Insulinoma with a challenging location and the use of EUS-guided radiofrequency ablation

Abstract Introduction Most insulinomas are benign, but can lead to severe hypoglycemia with alarming neuroglycopenic symptoms. Standard treatment is surgery, however post-operative complications such as fistulas can be demanding. Endoscopic ultrasound (EUS)-guided radiofrequency ablation (RFA) of pancreatic lesions is a novel treatment usually with mild sideeffects. Method - Result A 14 year old girl suffered from seizures and at the emergency ward hypoglycemia was discovered. During her hospital stay recurrent episodes of hypoglycemia together with hyperinsulinemia occurred, indicating an insulinoma. Diazoxide treatment was started. A 68Ga-DOTATOC-PET with CT revealed a 15 mm tumor with a challenging location in the pancreatic neck. An EUS with biopsy verified the diagnosis pancreatic neuroendocine tumor with a low proliferation rate. The case was discussed in a multidisciplinary therapy conference and the only surgical procedure considered possible was a pancreaticoduodenectomy. At our endoscopy unit we are setting up EUS-guided RFA treatment of pancreatic lesions and this lesion was considered suitable for RFA treatment, in order to avoid Whipple´s procedure. Standard therapeutic echoendoscope with a 4.0 mm working channel was used and RFA with EUS-guidance was performed by a 19-gauge, 5 mm probe with 50W setting. Postoperatively the girl had a mild hyperglycemia and abdominal pain. She was discharged on the following day. Blood glucose levels remained normal, and a follow-up CT showed a good treatment response. Discussion This case report shows that EUS-guided RFA can be a useful alternative to surgery in the treatment of insulinomas. To our knowledge, this is the first reported EUS-guided RFA of an insulinoma in Sweden.