Endocrine Abstracts

BackgroundIntroduction: Pancreatic neuroendocrine tumors (PNETs) are common pancreatic tumors with unclear molecular origins. Diagnosis involves testing and imaging, while a less favorable prognosis is associated with higher grade, metastasis, or larger size. Treatment at academic centers follows a 4-pronged approach: surgery, locoregional therapy, systemic therapy, and complication control. We present you a case of PNETs who underwent stenting for multiple episodes with RFA to the reduce the frequency of complication.

Case Report: A seventy-six-year-old white male was diagnosed with stage Ib well differentiated pancreatic neuroendocrine tumor WHO grade 2 in 2016 which was locally advanced. His Ki67 index was 17%. He was initially treated with 3 different chemotherapeutic regimens which includes Everolimus, Sinutinib and capecitabine+ temozolomide without significant response. He also received radiation to primary site. Afterwards, he was initiated on monthly lanreotide. He had undergone multiple ERCPs at another hospital but was not able to achieve biliary patency and was transferred to Thomas Hospital in Fairhope, AL. He presented in 2019 with ascending cholangitis with metastasis at the hepatic duct bifurcation in a Bismuth Type III anatomy.

Methods: Procedure: He underwent ERCP with stent removal X 2. Stone and pus were extracted, and a covered self-expanding metal stent was placed. Since his initial ERCP, he had been treated with RFA primarily on a three-month basis. Typically, procedures begin with sweeping the tract clear of stones and debris which allows for a clearer cholangiogram and ensures the RFA energy treats the malignant tissue vice the debris. Priority for treatment is based on identifying the stricture that if treated allows for recruitment of the most liver. Cholangioscopy is usually required to place a wire across the stricture. Treatment is accomplished using 7 watts above the bifurcation. This setting is continued as the catheter is withdrawn in a stepwise fashion after each 90-second treatment and a 30-second pause. Once the proximal electrode is entirely within the common hepatic duct, the power is increased to 10 watts. After the entire stricture has been treated, the RFA catheter is removed, and a 9-12 mm extraction balloon is placed above the area treated. Again, three complete sweeps are completed. In addition to the ERCPs, the patient also required a single stent to be placed by PTC to maintain liver segments 2 & 3 because it was not possible to pass a wire through the stricture at ERCP. His most recent configuration of stents is indicated in the picture below. This has required a total of 32 ERCP and as his cancer has progressed, they have become more frequent. His last procedure was last week and both the right and left hepatic ducts to the level of tertiary ducts were treated with good results.

Post-procedure: Reported adverse events included nausea post-procedure that resolved spontaneously. On two occasions he was hospitalized for supportive care to treat cholangitis. None of those events required the ICU. His overall survival since diagnosis is 7 years.

Results: After undergoing ERCP with stent removal and subsequent treatment with radiofrequency ablation (RFA) primarily on a three-month basis, the patient has shown good results. The RFA procedures, coupled with stent placements, have required a total of 32 ERCPs, and despite some reported adverse events and hospitalizations for supportive care, the patient’s overall survival since diagnosis is 7 years.

Conclusions: This case with a well-differentiated pancreatic neuroendocrine tumor WHO grade 2 showcases the challenges and complexities of managing such cases. Despite the multiple treatments and procedures, including stenting and radiofrequency ablation (RFA), the patient experienced some adverse events. However, the fact that the patient has shown an overall survival of 7 years since diagnosis highlights the resilience and ongoing efforts of the medical team in managing the condition.

ABSTRACT ID28255