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Until recently, the only widely accepted options for managing mucinous pancreatic cysts were indefinite radiographic surveillance or invasive surgical resection, both with significant limitations.
Main duct intraductal papillary mucinous neoplasms (IPMNs) with high-risk features have been excluded from most ablation trials to date, and no reports of main-duct ablation can be found in a literature search.
A 67-year-old man with heart failure presented to our facility for assessment of a cystic mass lesion in the pancreas. EUS-FNA showed high-risk features, and cytopathology results were consistent with IPMN. Enhanced CT scan showed dilation of the main pancreatic duct as seen in Video 1 (available online at www.VideoGIE.org; and Fig. 1). The patient was considered a high-risk surgical candidate given his cardiovascular history. Because of the success and safety of alcohol-free EUS-guided chemoablation at our institution, this option was considered.
Figure 1Initial enhanced CT scan showed dilation of the main pancreatic duct (red arrows) in the body and tail, measuring 18 mm in diameter without clear solid mass or pathologic lymphadenopathy.
EUS showed that the IPMN was notable for a dilated main duct beginning in the mid-body and extending to the tail, with notable high-risk features of thick walls and mural nodules (Fig. 2). A 19-gauge FNA needle was introduced, and 10 mL of mucinous fluid was aspirated, whereupon the same amount of a gemcitabine-paclitaxel mixture was injected, filling the main duct to the original dimensions, shown in Video 1 (available online at www.VideoGIE.org). The patient tolerated the procedure well, except for mild pancreatitis that required inpatient observation before discharge. The patient was evaluated in the emergency department for an orthopedic trauma 2 months later. CT showed inflammatory changes in the body and tail of the pancreas, and the patient was given a course of oral antibiotics. A scheduled second ablation was performed at 3 months but only showed inflammatory changes that could not be aspirated.
Figure 2EUS shows that the intraductal papillary mucinous neoplasm extends from the mid-body to the tail; red arrows highlight marked dilation of over 1 cm with thick walls and several epithelial-type mural nodules present.
Follow-up CT scan 6 months after the initial chemoablation showed no radiographic evidence of the IPMN (Fig. 3). The patient has remained asymptomatic. Our long-term follow-up plan is repeat CT scans, basic laboratory workup, and tumor marker evaluation every 6 months for the first year. If signs of complete ablation remain stable, surveillance with CT scan and tumor markers will be done annually.
Figure 3Follow-up enhanced CT scan 6 months after initial chemoablation showed excellent results from the ablation. No radiographic evidence of the intraductal papillary mucinous neoplasm was visible.
Main-duct IPMN has been a contraindication to alcohol-based ablation because of the potential of causing severe pancreatitis. The advent of alcohol-free ablation has demonstrated significantly increased safety, and this case is an example of successful EUS-guided chemoablation of a main duct IPMN with multiple high-risk features. Although no broad conclusion should be drawn from one case, this does suggest that alcohol-free chemoablation of main-duct IPMN may be considered in highly selective cases in which surgical risks are prohibitive.
Disclosure
Dr Levenick is a consultant for ERBE. Dr Moyer is a consultant for Boston Scientific. All other authors disclosed no financial relationships. Dr Moyer's pancreatic chemoablation research is funded by the Dr. Anna F. Fakadej research fund as well as the NIH, neither of which were used in this case.
(Image 1) Enhanced CT scan showed dilation of the main pancreatic duct, as shown by the red arrows in the body and tail, measuring 18 mm in diameter without clear solid mass or pathologic lymphadenopathy. (Image 2) An FNA needle is introduced into the center of the cyst and the mucinous fluid is fully aspirated, leaving only a small rim of fluid around the needle tip to prevent duct epithelial injury. The chemoablation admixture is immediately infused, refilling the cyst to its original dimensions. For further details on the technical aspects and steps involved in EUS-guided chemoablation, see Moyer et al.
(Image 3) EUS highlights the markedly dilated duct, over 1 cm, beginning in the neck and extending to the tail, with thick walls and several epithelial-type mural nodules present. A 19-gauge needle is introduced into the center of the cyst, and 10 mL of mucinous fluid is aspirated using a standard syringe. Subsequently, 10 mL of the gemcitabine-paclitaxel mixture is injected, represented by the hyperechoic specks filling the duct to its original dimension. (Image 4) The main duct intraductal papillary mucinous neoplasm has an indistinct hazy appearance and could not be aspirated, which can be visualized here. (Image 5) Follow-up enhanced CT scan shows excellent results from the ablation, with resolution of the main pancreatic duct intraductal papillary mucinous neoplasm (IPMN). No radiographic evidence of the IPMN is visible on this CT.
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