Endoscopic ultrasonography-guided photodynamic therapy for recurrent intraductal papillary mucinous neoplasm of the pancreas

Recurrence rates after partial pancreatectomy in patients with a noninvasive intraductal papillary mucinous neoplasm (IPMN) of the pancreas are reported as being 5.4 % to 10.7 % [1] [2] [3]. A recent case demonstrated the possibility of using photodynamic therapy (PDT) as an alternative therapeutic option for IPMN [4]. Herein, we present a patient who was treated with endoscopic ultrasonography (EUS)-guided PDT, which was used as an alternative, minimally invasive option for recurrent IPMN of the pancreas.

A 50-year-old man was admitted with recurrent pancreatitis. He had a history of distal pancreatectomy for combined-type IPMN 2 years previously, and the resection margins had been positive. A computed tomography (CT) scan revealed swelling of the remnant pancreas with a 13-mm hypodense lesion and prominent main pancreatic duct (MPD) dilatation. EUS-guided needle biopsy of a 5-mm nodular lesion in the MPD and a 15-mm hypoechoic mass in the stump demonstrated recurrent IPMN with low grade dysplasia ([Fig. 1]). The patient refused to undergo total pancreatectomy, so we decided to perform EUS-guided PDT ([Video 1]) [5].

Fig. 1 Endoscopic ultrasonography (EUS) image showing: a a 5-mm nodular lesion in the main pancreatic duct; b a 15-mm hypoechoic mass in the stump.

Video 1 Endoscopic ultrasonography-guided photodynamic therapy for recurrent noninvasive intraductal papillary mucinous neoplasm (IPMN) of the pancreas following a previous distal pancreatectomy.

Photolon (a chlorin e6 derivative; Belmedpreparaty, Belarus) was administered at a dose of 2.5 mg/kg, 3 hours before the procedure. The flexible laser-light probe (a quartz core and polymer cladding; PhotoGlow Inc., Yarmouth, Massachusetts, USA) was preloaded inside a 19 G EUS fine needle aspiration (FNA) needle (Cook Endoscopy, Winston-Salem, North Carolina, USA) and was inserted into the recurrent tumor. The tumor was then illuminated with a wavelength of 660 nm ([Fig. 2 a]). The energy dose was 100 J/cm of the diffuser length; the power of irradiation was 400 mW/cm of the diffuser length in each procedure. The total irradiation time in each needle pass was 250 seconds.

Fig. 2 Endoscopic ultrasonography (EUS) images showing: a a hyperechoic cloud in the area surrounding the laser diffuser tip during EUS-guided photodynamic therapy (PDT); b no evidence of tumor recurrence 2 years after the PDT.

At follow-up EUS 2 years after the PDT, there was no evidence of recurrence ([Fig. 2 b]). EUS-guided biopsy at the pancreas stump showed only acinar cells and interstitial fibrosis. The patient experienced no further episodes of pancreatitis during the follow-up period.

This study was approved by the Institutional Review Board of Asan Medical Center (IRB number: 2015-0111).

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• References

• 1 Kang MJ, Jang JY, Lee KB. et al. Long-term prospective cohort study of patients undergoing pancreatectomy for intraductal papillary mucinous neoplasm of the pancreas: implications for postoperative surveillance. Ann Surg 2014; 260: 356-363
• 2 Passot G, Lebeau R, Hervieu V. et al. Recurrences after surgical resection of intraductal papillary mucinous neoplasm of the pancreas: a single-center study of recurrence predictive factors. Pancreas 2012; 41: 137-141
• 3 Schnelldorfer T, Sarr MG, Nagorney DM. et al. Experience with 208 resections for intraductal papillary mucinous neoplasm of the pancreas. Arch Surg 2008; 143: 639-646 discussion 646
• 4 Topazian M, Zhong N, Baron TH. et al. Photodynamic therapy of intraductal papillary mucinous neoplasm. Endoscopy 2012; 44: 213-215
• 5 Choi JH, Oh D, Lee JH. et al. Initial human experience of endoscopic ultrasound-guided photodynamic therapy with a novel photosensitizer and a flexible laser-light catheter. Endoscopy 2015; 47: 1035-1038