Early-stage pancreatic neuroendocrine tumors (PNETs): Patience is a virtue

Abstract

The incidence of small, incidentally discovered, nonfunctional pancreatic neuroendocrine tumors (PNETs) is increasing, likely based on the increased use and sensitivity of cross-sectional imaging. 1 Lee L.C. Grant C.S. Salomao D.R. et al. Small, nonfunctioning, asymptomatic pancreatic neuroendocrine tumors (PNETs): Role for nonoperative management. Surgery. 2012; 152: 965-974 Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar , 2 Libutti S.K. Evolving paradigm for managing small nonfunctional incidentally discovered pancreatic neuroendocrine tumors. J Clin Endocrinol Metab. 2013; 98: 4670-4672 Crossref PubMed Scopus (10) Google Scholar , 3 Mansour J.C. Chavin K. Morris-Stiff G. et al. Management of asymptomatic, well-differentiated PNETs: Results of the Delphi consensus process of the Americas Hepato-Pancreato-Biliary Association. HPB (Oxford). 2019; 21: 515-523 Scopus (15) Google Scholar , 4 Rosenberg A.M. Friedmann P. Del Rivero J. Libutti S.K. Laird A.M. Resection versus expectant management of small incidentally discovered nonfunctional pancreatic neuroendocrine tumors. Surgery. 2016; 159: 302-309 Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar This scenario, however, presents a challenge to the clinician regarding the appropriate management of these patients with respect to expectant observation versus immediate resection. Pancreatic surgery, depending on the location of the lesion, can carry substantial morbidity even in the hands of experienced surgeons. Because these lesions are nonfunctional, the only benefit to the patient resulting from resection is to decrease the chance of life-limiting metastases. A growing body of literature has supported an expectant approach to grade 1 lesions less than 2 cm in size (with a strong consensus for lesions less than 1 cm in size), reserving operative resection for those lesions that increase in size over serial imaging or those of a higher grade. 1 Lee L.C. Grant C.S. Salomao D.R. et al. Small, nonfunctioning, asymptomatic pancreatic neuroendocrine tumors (PNETs): Role for nonoperative management. Surgery. 2012; 152: 965-974 Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar , 2 Libutti S.K. Evolving paradigm for managing small nonfunctional incidentally discovered pancreatic neuroendocrine tumors. J Clin Endocrinol Metab. 2013; 98: 4670-4672 Crossref PubMed Scopus (10) Google Scholar , 3 Mansour J.C. Chavin K. Morris-Stiff G. et al. Management of asymptomatic, well-differentiated PNETs: Results of the Delphi consensus process of the Americas Hepato-Pancreato-Biliary Association. HPB (Oxford). 2019; 21: 515-523 Scopus (15) Google Scholar , 4 Rosenberg A.M. Friedmann P. Del Rivero J. Libutti S.K. Laird A.M. Resection versus expectant management of small incidentally discovered nonfunctional pancreatic neuroendocrine tumors. Surgery. 2016; 159: 302-309 Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar For grade 1 lesions that are less than 2 cm in size and remain stable, the risk of developing metastases is extremely low. 1 Lee L.C. Grant C.S. Salomao D.R. et al. Small, nonfunctioning, asymptomatic pancreatic neuroendocrine tumors (PNETs): Role for nonoperative management. Surgery. 2012; 152: 965-974 Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar ,4 Rosenberg A.M. Friedmann P. Del Rivero J. Libutti S.K. Laird A.M. Resection versus expectant management of small incidentally discovered nonfunctional pancreatic neuroendocrine tumors. Surgery. 2016; 159: 302-309 Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar