Endoscopic ultrasound-guided ablation of small pancreatic neuroendocrine neoplasms: Bridging the gap between surveillance and surgery

Table 3 Comparison of active surveillance, endoscopic ultrasound-guided ablation, and surgery for small pancreatic neuroendocrine neoplasms

Parameter	Active surveillance	EUS-guided ablation	Surgery
Main clinical role	Observation of low-risk lesions	Minimally invasive local treatment in selected patients	Definitive treatment when oncological resection is indicated
Most appropriate setting	Small, asymptomatic, NF, well-differentiated, stable panNENs	Small insulinomas and selected localized low-grade NF-panNENs	Tumors with higher-risk biological or anatomical features
Pathological confirmation	Based on biopsy when performed	Pretreatment biopsy required; no resection specimen	Complete surgical specimen available
Assessment of margins	Not applicable	Not available	Available
Lymph-node assessment	Not available	Not available	Available when lymphadenectomy is performed
Oncological certainty	Limited during observation	Limited; imaging response does not prove eradication	Highest among the three strategies
Procedure-related morbidity	None	Generally lower than surgery, but pancreatitis, pain, and ductal injury may occur	Substantial, depending on procedure type and location
Hospital stay	None	Usually short	Usually longer
Pancreatic preservation	Complete	Usually preserved	Variable; risk of endocrine and exocrine insufficiency
Local residual or recurrent disease	Tumor remains untreated and monitored	Possible; repeat ablation may be required	Lower after complete resection, although recurrence remains possible
Need for repeat intervention	Possible if growth or progression occurs	Relatively common after incomplete response or recurrence	Usually not required for local control after complete resection
Main advantage	Avoids overtreatment and procedural morbidity	Pancreas-preserving local treatment with lower short-term burden	Definitive pathology and oncological resection
Main limitation	Persistent uncertainty and need for long-term follow-up	No nodal staging or confirmation of complete microscopic eradication	Operative morbidity and potential long-term pancreatic dysfunction
Evidence base	Supported by prospective observational data in selected NF-panNENs	Mainly retrospective series, small prospective cohorts, and limited comparative data	Established standard for tumors requiring active definitive treatment

EUS: Endoscopic ultrasound; NF-panNENs: Non-functioning pancreatic neuroendocrine neoplasms; NF: Non-functioning; panNENs: Pancreatic neuroendocrine neoplasms.