P-HPB-25: An emerging indication for endoscopic ultrasound: Case report of endoscopic ultrasound -guided ablation of a multifocal insulinoma

BACKGROUND: There is an increasing role for endoscopic ultrasound (EUS) in the treatment of pancreatic tumors. Here, we describe a case of a multifocal insulinoma treated with two ablation modalities. CASE REPORT: A 62-year-old gentleman was diagnosed with multiple endocrine neoplasia type I since 1993. A distal pancreatectomy was done previously for insulinoma. He was noted to have recurrent hypoglycemia since 2015, with a glucose level range of 2.3–3.0 mmol/L. A computed tomography of the pancreas showed two pancreatic nodules at the head (0.8 cm) and body (2 cm). A diagnosis of recurrent insulinoma was made. He was treated with diazoxide but only partially responded to therapy. As he was not keen for surgery, we proceeded to perform EUS-guided ablation therapy. The decision was made to ablate the body lesion with radiofrequency ablation (RFA) but the head lesion with ethanol as it was technically difficult to perform RFA for lesions in the head due to the stiffness of the RFA probe. 1.5 ml of absolute ethanol was injected into the 8 mm lesion at the head of pancreas using a 22-gauge Expect™ needle (Boston Scientific). An 18-gauge (1.7 mm tip diameter) RFA probe EUSRA™ using “continuous mode” of 50 watts, VIVA Combo™ RF System (TaeWoong Medical) was applied to a 2 cm lesion at the body of pancreas. There were no peri/post-operative complications. After 2 weeks postablation, there was marked improvement. He was no longer hypoglycemic with a fasting glucose level of 5.3 mmol/L. CONCLUSIONS: There appears to be a promising role for EUS-guided ablation of small pancreatic tumors. However, larger studies are needed to evaluate the long-term outcome of the procedure.