Endoscopic ultrasound-guided fine needle injection of alcohol for ablation of an insulinoma: a well documented successful procedure
11 January 2019 (online)
A 21-year-old woman presented with recurrent hypoglycemia, syncope, and episodic seizures, associated with rapid weight gain (body mass index [BMI] 60). Hyperinsulinemia was confirmed and she was started on treatment with diazoxide. Magnetic resonance imaging showed a 1.5-cm nodule at the pancreatic head. Endoscopic ultrasound (EUS) confirmed a 1.5-cm hyperechoic nodule within the pancreatic head, between the common bile duct and the main pancreatic duct. EUS-guided fine needle aspiration (EUS-FNA) was performed with a 22-gauge needle (Echo-Tip; Cook Medical, Limerick, Ireland) ([Fig. 1]) and the definitive diagnosis of an insulinoma was established by immunohistochemical analysis ([Fig. 2]).
Surgical treatment (Whipple’s procedure) was contraindicated because of the patient’s high BMI. Therefore, EUS-guided fine needle injection (EUS-FNI) was suggested to ablate the lesion. The patient was hospitalized for prior hyper-hydration. EUS-FNI was performed with 99 % ethanol (1.5 mL) using a 22-gauge needle (Echo-Tip), with the patient under general anesthesia. After 60 seconds, ultrasound monitoring showed the typical image of a hyperechogenic shadow forming from within the lesion. No portal vein thrombosis was detected on EUS after the alcohol injection ([Video 1]) and there was no evidence of acute pancreatitis after 2 days of in-hospital observation. At follow-up 2 weeks after discharge, the patient’s serum glucose had returned to normal levels, she had lost 4 kg and the diazoxide dose was reduced.
Video 1 Endoscopic ultrasound-guided fine needle injection (EUS-FNI) of 99 % ethanol into an insulinoma.
Pancreatic neuroendocrine tumors (pNETs) account for 1 % – 2 % of all pancreatic tumors. PNETs are classified as either functional or nonfunctional, the latter being more common (up to 85 %). Among functional pNETs, insulinomas are the most common  . EUS is a useful diagnostic tool, showing a sensitivity of up to 85 % . Insulinoma resection was first reported in 1929 and remains the treatment of choice . Nevertheless, EUS-FNI of ethanol into an insulinoma has been described as an efficient and safe technique for hypoglycemia resolution, and is indicated for patients with a prohibitive surgical risk .
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