To burn or not to burn?
I once wrote a post about Pancreatic NET “to cut or not to cut”. You can read that here. Surgery for small pancreatic NETs remains controversial with most guidelines and study guidelines recommending surveillance for small primary tumours less than 2cm. There are exceptions to that, e.g. preventative surgery if the tumour is threatening important vessels and for functional cases where the surgery is palliative in nature. Contrast that against some patient perspectives where they just want it cut out (and some will ‘surgeon-shop’ until they find someone who will).
Most pancreatic NET are lower grades (e.g. Grade 1 and 2) well differentiated, most are non-functional, many are localised. Functional tumours such as Insulinoma are mostly small and localised.
A lack of sensitive and specific markers that can predict the patients most likely to have tumours that will grow and/or metastasise is still a work in progress, it’s a tough call as the biological behavior of an individual PNET remains unpredictable.
The Hippocratic oath can often guide doctors (and guideline writers) as radical surgery can present considerable morbidity (and a small risk of mortality) which might harm the patient more than the tumour.
Pancreatic NETs are growing as a research topic and in 2022, I noticed an increase in studies suggesting ablation as a method of removing sporadic small pancreatic NETs which is less risky and reduces the chance of severe morbidity but has comparable efficiency. The technique is not new but is not normally used in pancreatic NET cases. As science progresses, so will ablation techniques. But is there enough data to make this a standard of care?
I followed this thread on Twitter following the publishing of a small study as mentioned above. I witnessed the differing views. The author is known for pragmatism and often plays ‘devil’s advocate’ to provoke discussion (I’m sure he won’t mind me taking that view!)
Ablation vs Surveillance
I followed a thread on Twitter (see below) following the publishing of a small study as mentioned above. I witnessed the differing views, although the author is known for pragmatism and often plays ‘devil’s advocate’ to provoke discussion (I’m sure he won’t mind me taking that view!). The first graphic below is the thread comprising a tweet in 3 parts and then some comments from those following the thread in the second graphic. As you can see there it’s just as controversial as the surgery vs surveillance issue. One thing that was generally agreed was the need for more studies to confirm this is a viable option.
The study was suggesting Endoscopic Ultrasound (EUS) guided ethanol ablation, but other studies stick to EUS-guided radiofrequency ablation (RFA). I will attach samples of both below.
The final comment mentions a study (ASPEN) that I have already published indicating there is clinical evidence that surveillance is the best option in most cases. You can read that by clicking here.
Comparison of EUS-guided ablation and surgical resection for non-functioning small pancreatic neuroendocrine tumors: a propensity score matching study
Hoonsub So, M.D., Sung Woo Ko, M.D., PhD., Seung Hwan Shin, M.D., Eun Ha Kim, R.N., Jimin Son, M.D., SuHyun Ha, M.D., Ki Byung Song, M.D. PhD., Hwa Jung Kim, M.D. PhD., Myung-Hwan Kim, M.D., PhD., Do Hyun Park, M.D., Ph.D. PII: DOI: Reference: S0016-5107(22)02141-1 https://doi.org/10.1016/j.gie.2022.11.004 YMGE 13469
EUS-RFA for Pancreatic Insulinoma
This study conclusion is interesting.
Conclusion
EUS-RFA is safer than surgery and highly effective for the treatment of PI. If confirmed in a randomized study, EUS-RFA treatment can become first line therapy for sporadic PI.
Read the article abstract by clicking here
EUS-RFA of the pancreas: where are we and future directions
Gollapudi LA, Tyberg A. EUS-RFA of the pancreas: where are we and future directions. Transl Gastroenterol Hepatol. 2022 Apr 25;7:18. doi: 10.21037/tgh-2020-11. PMID: 35548478; PMCID: PMC9081919.
Or try this 2025 paper
Masciangelo G, Campana D, Ricci C, Andrini E, Rakichevikj E, Fusaroli P, Lisotti A. Endoscopic Ultrasound-Guided Locoregional Treatments for Pancreatic Neuroendocrine Neoplasms.
Curr Oncol. 2025 Feb 16;32(2):113. doi: 10.3390/curroncol32020113. PMID: 39996913; PMCID: PMC11854204.
Conclusion
In conclusion, preliminary findings suggest that EUS-guided loco-regional ablation techniques could be considered as safe and effective therapeutic options in the treatment of patients suffering from pNENs. Current ENETS and North America NeuroEndocrine Tumor Society (NANETS) guidelines strongly recommend surgical resection for neoplasms larger than 2 cm, those with aggressive features (i.e., G2–G3, Ki-67 > 5% or local invasion), or in the case of F-pNENs causing symptoms due to hormonal secretion [3,34]. In this field, minimally invasive (laparoscopic or robotic) pancreatic surgery has improved the safety outcomes; however, pancreatectomy is still burdened by significant morbidity including pancreatic fistula, diabetes, and exocrine insufficiency [6]. On the other hand, watchful follow-up is an accepted strategy for small (≤2 cm), asymptomatic, low-grade NF-pNENs, as demonstrated by several studies suggesting a low risk of progression or cancer-related mortality over time [3,4]. When considering treatment options for small pNENs, EUS loco-regional ablation could be taken into account as an alternative therapeutic option in comparison with surgical resection and active surveillance. EUS-guided loco-regional ablation presents a potential middle ground—offering a non-surgical approach that avoids the risks of pancreatectomy while addressing tumors that may otherwise progress during surveillance. However, its role remains undefined due to a lack of long-term oncological data. Until robust prospective trials confirm the safety, EUS ablation should be reserved for selected patients such as those unfit for surgery or with F-pNENs requiring symptom control. Although many studies support the safety and technical feasibility of these techniques, robust trials are needed to provide evidence that can support the clinical indication and standardized application protocols. In particular, EUS-RFA seems to represent a valid therapeutic option for pNENs, especially in patients who present secretory symptoms resulting from F-pNENs, and in high-risk surgical patients.
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Love that you wrote about this, it’s kinda my crusade. I see so many of the small PNET crowd going for pancreatic surgery instead of surveillance and wish the ablation option would be presented to them. Surgeons don’t even know it’s an option. I was lucky enough to consult with several surgeons about my small PNET and one of them seemed particularly interested in my case, was similar in age to me, lived nearby, etc. I asked him what he thought about ablation and he said he didn’t know anything but he’d ask the Interventional Radiologist that he was friends with. He called me the next day and said, gee, it’s totally possible, he’ll do it, no biggie. Give him a call. I haven’t actually done it because of the ASPEN study and other doctors said it wasn’t necessary, plus not many IR’s have experience. I think I’m going to do it anyway. Tired of wondering if this thing is sitting there metastasizing, as are most of the small PNET crew.
I hope you consider it carefully