome regression. Data on the safety and long-term effectiveness of this approach are scarce, and EUS-RFA procedures are not standardized.

Case summary: The present case series reports 3 elderly patients with a pancreatic insulinoma and comorbidities, locally treated by EUS-guided RFA with clinical success in terms of hypoglycemic symptoms. RFA procedures were performed during deep sedation, under EUS control with a 19 G needle, an electrode 5-mm in size at a power of 30 W and multiple RFA applications during the same session in order to treat the whole area of the lesions. Immediate relief of symptoms was evident in 2 patients after the first EUS-RFA, while in the third patient a second endoscopic treatment was needed. All 3 patients are symptom-free without need of medications after 24 mo of follow-up with imaging follow-up showing no disease recurrence. A single adverse event of intraprocedural bleeding occurred, which was successfully treated endoscopically.

Conclusion: EUS-RFA represents an effective and safe alternative to surgery for the treatment of insulinomas in elderly patients at high surgical risk. However, larger multicenter studies with longer follow-up are needed in order to better assess its safety and clinical success.

Keywords: Ablative therapies; Case report; Endoscopic ultrasound; Insulinomas; Neuroendocrine neoplasms; Radiofrequency ablation.

Figure 1

Radiofrequency ablation system. A: Needle, similar to an endoscopic ultrasound fine needle aspiration or biopsy needle; B: Peristaltic pump which can infuse during the ablation, the electrode with chilled solution, maximizing volume ablation; C: Electrode on the distal needle tip, delivering radiofrequency ablation; D: Radiofrequency generator, with the possibility to monitor ablation parameters: Power, time, impedance. Citation: Rossi G, Petrone MC; Capurso G, Albarello L, Testoni SGG, Archibugi L, Lena MS, Doglioni C, Arcidiacono PG. Standardization of a Radiofrequency Ablation Tool in an Ex-Vivo Porcine Liver Model. Gastrointest Disord 2020; 2: 300-309. Copyright© The Authors 2020. Published by MDPI. No special permission is required to reuse all or part of article published by MDPI, including figures and tables, see https://www.mdpi.com/openaccess#Permissions. The authors have obtained the permission for figure using from Rossi G (Supplementary material).

Figure 2

Case 2 imaging. A: A hyper-vascularized lesion compatible with an insulinoma, extremely close to the gastroduodenal artery is visible; B: Submucosal bleeding after radiofrequency ablation, treated by endoscopic hemostasis; C: Computed tomography scan 72 h after radiofrequency ablation: An 8 mm hypodense necrotic area at the previous lesion location, without signs of bleeding.