Endoscopy 2014; 46(S 01): E380-E381
DOI: 10.1055/s-0034-1377376
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic ultrasound-guided Nd:YAG laser ablation of recurrent pancreatic neuroendocrine tumor: a promising revolution?

Francesco Di Matteo
1   Digestive Endoscopy Unit, Campus Bio-Medico University of Rome, Rome, Italy
,
Francesca Picconi
1   Digestive Endoscopy Unit, Campus Bio-Medico University of Rome, Rome, Italy
,
Margareth Martino
1   Digestive Endoscopy Unit, Campus Bio-Medico University of Rome, Rome, Italy
,
Monica Pandolfi
1   Digestive Endoscopy Unit, Campus Bio-Medico University of Rome, Rome, Italy
,
Claudio Maurizio Pacella
2   Radiology Unit, Regina Apostolorum Hospital, Albano, Rome, Italy
,
Emiliano Schena
3   Unit of Measurements and Biomedical Instrumentation, Center for Integrated Research, Campus Bio-Medico University of Rome, Rome, Italy
,
Guido Costamagna
4   Surgical Endoscopy Unit, Sacred Heart Catholic University of Rome, Rome, Italy
› Author Affiliations
Further Information

Corresponding author

Francesco Maria Di Matteo, MD
Digestive Endoscopy Unit
Campus Bio-Medico University of Rome
Via Alvaro del Portillo 200
00128 Rome
Italy   
Fax: +39-06-225411658   

Publication History

Publication Date:
25 September 2014 (online)

 

Endoscopic ultrasound (EUS) has developed from a diagnostic tool into a therapeutic one [1]. A 46-year-old woman was diagnosed with recurrent pancreatic neuroendocrine tumor (PNET) by positive 68Ga-[1, 4, 7, 10-tetraazacyclododecane-1, 4, 7, 10-tetraacetic acid]-1-NaI3-octreotide (68Ga-DOTA-NOC) positron emission tomography (PET) ([Fig. 1 a]). Two years earlier she had undergone curative distal pancreatectomy for previous PNET in the setting of multiple endocrine neoplasia type I. At computed tomography (CT) scan, the lesion appeared as a 9-mm nodular area with early contrast enhancement on the pancreatic residual body ([Fig. 2 a]).

Zoom Image
Fig. 1 Pre-treatment 68Ga-DOTA-NOC positron emission tomography (PET) revealed a lesion in the residual pancreatic body with metabolic activity (arrow). 68Ga-DOTANOC PET 1 year after laser ablation (on the right), showed no metabolic activity in the pancreatic region.
Zoom Image
Fig. 2 Computed tomography scan. a Recurrent pancreatic neuroendocrine tumor appeared as a 9-mm nodular area with early contrast enhancement on the pancreatic residual body. b At the same site after treatment, a 35-mm coagulative necrotic area was seen with the onset of a small fluid collection in the omental bursa.

The patient refused total pancreatectomy. Laser ablation under EUS guidance was therefore performed using a neodymium-doped yttrium aluminum garnet (Nd:YAG) laser, at 4.0 W for 300 seconds ([Fig. 3]). No complications occurred during the procedure. At CT immediately after laser ablation, the ablated lesion appeared as a well-defined 35-mm coagulative necrotics area ([Fig. 2 b]). Neither perilesional parenchymal alteration nor vascular damages were observed. The 2-month follow-up CT scan showed the ablated area to be 18 mm ([Fig. 4 a]); at 1 year the area was 9 mm ([Fig. 4 b]), with no metabolic activity on 68Ga-DOTA-NOC PET ([Fig. 1 b]).

Zoom Image
Fig. 3 Endoscopic ultrasound-guided laser ablation. a A hyperechoic line identified the laser fiber protruding from the tip of the needle. b During laser ablation, a slowly enlarging and coalescing hyperechoic zone appeared around the distal tip of the laser fiber. c After laser ablation, the entire treated area was occupied by an irregular and poorly defined echogenic zone.
Zoom Image
Fig. 4 Follow-up computed tomography scans. a At 2 months after laser ablation, the ablated area was further reduced (18 mm vs. 35 mm). b At 1 year after laser ablation, a 9-mm area of coagulative necrosis remained.

