Aims Insulinomas, although rare, are amongst the most common functional pancreatic neuroendocrine
neoplasms (pNEN) causing debilitating and recurrent hypoglycemic episodes and severely
affecting quality of life. The vast majority of insulinomas are benign and below 2
cm at the time of diagnosis. Traditionally, surgery is offered as curative treatment,
but the morbidity related to the surgical procedure is substantial and the convalescence
period is long. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) is
a novel and minimally invasive approach offering symptom relief even for patients
who are not surgical candidates. Here, we present our first experience with this procedure.
Methods We prospectively included patients with clinical suspicion of insulinomas (based
on positive fasting test and/or imaging) with debilitating hypoglycemic episodes.
Lesions considered for RFA treatment were biopsy proven G1 or G2 pNEN less than 25
mm in size and with no signs of extrapancreatic disease. The procedures were performed
in general anesthesia using either 5 mm or 10 mm tip EUSRA™ RFA electrode (Taewoong
Medical, South Corea) at 50W power setting. Effects of the treatment were examined
by echocontrast examination, and any adverse events were recorded and graded according
to the AGREE classification [1]. The patients were admitted for 24-hour observation and discharged to follow-up
in outpatient clinic. Clinical success was defined as symptom improvement with documented
increase in blood sugar levels and was measured at 30 days and one year. In case of
incomplete response, patients were eligible for a second treatment.
Results Between 2022 and 2024, 14 patients with insulinomas underwent EUS-RFA. Mean age was
60 years (range 31–79) and 50% (n=7) were female. The majority of the lesions were
located in the body of the pancreas (n=7), and the average lesion size was 15.4 mm
(range 9.0–23.0 mm). The median number of RFA applications during a single RFA procedure
was 4 (IQR 3.25–6.5). No adverse events were observed during the procedure and all
patients were discharged after uneventful hospitalization. One patient (7.1%) presented
with acute necrotizing pancreatitis (grade IIIb adverse event) 13 days after the procedure
and underwent EUS-guided drainage of peripancreatic collections. Clinical success
was very high 92.9% (n=13/14) at 30 days and 85.7% (n=6/7) one year following the
procedure. Three patients (21.4%) required a second EUS-RFA treatment, with complete
symptom withdrawal in two and persistent hypoglycemia in one patient.
Conclusions EUS-RFA is a new and effective minimally invasive treatment option for symptomatic
pancreatic neuroendocrine neoplasms. The procedure seems to have a superior safety
profile compared to conventional surgery, but long-term efficacy of EUS-RFA is yet
to be evaluated.
