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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.
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.
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2 thoughts on “EUS Guided Ablation for small pancreatic NETs (Less than 2cm)”
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