Treatment of a pancreatic endocrine tumor by ethanol injection (PEI) guided by endoscopic ultrasound.

with double endocrine neoplasia type 1. Echoendoscopy (EUS) revealed two nodular hypoechoic lesions (l" Fig. 1), with a color Doppler hypervascular pat− tern located in the pancreas. We carried out an EUS−guided fine−needle aspiration (FNA) biopsy [1] (l" Fig. 2), which showed a neuroendocrine islet tumor in the pathology report 2 weeks later. Tumor sizes were 11 and 7 mm respectively. Because the patient refused surgical ther− apy, we performed an ethanol injection under EUS guidance into the nodule. Ethanol concentration was 40 % [2] and its amount did not exeed 2 ml. At the same time celiac plexus neurolysis was carried out to control abdominal pain. Clinical, biochemical, and transabdomin− al ultrasonography controls after the EUS−guided injection session and antibio− tic treatment were well tolerated, with− out adverse effects. The patient was dis− charged from hospital 5 days later. After the first injection, the patient un− derwent a second session following the same procedure. Unfortunately, during needle retraction, there was minimal ethanol effusion that caused a small pan− creatic necrotic lesion, which was treated with laparoscopic necrosectomy. Two months later, we performed an Oc− treoscan and serum tests of vasoactive intestinal peptide (VIP) and chromogra− nin A (CgA), which were normal. EUS with contrast enhanced detected areas of fibrosis [3]. At present, after a follow−up period of 18 months, the patient is asymptomatic, without recurrent dis− ease; abdominal nuclear magnetic reso− nance is negative. EUS is particularly useful in the assess− ment of small pancreatic tumors missed by other imaging techniques [3± 5]. EUS− FNA [1] is a gold standard in the manage− ment of pancreatic tumors. Unusually, we have explored a new field of EUS that per− mits injection of drugs directly into the tumor. In our experience, if surgical ther− apy is refused by the patient or contra− indicated because of poor general health conditions, EUS−guided injection is a safe and effective treatment in endocrine le− sions, which can eliminate hormonal al− terations. It has been demonstrated that ethanol in− jection is a safe technique for the treat− ment of hepatic and thyroid lesions [6]. In our case we have used the same tech− nique to treat pancreatic lesions, thus avoiding surgery, which has high morbid− ity and mortality; the duration of hospi− talization was also reduced. A multicen− ter study is necessary to establish a standardized procedure for EUS−ethanol injection in neuroendocrine pancreatic tumors.