Ambreen A. Merchant, MBBS1, Ahmed Messallam, MD2, Maria Diab, MD2, Shishir Maithel, MD2, Pretesh Patel, MD2, Vaishali Patel, MD3, Saurabh Chawla, MD, FACG3, Steven Keilin, MD3, Field Willingham, MD, MPH3 1Emory University, Decatur, GA; 2Emory University, Atlanta, GA; 3Emory University School of Medicine, Atlanta, GA
Introduction: Non-metastatic pancreatic tumors are primarily managed by surgical resection with or without adjuvant therapy. Patients who are not surgical candidates have limited therapeutic options. Endoscopic ultrasound (EUS)-guided radiofrequency ablation (RFA) may be a feasible local intervention in this patient population.
Case Description/Methods: This is a 64-year old male with a history of MEN1 syndrome, panhypopituitarism status post trans-sphenoidal resection and radiation for prolactinoma, subtotal parathyroidectomy, seizure disorder, and morbid obesity. He had undergone distal pancreatectomy for a non-functioning pancreatic neuroendocrine tumor, complicated by a prolonged post-operative course. 25 years after resection, restaging scans revealed a pancreatic lesion at the surgical margin measuring 1.7x2.3x1.6cm. EUS-guided fine needle aspiration confirmed a well-differentiated, low-grade pancreatic neuroendocrine tumor (synaptophysin and chromogranin positive, CD56 positive, Ki-67 < 1%). After discussion in multidisciplinary tumor board, a consensus recommendation was made for EUS-guided RFA. On endosonographic examination, a 26 x 19 mm mass was observed in the pancreatic body with an adjacent 7.3 mm hypoechoic lesion. A 10mm ablation zone EUS RFA trocar (EUSRA, Starmed, Gyeonggi-do, South Korea) was utilized. After excluding intervening vessels using doppler ultrasound, the larger lesion was punctured under EUS guidance. Ablation was performed using 30 watts for approximately 20 seconds per ablation. Real time EUS imaging demonstrated a hyperechoic bubbling effect at the site of the ablation (figure 1). This was repeated throughout the lesion for a total of 8 ablation cycles. The 7.3 mm mass was ablated once with 30 Watts energy applied for 20 seconds. The patient received antibiotic prophylaxis with levofloxacin. The patient experienced mild discomfort following the ablation. He was observed overnight with no post procedural complications and was discharged the next day on a regular diet with no complaints.
Discussion: For patients who are not surgical candidates, radiofrequency ablation of well-differentiated, low-grade pancreatic neuroendocrine tumors in the setting of MEN1 appeared to be safe and well tolerated. Prior to ablation, EUS-RFA should be weighed alongside other therapeutic options such as resection, chemotherapy, and radiation in a multidisciplinary setting such an institutional tumor board.
Figure: Figure 1: Endosonographic images using a 7.5MHz linear echoendoscope demonstrating small neuroendocrine tumors in the pancreatic body pre-ablation (A and B). Post-ablation images (C and D) showing the radiofrequency trocar in the lesions with the characteristic hyperechoic bubbling appearance confirming the distribution of the ablation zone.
Ambreen Merchant indicated no relevant financial relationships.
Ahmed Messallam indicated no relevant financial relationships.
Maria Diab indicated no relevant financial relationships.
Shishir Maithel indicated no relevant financial relationships.
Pretesh Patel indicated no relevant financial relationships.
Vaishali Patel indicated no relevant financial relationships.
Saurabh Chawla indicated no relevant financial relationships.
Steven Keilin indicated no relevant financial relationships.
Field Willingham: Boston scientific – Grant/Research Support. Cancer Prevention Pharmaceuticals – Grant/Research Support. Cook medical – Grant/Research Support. PCI Biotech – Grant/Research Support. Steris – Grant/Research Support.
Ambreen A. Merchant, MBBS1, Ahmed Messallam, MD2, Maria Diab, MD2, Shishir Maithel, MD2, Pretesh Patel, MD2, Vaishali Patel, MD3, Saurabh Chawla, MD, FACG3, Steven Keilin, MD3, Field Willingham, MD, MPH3. P0042 - Radiofrequency Ablation of Recurrent Pancreatic Neuroendocrine Tumor in Multiple Neuroendocrine Neoplasia Type 1, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.