Successful EUS-guided ethanol ablation of insulinoma, four-year follow-up. Case report and literature review
Abstract
Introduction: EUS-guided ethanol ablation of insulinoma is a new method of treatment of this neuroendocrine tumour. Ablation is recommended in patients who are poor surgical candidates or refuse surgery. We present a case of an 81-year-old female with symptomatic insulinoma, treated successfully with EUS-guided alcoholic ablation, along with a literature review including 28 other previously described cases. The effectiveness, safety of the therapy, and technical procedure-related issues are summarised. To the best of our knowledge, this is the first described case of successful insulinoma EUS-guided ablation in Poland.
Material and methods: We searched the PubMed/Medline database to identify cases of EUS-guided alcoholic ablation. Our analysis included 14 articles (case reports or case series), with a total of 27 patients and 31 tumours described, published before February 2017.
Results: The described tumours were relatively small (mean 13 mm), and the most common location was pancreatic head. The mean ethanol volume injected to the tumour was 1.8 ml and the concentration of infused alcohol varied from 95% to 98%.Side effects were observed in six cases; apart from one, they were mild and self-limiting. There was only one severe adverse event, treated conservatively with success. The median follow-up was 14.4 months (2–55 months). In all described cases ablation led to improvement of the symptoms and normalisation of glycaemia.
Conclusions: The EUS-guided alcoholic ablation of insulinoma is a safe and effective method of treatment in patients who are poor surgical candidates and/or refuse surgery. The adverse effects are rare and mild and were observed when the volume of injected ethanol was equal to or above 3.0 ml. However, the data is limited, the follow-up is relatively short, and prospective studies are needed to confirm the long-term effects of treatment. The study shows also that there are important procedural differences (concentration and volume of alcohol, needle gauge, number of sessions) between the endoscopists, which should be specified.
Keywords: insulinomaalcoholic ablationEUS
References
- Kos-Kudła B, Rosiek V, Borowska M. Pancreatic neuroendocrine neoplasms — management guidelines (recommended by the Polish Network of Neuroendocrine Tumours). Endokrynol Pol. 2017; 68(2): 169–198.
- Gill GV, Rauf O, MacFarlane IA. Diazoxide treatment for insulinoma: a national UK survey. Postgrad Med J. 1997; 73(864): 640–641.
- Falconi M, Eriksson B, Kaltsas G, et al. Vienna Consensus Conference participants. ENETS Consensus Guidelines Update for the Management of Patients with Functional Pancreatic Neuroendocrine Tumors and Non-Functional Pancreatic Neuroendocrine Tumors. Neuroendocrinology. 2016; 103(2): 153–171.
- Jawiarczyk A, Bolanowski M, Syrycka J, et al. Effective therapy of insulinoma by using long-acting somatostatin analogue. A case report and literature review. Exp Clin Endocrinol Diabetes. 2012; 120(2): 68–72.
- Bernard V, Lombard-Bohas C, Taquet MC, et al. French Group of Endocrine Tumors. Efficacy of everolimus in patients with metastatic insulinoma and refractory hypoglycemia. Eur J Endocrinol. 2013; 168(5): 665–674.
- Chen J, Wang C, Han J, et al. Therapeutic effect of sunitinib malate and its influence on blood glucose concentrations in a patient with metastatic insulinoma. Expert Rev Anticancer Ther. 2013; 13(6): 737–743.
- van Schaik E, van Vliet EI, Feelders RA, et al. Improved control of severe hypoglycemia in patients with malignant insulinomas by peptide receptor radionuclide therapy. J Clin Endocrinol Metab. 2011; 96(11): 3381–3389.
- Maiza JC, Vezzosi D, Grunenwald S, et al. Treatment with somatostatin analogs and chemoembolization of liver metastases for severe hypoglycemia in malignant insulinomas. J Endocrinol Invest. 2011; 34(9): e253–e258.
- de Herder WW, van Schaik E, Kwekkeboom D, et al. New therapeutic options for metastatic malignant insulinomas. Clin Endocrinol (Oxf). 2011; 75(3): 277–284.
- Łabuzek K, Duda K, Cholewa H, et al. [The newest perspectives on diagnostic methods and treatment of insulinoma]. Wiad Lek. 2014; 67(2 Pt 1): 85–92.
- Waung JA, Todd JF, Keane MG, et al. Successful management of a sporadic pancreatic insulinoma by endoscopic ultrasound-guided radiofrequency ablation. Endoscopy. 2016; 48 Suppl 1: E144–E145.
- Toaiari M, Davì MV, Dalle Carbonare L, et al. Presentation, diagnostic features and glucose handling in a monocentric series of insulinomas. J Endocrinol Invest. 2013; 36(9): 753–758.
- Jilesen APJ, van Eijck CHJ, Busch ORC, et al. Postoperative Outcomes of Enucleation and Standard Resections in Patients with a Pancreatic Neuroendocrine Tumor. World J Surg. 2016; 40(3): 715–728.
- Chua TC, Yang TX, Gill AJ, et al. Systematic Review and Meta-Analysis of Enucleation Versus Standardized Resection for Small Pancreatic Lesions. Ann Surg Oncol. 2016; 23(2): 592–599.
- Ito T, Lee L, Jensen RT. Treatment of symptomatic neuroendocrine tumor syndromes: recent advances and controversies. Expert Opin Pharmacother. 2016; 17(16): 2191–2205.
