Current Management of Pancreatic Neuroendocrine Tumors: From Demolitive Surgery to Observation

Abstract

Incidental diagnosis of pancreatic neuroendocrine tumors (PanNETs) greatly increased in the last years. In particular, more frequent diagnosis of small PanNETs leads to many challenging clinical decisions. These tumors are mostly indolent, although a percentage (up to 39%) may reveal an aggressive behaviour despite the small size. Therefore, there is still no unanimity about the best management of tumor smaller than 2 cm. The risks of under/overtreatment should be carefully evaluated with the patient and balanced with the potential morbidities related to surgery. The importance of the Ki-67 index as a prognostic factor is still debated as well. Whenever technically feasible, parenchyma-sparing surgeries lead to the best chance of organ preservation. Lymphadenectomy seems to be another important prognostic issue and, according to recent findings, should be performed in noninsulinoma patients. In the case of enucleation of the lesion, a lymph nodal sampling should always be considered. The relatively recent introduction of minimally invasive techniques (robotic) is a valuable option to deal with these tumors. The current management of PanNETs is analysed throughout the many available published guidelines and evidences with the aim of helping clinicians in the difficult decision-making process.

Metastatic insulinoma presenting 14 years after benign tumour resection: a rare case and management dilemma

“…Pancreatic neuroendocrine tumours (pNET) are uncommon, comprising less than 5% of all pancreatic tumours and 7% of all neuroendocrine tumours ( 4 ). Eighty percent of these are benign (non-functional), although their incidence is increasing due to an improvement in imaging modalities.…”

Endoscopic Ultrasound-Guided Ablation of Focal Pancreatic Lesions: The GRUPUGE Perspective

“…Incidental diagnosis of small pNETs (≤2 cm) has greatly increased in the last years [17]. These tumours are mostly non-functional and indolent, although a significant proportion (up to 39%) may reveal an aggressive behaviour despite their small size [18]. Therefore, there is still no consensus on the best management for non-functional tumours <2 cm and institutional experiences may be quite variable [19].…”

“…Therefore, there is still no consensus on the best management for non-functional tumours <2 cm and institutional experiences may be quite variable [19]. The risks of under-/overtreatment should be carefully evaluated with the patient and balanced with the potential morbidities related to surgery [18]. Current guidelines consider only 2 opposite approaches for these small lesions, jumping from observation to surgery, and advocating surgery even for some symptomatic pNETs with a low malignant potential, such as insulinomas [18, 19].…”

“…The risks of under-/overtreatment should be carefully evaluated with the patient and balanced with the potential morbidities related to surgery [18]. Current guidelines consider only 2 opposite approaches for these small lesions, jumping from observation to surgery, and advocating surgery even for some symptomatic pNETs with a low malignant potential, such as insulinomas [18, 19]. In fact, management decisions about small pNETs can be challenging and must consider the clinical presentation as well as size, grade, and location of the tumour within the pancreas, together with the patient’s health status, age, and wishes [18].…”

Operationsindikationen bei neuroendokrinen Neoplasien des Pankreas

“…Die Prognose der pNEN wird wiederum durch verschiedene Faktoren beeinflusst, wie der Differenzierung und der Graduierung [7]. Die Graduierung wird anhand des Ki-67-Indexes und der Mitoserate ermittelt und die Tumoren in 3 Gruppen unterteilt.…”