S4173 Endoscopic Ultrasound-Guided Radiofrequency Ablation for a Pancreatic Cystic Neoplasm in a Non-Surgical Candidate

Introduction: Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has emerged as minimally invasive therapy for selected neoplastic pancreatic lesions. While surgery remains standard for high-risk pancreatic cystic neoplasms (PCNs), operative morbidity can be prohibitive in older or comorbid patients. EUS-RFA induces localized necrosis using thermal energy and has shown promise with a favorable safety profile in small studies. Case Description/Methods: We present a 79-year-old woman with a 3-cm multiloculated pancreatic neck cyst, consistent with intraductal papillary mucinous neoplasm (IPMN). She had significant comorbidities—including morbid obesity, diabetes, prior breast cancer—and a family history of pancreatic cancer. Multidisciplinary consensus supported EUS-RFA given surgical ineligibility. EUS revealed a 31 × 18-mm cyst communicating with the main duct. A 19-gauge needle was used to aspirate approx. Eighty percent of the cyst’s viscous contents for analysis. A 19-gauge, 10-mm-tip RFA needle was then advanced into the decompressed cystic lesion. Ablation was performed at 50W in 7 cycles (6-24s) until hyperechoic bubbles appeared, indicating effective thermal necrosis and tissue vaporization. Gradual RFA redirection from the distal to the proximal portion ensured complete lesion coverage. The patient was discharged the next day without adverse events. Fluid CEA was 78 ng/mL, cytology was benign, and no KRAS or GNAS mutations were detected. Magnetic resonance imaging at 3 months showed complete resolution, confirmed on repeat EUS. Discussion: Mucinous PCNs, particularly IPMNs, carry a risk of malignant transformation but are often challenging to manage in nonoperative candidates. EUS-RFA is a minimally invasive alternative with reported complete or partial cyst resolution in several smaller studies and a 3.5–10% complication rate (primarily pancreatitis, infection, perforation). Prophylactic nonsteroidal anti-inflammatory drugs, antibiotics, and cyst decompression prior ablation reduce these risks. This case underscores EUS-RFA’s therapeutic potential in non-surgical patients with PCNs. Long-term data suggest sustained cyst shrinkage, possibly due to both thermal and immunologic effects. Further studies and randomized trials are needed to refine protocols and compare EUS-RFA with endoscopic alternatives (e.g., chemoablation). Watch the video: https://tinyurl.com/25ACGS4173