Massironi S, Dell'Anna G, Biamonte P, Bernardi F, Danese S. Endoscopic ultrasound-guided ablation of small pancreatic neuroendocrine neoplasms: Bridging the gap between surveillance and surgery. World J Gastrointest Endosc 2026; 18(10): 125918 [DOI: 10.4253/wjge.125918]
Corresponding Author of This Article
Sara Massironi, Associate Professor, Department of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, Milan 20132, Lombardy, Italy. sara.massironi@libero.it
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Gastroenterology & Hepatology
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review-article
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Massironi S, Dell'Anna G, Biamonte P, Bernardi F, Danese S. Endoscopic ultrasound-guided ablation of small pancreatic neuroendocrine neoplasms: Bridging the gap between surveillance and surgery. World J Gastrointest Endosc 2026; 18(10): 125918 [DOI: 10.4253/wjge.125918]
World J Gastrointest Endosc. Oct 16, 2026; 18(10): 125918 Published online Oct 16, 2026. doi: 10.4253/wjge.125918
Endoscopic ultrasound-guided ablation of small pancreatic neuroendocrine neoplasms: Bridging the gap between surveillance and surgery
Sara Massironi, Giuseppe Dell'Anna, Paolo Biamonte, Francesca Bernardi, Silvio Danese
Sara Massironi, Giuseppe Dell'Anna, Paolo Biamonte, Francesca Bernardi, Silvio Danese, Department of Medicine and Surgery, Vita-Salute San Raffaele University, Milan 20132, Lombardy, Italy
Giuseppe Dell'Anna, Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan 20132, Lombardy, Italy
Giuseppe Dell'Anna, Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS Policlinico San Donato, San Donato Milanese 20097, Lombardy, Italy
Paolo Biamonte, Francesca Bernardi, Unit of Gastroenterology, Ospedale Maggiore della Carità di Novara, Novara 28100, Piedmont, Italy
Silvio Danese, Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan 20132, Lombardy, Italy
Author contributions: Massironi S conceived and designed the review, supervised the project, critically interpreted the literature, and drafted and revised the manuscript; Dell’Anna G performed the literature search, contributed to data collection and interpretation, and drafted and revised the manuscript; Biamonte P and Bernardi F contributed to literature review, data interpretation, and critical revision of the manuscript; Danese S provided scientific supervision, contributed to interpretation of the evidence, and critically revised the manuscript for important intellectual content; all authors reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work.
AI contribution statement: During revision of the manuscript, OpenAI’s ChatGPT was used to assist with English-language editing and stylistic refinement. All scientific content, interpretations, references, figure structure, labels, and final wording were critically reviewed and approved by the authors, who take full responsibility for the manuscript. The tool was not used to generate original data, perform statistical analyses, select references autonomously, or determine scientific conclusions.
Conflict-of-interest statement: All authors declare no conflict of interest in publishing the manuscript.
Corresponding author: Sara Massironi, Associate Professor, