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Background Pancreatic neuroendocrine tumors (p-NETs) are frequently asymptomatic and are often discovered incidentally or during evaluation of nonspecific constitutional symptoms. The decision-making process in managing p-NETs (<2cm) concerning whether to follow up or intervene is difficult, especially in those patients who have significant medical comorbidities and therefore have an increased risk of surgical complications. 5% of low-grade tumors NETs metastasize early to distant organs on follow-up. Endoscopic Ultrasound (EUS)-Guided Ethanol Ablation offers a minimally invasive therapeutic approach to treating these patients, along with Biopsy in the same sitting.Methods We describe the case of a 70-year-old man diagnosed with Type II Diabetes Mellitus; he had also recently received an automated implantable cardioverter defibrillator (AICD) due to tachy-brady arrhythmias. He presented over the course of approximately 8 months with progressive unexplained weight loss & generalized fatigue. His laboratory studies were notable for a mild elevation in CA 19-9 (62.9 U/mL → 68.4 U/mL); all endocrine studies were normal, further supporting that this represented tumor on contrast-enhanced computed tomography (CT) scan of the abdomen, which demonstrated a 7.8 x 7mm arterially enhancing mass in the pancreatic tail; this finding was suggestive of a p-NET. EUS confirmed a well-defined hypoechoic lesion ( IDDF2026-ABS-0072 Figure 1. Well-defined, round, hypoechoic lesion before ablation) without vascular invasion away from the main pancreatic duct. Fine-needle biopsy (FNB) was performed using a single-pass 22-gauge needle, followed during the same procedure by injection of 2.5 mL of absolute ethanol into the lesion for diagnostic and therapeutic purposes.Results Following the ablative therapy, post-ablation imaging studies demonstrated intralesional hyper-echogenicity consistent with coagulative necrosis ( IDDF2026-ABS-0072 Figure 2. Post-ablation EUS consistent with intralesional hyperechogenicity). Immunohistochemistry showed diffuse positivity for cytokeratin and synaptophysin, with a Ki-67 proliferative index <2%. These findings are consistent with a well-differentiated pancreatic neuroendocrine tumor (p-NET), Grade I (WHO G1) (IDDF2026-ABS-0072 Figure 3. Histopathology from EUS-guided FNB consistent). Additionally, the patient reported subjective improvement in fatigue and a weight gain of approximately 1.5 kg within a week. There were no complications associated with the procedure and repeat imaging studies in the form of a GA-68 DOTATE PET/CT scan one month after the procedure reported no hypermetabolic lesion.Conclusions This case study demonstrates the feasibility and clinical benefit of EUS-guided ablation as a safe and organ-preserving alternative to surgical treatment of selected patients with small p-NETs. The early symptomatic improvement experienced by this patient suggests that minimally invasive ablative therapies may represent a viable option for patients at high risk for surgical complications or who prefer non-surgical treatment strategies.Abstract IDDF2026-ABS-0072 Figure 2Abstract IDDF2026-ABS-0072 Figure 1Abstract IDDF2026-ABS-0072 Figure 3