David L. Cheung, MD1, Tina Zhou, BS2, Amirali Tavangar, MD2, Jun Ho, 2, Peter Nguyen, MD2, Joshua Kwon, MD2, Jason Samarasena, MD2, John Lee, MD2 1UC Irvine, Orange, CA; 2University of California Irvine, Orange, CA
Introduction: Insulinomas are the most common pancreatic endocrine tumor and can develop life threatening hypoglycemia. Laparoscopic surgical pancreatectomy or enucleation has largely been the first line treatment, but recently laparoscopic or EUS guided radiofrequency ablation (RFA) has shown promise as a non-invasive alternative. This is a case of an incomplete enucleation of a symptomatic pancreatic insulinoma that underwent EUS-guided RFA with complete resolution of symptoms.
Case Description/Methods: A 45-year-old female with a history of pancreatic body insulinoma status post laparoscopic enucleation presents for EUS evaluation after recurrence of intermittent tremors, presyncope, and confusion. Initial biopsy of laparoscopic enucleation revealed positive margins, and surveillance imaging revealed redemonstration of a 1.5 cm x 1.1 cm hyper-enhancing lesion within the pancreatic body with 3-4 mm ductal dilation (Image A). EUS with biopsy confirmed recurrence of neuroendocrine tumor. Given hesitancy to undergo repeated surgery, the patient elected to undergo RFA over open distal pancreatectomy. EUS revealed atrophy within the pancreatic tail and the tumor received 5 cycles of 20-watt RFA via a 7 mm catheter with consistent bubbling (Image B and C). Patient tolerated the procedure well without complications and denied any repeat episodes of hypoglycemia on follow up visit.
Discussion: While surgical pancreatectomy or enucleation is the first line management for insulinoma, evidence of recurrence, incomplete resection or patient hesitancy can make EUS-guided RFA a more favorable option. This case demonstrates an effective use of RFA ablation in a case of incompletely resected insulinoma with complete resolution of symptoms. EUS-guided RFA of insulinomas, however, are limited anatomically--with tumors close to the mesenteric vessels, pancreatic or common bile ducts, or within the periphery at a higher risk of perforation or thermal injury of surrounding structures. For these lesions, surgical management may be more favorable. A retrospective study comparing surgical resection and EUS guided RFA, however, suggested that RFA offered less post operative complications and shortened hospital stay. As patients elect for more non-invasive procedures, EUS guided RFA may become a more favorable gold standard for management of insulinomas. Further head-to-head studies will need to be conducted to evaluate the safety and efficacy of surgical pancreatectomy, enucleation, and RFA compared to EUS-guided RFA.
Figure: A) A 13.5 x 13 mm Insulinoma seen on EUS B) Advancement of 7mm EUSRA EUS-Guided RFA into the insulinoma C) Radiofrequency ablation of the insulinoma with 5 cycles of 20-watt RFA with consistent bubbling
David Cheung indicated no relevant financial relationships.
Tina Zhou indicated no relevant financial relationships.
Amirali Tavangar indicated no relevant financial relationships.
Jun Ho indicated no relevant financial relationships.
Peter Nguyen indicated no relevant financial relationships.
Joshua Kwon indicated no relevant financial relationships.
Jason Samarasena: Applied Medical – Advisor or Review Panel Member. Boston Scientific – Consultant. Conmed – Consultant. Cook – Educational Grant. Neptune Medical – Consultant. Olympus – Consultant. Steris – Consultant.
John Lee indicated no relevant financial relationships.
David L. Cheung, MD1, Tina Zhou, BS2, Amirali Tavangar, MD2, Jun Ho, 2, Peter Nguyen, MD2, Joshua Kwon, MD2, Jason Samarasena, MD2, John Lee, MD2. P0148 - Symptomatic Recurrent Insulinoma Status Post Radiofrequency Ablation with Resolution of Symptoms, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.