Endoscopic ultrasound-guided tandem dual-modality ablation case report: a novel approach for managing branch duct intraductal papillary mucinous neoplasms.

Endoscopic ultrasound (EUS)-guided radiofrequency ablation (EUS-RFA) and chemoablation are nonsurgical options for managing pancreatic cystic lesions. Prior studies do not provide evidence-based escalation pathways for nonresponders to single-modality therapy. This case highlights a novel approach to managing branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) using a combination of EUS-RFA and chemoablation to treat a 50- × 39-mm BD-IPMN. Our strategy integrated EUS-guided needle-based confocal laser endomicroscopy and cyst fluid molecular analysis via next-generation sequencing for accurate diagnosis and risk stratification. We demonstrate the effectiveness of tandem approach, not planned a priori, in which EUS-RFA elicited a partial response, followed by salvage chemoablation that achieved complete cyst resolution. The patient developed mild acute pancreatitis after chemoablation, which did not require hospitalization. This case underscores the potential for further investigation of multimodal ablative therapy for large BD-IPMNs in patients who are poor surgical candidates.