Laser ablation is a minimally invasive method for destroying tumors within solid organs, and works by directing low-power laser light energy into the tissue. It has been used for primary and secondary liver tumors [2] [3] [4]. The potential advantage of laser ablation over other laser-induced thermotherapies is the short application time and the well-defined ablation area. Moreover, the use of thinner laser fibers enables insertion into standard EUS-needles and their potential application in deep abdominal organs, such as the pancreas, which are untreatable using the percutaneous approach. To date, our group has demonstrated the efficacy and safety of laser ablation with Nd:YAG in an in vivo animal model [5]. The current case is the first time we have applied this minimally invasive laser treatment to the human pancreas.

These results must be further assessed in additional patients affected by PNETS who are not suitable for conventional treatments.

Endoscopy_UCTN_Code_TTT_1AS_2AD


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Competing interests: None

  • References

  • 1 Carrara S, Petrone MC, Testoni PA et al. Tumors and new endoscopic ultrasound-guided therapies. World J Gastrointest Endosc 2013; 5: 141-147
  • 2 Pacella CM, Bizarri G, Francica G et al. Analysis of factors predicting survival in patients with hepatocellular carcinoma treated with percutaneous laser ablation. J Hepatol 2006; 44: 902-909
  • 3 Francica G, Petrolati A, Di Stasio E et al. Effectiveness, safety, and local progression after percutaneous laser ablation for hepatocellular carcinoma nodules up to 4 cm are not affected by tumor location. AJR Am J Roentgenol 2012; 199: 1393-1401
  • 4 Vogl TJ, Freier V, Nour-Eldin NE et al. Magnetic resonance-guided laser-induced interstitial thermotherapy of breast cancer liver metastases and other noncolorectal cancer liver metastases: an analysis of prognostic factors for long-term survival and progression-free survival. Invest Radiol 2013; 48: 406-412
  • 5 Di Matteo F, Martino M, Rea R et al. EUS-guided Nd:YAG laser ablation of normal pancreatic tissue: a pilot study in a pig model. Gastrointest Endosc 2010; 72: 358-363

Corresponding author

Francesco Maria Di Matteo, MD
Digestive Endoscopy Unit
Campus Bio-Medico University of Rome
Via Alvaro del Portillo 200
00128 Rome
Italy   
Fax: +39-06-225411658   

  • References

  • 1 Carrara S, Petrone MC, Testoni PA et al. Tumors and new endoscopic ultrasound-guided therapies. World J Gastrointest Endosc 2013; 5: 141-147
  • 2 Pacella CM, Bizarri G, Francica G et al. Analysis of factors predicting survival in patients with hepatocellular carcinoma treated with percutaneous laser ablation. J Hepatol 2006; 44: 902-909
  • 3 Francica G, Petrolati A, Di Stasio E et al. Effectiveness, safety, and local progression after percutaneous laser ablation for hepatocellular carcinoma nodules up to 4 cm are not affected by tumor location. AJR Am J Roentgenol 2012; 199: 1393-1401
  • 4 Vogl TJ, Freier V, Nour-Eldin NE et al. Magnetic resonance-guided laser-induced interstitial thermotherapy of breast cancer liver metastases and other noncolorectal cancer liver metastases: an analysis of prognostic factors for long-term survival and progression-free survival. Invest Radiol 2013; 48: 406-412
  • 5 Di Matteo F, Martino M, Rea R et al. EUS-guided Nd:YAG laser ablation of normal pancreatic tissue: a pilot study in a pig model. Gastrointest Endosc 2010; 72: 358-363

Zoom Image
Fig. 1 Pre-treatment 68Ga-DOTA-NOC positron emission tomography (PET) revealed a lesion in the residual pancreatic body with metabolic activity (arrow). 68Ga-DOTANOC PET 1 year after laser ablation (on the right), showed no metabolic activity in the pancreatic region.
Zoom Image
Fig. 2 Computed tomography scan. a Recurrent pancreatic neuroendocrine tumor appeared as a 9-mm nodular area with early contrast enhancement on the pancreatic residual body. b At the same site after treatment, a 35-mm coagulative necrotic area was seen with the onset of a small fluid collection in the omental bursa.
Zoom Image
Fig. 3 Endoscopic ultrasound-guided laser ablation. a A hyperechoic line identified the laser fiber protruding from the tip of the needle. b During laser ablation, a slowly enlarging and coalescing hyperechoic zone appeared around the distal tip of the laser fiber. c After laser ablation, the entire treated area was occupied by an irregular and poorly defined echogenic zone.
Zoom Image
Fig. 4 Follow-up computed tomography scans. a At 2 months after laser ablation, the ablated area was further reduced (18 mm vs. 35 mm). b At 1 year after laser ablation, a 9-mm area of coagulative necrosis remained.