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!)