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Neuroendocrinology and Pituitary

SAT-042 - Etomidate Infusion to Bridge to Endoscopic Ultrasound-Guided Radiofrequency Ablation of an ACTH-Secreting Pancreatic Neuroendocrine Tumor in A Patient with Severe Cushing Syndrome

Saturday, June 13, 2026
9:30 AM - 4:30 PM CT
Location: ENDOExpo; Poster Floor
Disclosure(s):
Muhammed Kizilgul, Clinical Fellow: No financial relationships to disclose
Tasma Harindhanavudhi, MD: No financial relationships to disclose


Background: We present a case of severe ectopic Cushing syndrome caused by an ACTH-secreting pancreatic neuroendocrine tumor (pNET), treated with an intravenous etomidate infusion as a bridge to endoscopic ultrasound (EUS)-guided radiofrequency ablation (RFA).

Case Report: A 63-year-old woman presented with peripheral edema, easy bruising, hyperglycemia, and hypertension. Laboratory evaluation ultimately confirmed ACTH-dependent Cushing syndrome with ACTH 86 pg/mL (ref < 47 pg/mL), serum cortisol 55.1 mcg/dL (ref 4-22 mcg/dL), and 24-hour urine free cortisol 377.6 mcg/dL (ref ≤ 45mcg). CT abdomen demonstrated a 3.5 x 2.4 cm pancreatic head lesion. MRI pituitary was negative for a sellar lesion and DOTATATE PET/CT was negative for metastases. EUS-guided biopsy of the pancreatic lesion confirmed a well-differentiated pNET that stained positive for ACTH. During further evaluation, she was found to have acute cerebral infarcts, extensive bilateral pulmonary emboli, and cavitary pneumonia caused by Rhodococcus. She was initially started on oral ketoconazole and metyrapone. However, her neurological status subsequently deteriorated, requiring emergent thrombectomy with carotid stent placement and admission to the intensive care unit for intubation.

As metyrapone could not be crushed to administer via a feeding tube, she was started on a continuous intravenous etomidate infusion at 0.02 mg/kg/hr with dose titration to maintain serum cortisol levels ~20 mcg/dL. Within 24 hours, serum cortisol decreased from a peak of 81.1 mcg/dL to 41.9 mcg/dL and further decreased to 17.1 mcg/dL within 72 hours. Ketoconazole was held due to worsening transaminitis.

Given her critically ill condition, surgical resection of the pNET was considered too high risk. Embolization was considered, but there was a high probability of precipitating severe pancreatitis. The decision was made to proceed with EUS-guided RFA with pre-operative glucocorticoid stress dosing to mitigate the risk of adrenal insufficiency. After a single RFA session, 75% of the tumor was estimated to have been ablated. Within 12 hours post-RFA, the etomidate infusion was discontinued. Low-dose ketoconazole was restarted as monotherapy.

Additional RFA sessions were planned to ensure adequate disease control, however, given her poor neurological prognosis, the patient's family ultimately decided to transition to comfort care.

Conclusion: This case highlights two critical management strategies in severe hypercortisolism: 1) the use of intravenous etomidate to rapidly lower serum cortisol in a critically ill patient with ectopic Cushing syndrome as a bridge to definitive therapy, and 2) the application of EUS-guided RFA to treat functional pNETs in high-risk patients who are not surgical candidates.

*Unless otherwise noted, all abstracts presented at ENDO must not be released to the press or the public until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.*