- Scott A, Hinwood D, Donnelly R. Radio-frequency ablation for symptom control in a patient with metastatic pancreatic insulinoma. Clin Endocrinol (Oxf). 2002; 56(4): 557–559.
- Jürgensen C, Schuppan D, Neser F, et al. EUS-guided alcohol ablation of an insulinoma. Gastrointest Endosc. 2006; 63(7): 1059–1062.
- Bor R, Farkas K, Bálint A, et al. [Endoscopic ultrasound-guided ethanol ablation: an alternative option for the treatment of pancreatic insulinoma]. Orv Hetil. 2014; 155(41): 1647–1651.
- Deprez PH, Claessens A, Borbath I, et al. Successful endoscopic ultrasound-guided ethanol ablation of a sporadic insulinoma. Acta Gastroenterol Belg. 2008; 71(3): 333–337.
- Lee MJ, Jung CH, Jang JE, et al. Successful endoscopic ultrasound-guided ethanol ablation of multiple insulinomas accompanied with multiple endocrine neoplasia type 1. Intern Med J. 2013; 43(8): 948–950.
- Levy MJ, Thompson GB, Topazian MD, et al. US-guided ethanol ablation of insulinomas: a new treatment option. Gastrointest Endosc. 2012; 75(1): 200–206.
- Qin Sy, Lu Xp, Jiang Hx. EUS-guided ethanol ablation of insulinomas: case series and literature review. Medicine (Baltimore). 2014; 93(14): e85.
- Bor R, Farkas K, Bálint A et al. Endoscopic ultrasound-guided fine needle injection: alternative option for the treatment of pancreatic insulinoma. Case report. http://dxdoiorg/101556/OH201430012.
- Schnack C, Hansen CØ, Beck-Nielsen H, et al. [Treatment of insulinomas with alcoholic ablation]. Ugeskr Laeger. 2012; 174(8): 501–502.
- Trikudanathan G, Mallery SJ, Amateau SK. Successful Endoscopic Ultrasound-Guided Alcohol Ablation of Sporadic Insulinoma Using Three-Dimensional Targeting (with Video). Clin Endosc. 2016; 49(4): 399–401.
- Vleggaar FP, Bij de Vaate EA, Valk GD, et al. Endoscopic ultrasound-guided ethanol ablation of a symptomatic sporadic insulinoma. Endoscopy. 2011; 43 Suppl 2 UCTN: E328–E329.
- Yang D, Inabnet WB, Sarpel U, et al. EUS-guided ethanol ablation of symptomatic pancreatic insulinomas. Gastrointest Endosc. 2015; 82(6): 1127.
- Paik WH, Seo DW, Dhir V, et al. Safety and Efficacy of EUS-Guided Ethanol Ablation for Treating Small Solid Pancreatic Neoplasm. Medicine (Baltimore). 2016; 95(4): e2538.
- Matsumoto K, Kato H, Tsutsumi K, et al. Efficacy and Safety of Endoscopic Ultrasound-guided Ethanol Ablation Therapy for Pancreatic Neuroendocrine Tumors. Acta Med Okayama. 2016; 70(4): 313–316.
- Pai M, Habib N, Senturk H, et al. Endoscopic ultrasound guided radiofrequency ablation, for pancreatic cystic neoplasms and neuroendocrine tumors. World J Gastrointest Surg. 2015; 7(4): 52–59.
- Armellini E, Crinò SF, Ballarè M, et al. Endoscopic ultrasound-guided ethanol ablation of pancreatic neuroendocrine tumours: A case study and literature review. World J Gastrointest Endosc. 2016; 8(3): 192–197.
- Zhang WY, Li ZS, Jin ZD. Endoscopic ultrasound-guided ethanol ablation therapy for tumors. World J Gastroenterol. 2013; 19(22): 3397–3403.
- Muscatiello N, Salcuni A, Macarini L, et al. Treatment of a pancreatic endocrine tumor by ethanol injection (PEI) guided by endoscopic ultrasound. Endoscopy. 2008; 40 Suppl 2: E83–E259.
- Mathers BW, Harvey HA, Dye CE, et al. Endoscopic ultrasound-guided ethanol ablation of a large metastatic carcinoid tumor: success with a note of caution. Endosc Int Open. 2014; 2(4): E256–E258.
- Lakhtakia S. Complications of diagnostic and therapeutic Endoscopic Ultrasound. Best Pract Res Clin Gastroenterol. 2016; 30(5): 807–823.
- Burghardt K, Kaemmerer D, Michael A, et al. Successful endoscopic ultrasound-guided ethanol ablation of a symptomatic sporadic insulinoma in a patient with severe comorbidities not suitable for pancreatic surgery. Diabetes Metab. 2017 [Epub ahead of print].
- Luo Y, Li Ji, Yang A, et al. 68Ga-Exendin-4 PET/CT in Evaluation of Endoscopic Ultrasound-Guided Ethanol Ablation of an Insulinoma. Clin Nucl Med. 2017; 42(4): 310–311.
- Park DoH, Choi JH, Oh D, et al. Endoscopic ultrasonography-guided ethanol ablation for small pancreatic neuroendocrine tumors: results of a pilot study. Clin Endosc. 2015; 48(2): 158–164.