ultrasound ( eus)-guided celiac plexus neurolysis ( cpn ) has been reported to be effective in inducing pain relief . however ,
a 75-year - old man suffering from opioid refractory pain ( recorded as 9 according to visual analog scale ( vas ) ) due to an advanced stage iv histologically - proven pancreatic adenocarcinoma with liver metastases and celiac trunk infiltration not suitable for surgery , was referred to our center .
eus confirmed the nodular hypoechoic lesion of 40  38  33 mm in the pancreas [ figure 1 ] .
as the tumor stage was beyond any possibility of surgical radical care and in order to relieve patient 's symptoms , after informed consent was obtained , eus - guided cpn combined to eus - guided tumor ablation was arranged . under sedation with propofol
, eus was conducted with a pentax fg-36ua ultrasound endoscope ( pentax europe ltd , hamburg , germany ) using a curved - array transducer .
a 22 g needle ( cook medical inc , bloomington , indiana , usa ) was introduced though the endoscope 's working channel to inject 10 ml 2.0% lidocaine and 20 ml of ethylic alcohol 95% into the base of the celiac trunk at its origin from the aorta [ central approach , figure 2 ] . after performing cpn , 40 ml 75% of lesion volume of ethanol ( concentration 95% ) were directly injected into the tumor [ figure 3 ] .
tumoral nodule in the body of the pancreas celiac plexus neurolysis performed via the central approach ethanol ablation of the pancreatic tumor no major complications were recorded during the procedure . in the days following the procedure , mild ( grade 2 ) diarrhea and fever were the only minor complications experienced by the patient .
complete tumor devascularization was assessed by means of computed tomography ( ct ) 48 h after the procedure [ figure 4 ] .
ca 19 - 9 dropped down to 56.84 u / ml at 2 weeks after eus .
tumor response assessed by means of computed tomography ( ct ) 48 h after the procedure complete pain relief , namely vas 0 , was achieved 3 days after the endoscopic ablation .
the patient remained pain - free without need of opioid , and was treated only with paracetamol for 20 weeks and afterwards experienced pain relief , ( defined as pain within 30% of baseline ) until death occurred 30 weeks after the procedure .
advanced pancreatic cancer commonly induces severe refractory pain . in such patients , where opioids result often ineffective ,
eus - guided cpn has been reported to induce pain relief in 70 - 80% of cases .
however , most patients achieve only suboptimal and transient relief , probably due to technical failure or further nociceptive impulses which can not be interrupted by the neurolysis . furthermore , definitive data on its efficacy in improving survival is still lacking .
therefore , it was decided to try a combined approach directed both to the celiac plexus and the neoplastic mass , in order to delay tumor progression and lengthen pain - free survival as well as overall survival .
the results were optimal in terms of pain relief and immediate tumor response ( assessed by means of ct and tumor marker levels ) .
the present case demonstrates that the combined approach ( eus - guided ethanol ablation and cpn ) may be a valuable option aimed at improving both prognosis and pain control in patients with pancreatic cancer .
randomized - controlled trials comparing eus - cpn alone to cpn associated to tumor ablation are needed to confirm this result .
 a 75-year - old man suffering from opioid - refractory due to an advanced pancreatic adenocarcinoma was treated with endoscopic ultrasound ( eus)-guided celiac plexus neurolysis ( cpn ) combined to eus - guided tumor ablation . 
 no major complications were recorded during the procedure . in the days following the procedure , 
 mild diarrhea and fever were the only minor complications experienced by the patient . 
 complete tumor devascularization was assessed by means of computed tomography ( ct ) 48 h after the procedure . 
 the patient remained pain - free without need of opioid , and was treated only with paracetamol for 20 weeks . 
 our results were optimal in terms of pain relief and immediate tumor response ( assessed by means of ct and tumor marker levels ) . 
 the present case demonstrates that the combined approach ( eus - guided ethanol ablation and cpn ) may be a valuable option in patients with pancreatic cancer . 
 randomized - controlled trials are needed to confirm this result . 