Manejo endoscópico de neoplasia mucinosa papilar intraductal maligna en un paciente de edad avanzada

Malignant transformation of pancreatic main duct intraductal papillary mucinous neoplasms (IPMNs) in elderly patients with comorbidities presents significant therapeutic dilemmas. We aimed to assess sequential endoscopic multimodal therapies for palliative control in a nonsurgical IPMN-derived adenocarcinoma patient.

A 92-year-old man with obstructive jaundice and endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNA)-confirmed adenocarcinoma underwent staged interventions. Initial management included pancreatoscopy-guided radiofrequency ablation (RFA) of the main pancreatic duct lesion with dual pancreatic/biliary plastic stent placement. At 5-month follow-up, tumor progression prompted repeat RFA and cryoablation. Subsequent failed ERCP cannulation due to duodenal tumor invasion necessitated salvage EUS-guided biliary drainage (EUS-BD) and pancreatic duct rendezvous (EUS-PD) with covered metal stent deployment. Iterative stent revisions and EUS-guided cryoablation were performed for recurrent obstructions.

The patient survived 18 months post initial intervention, maintaining oral intake and ambulation until terminal hospitalization. Technical success was achieved in all procedures despite challenges including stent migration, tumor progression requiring ablation escalation, and anatomic distortion mandating EUS-guided salvage. Hepatic metastasis progression preceded palliative stent replacement and patient demise.

Multimodal endoscopic therapy combining RFA, cryoablation, and advanced EUS-guided drainage techniques can provide sustained symptom control and local tumor management in elderly patients with unresectable malignant IPMNs.