LAUSR

To the Editor, We present a 62-year-old male with a past medical history of hepatitis C cirrhosis, portal hypertension and inoperable cholangiocarcinoma undergoing chemotherapy, who was found to have a 1.6-cm enhancing exophytic pancreatic body mass on a contrast enhanced multi-phasic computed tomography (CT) done for staging of his cholangiocarcinoma (Fig. 1). Four months after diagnosis of the pancreatic mass, the patient developed symptoms of intractable fasting hypoglycemia requiring three admissions over the course of a month to outside institutions for dextrose infusions. The patient had no prior history of diabetes or hypercalcemia and no family history of parathyroid, pituitary, or pancreatic disease. He was initially treated conservatively with diazoxide and achieved euglycemia. However, two months after starting diazoxide, he developed palpitations, requiring its cessation. With that, his hypoglycemia returned and within two weeks he presented to our institution with a fasting glucose level of 14 mg/dL. The diagnosis of pancreatic insulinoma was established based on pharmacological tests and contrast enhanced multi-phasic CT. A 10% dextrose (D10) intravenous infusion was initiated and a surgical consultation was obtained, given the intractable nature of the symptomatic hypoglycemia. Surgical intervention was determined high risk considering the patient’s underlying cirrhosis and portal hypertension. The patient was referred to interventional radiology for possible minimally invasive treatment. The patient’s history, laboratory values, and imaging were all reviewed. Given the avid enhancement of the mass on a prior contrast enhanced CT, it was initially felt that the patient could potentially benefit from bland embolization as previously described [1]. Selective bland embolization was then performed using 70–150 lm LC Bead LUMI radiopaque microspheres (Boston Scientific, Marlborough, MA) via microcatheter (Fig. 2A). Immediate post-embolization noncontrast CT demonstrated heterogeneous staining of the pancreatic mass suggesting incomplete embolization (Fig. 2B). Postembolization the patient’s severe hypoglycemia did not improve, requiring continued hospitalization and D10 infusion. Two days post attempted embolization, it was decided to ablate the insulinoma using cryoablation. The patient underwent CT-guided placement of two cryoprobes (IceRod 1.5, Boston Scientific). The freezing protocol consisted of two cycles of a 10-min freeze and 8-min active thaw. Periodic CT imaging was performed during the & Robert P. Liddell [email protected]