Endoscopic ultrasound-guided ethanol and radiofrequency ablation of pancreatic insulinomas: a systematic literature review

Abstract

Background: Insulinoma is the most common neuroendocrine neoplasm of the pancreas, characterised by hypoglycaemic symptoms. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) and ethanol ablation (EUS-EA) are novel methods for treating insulinoma. We aimed to perform a systematic review to assess the efficacy and safety of EUS-guided ablation techniques for pancreatic insulinomas. Methods: We systematically searched for articles detailing EUS-guided ablations of insulinomas. We performed a qualitative analysis and summarised data on the efficacy and safety of EUS-RFA and EUS-EA techniques. Results: In total, we identified 35 case reports and case series describing 75 patients with insulinomas treatment with EUS-guided ablation. Twenty-seven patients were treated with EUS-RFA, 47 patients with EUS-EA, and 1 patient received EUS-EA and EUS-RFA in the same session. In total, 84 insulinomas were ablated (EUS-RFA: 31, EUS-EA: 53). Most insulinomas were in the head of the pancreas (40%). The clinical success rate for EUS-guided ablation techniques was 98.5%. The median glucose level was 1.95 (Q1-Q3: 1.69–2.13) mmol/L before ablation compared to 6.20 (Q1-Q3: 5.30–7.05) mmol/L after treatment. The median insulin and C-peptide levels before and after RFA/EA were 230 (Q1–Q2: 120–257) pmol/L and 41 (Q1–Q2 35–42) pmol/L; 2077 (Q1–Q2 1644–2459) pmol/L and 819 (Q1–Q2 696–1072) pmol/L, respectively. There were eleven adverse events: seven abdominal pain, two mild acute pancreatitis, one necrotising acute pancreatitis and one local hematoma. All patients recovered, and there were no periprocedural deaths. Conclusions: EUS-guided ablation of insulinoma seems to be a safe and effective treatment and is an alternative to surgical resection in selected cases.

Endoscopic ultrasound-guided ethanol ablation versus surgical resection of insulinomas

“…Also, in our cohort one patient with reoperation died from surgical complications but would not have been eligible for ethanol treatment due to the proximity to the aorta and poor endosonographic image quality. In contrast, ethanol injection or other minimally invasive procedures to target insulinomas may harbor a much lower complication risk [25]. In this study, no patient in the ethanol group had a post-interventional complication higher than Clavien-Dindo I (if re-interventions are excluded).…”

“…Given the high effectiveness of ethanol injection in hypoglycemia resolution (even if multiple injections become necessary) and the less severe complications, ethanol injection appears to represent a valuable alternative in selected patients [25]. Even though two of nine patients had to be injected twice, both were free of symptoms after the second injection.…”

Aggressive versus indolent insulinomas: new clinicopathological insights

“…Solitary pancreatic insulinomas are usually treated by surgery with curative intention. In selected cases, endoscopic radiofrequency ablation or ethanol ablation results in symptom control with few side effects (Hofland et al 2019, El Sayed et al 2021. In case of metastatic insulinoma, the treatment options are in line with the guidelines for metastasized PanNETs, with a preference for debulking strategies such as metastasectomy, radiofrequency ablation, electroporation or embolization.…”

Management of small, asymptomatic, non-functioning pancreatic neuroendocrine tumours: follow-up, ablation, or surgery?

“…El Sayed et al reviewed outcomes for 75 patients with insulinoma, 47 of whom were treated with ethanol ablation, 27 with radiofrequency ablation, and one with both methods. The authors found that both methods were safe and effective, with an overall success rate of 98.5% [42]. Complications of concern, apart from mild self-limiting pancreatitis, were delayed ulceration of the duodenal wall with hematoma and stricture of the pancreatic duct, both of which were resolved endoscopically [43].…”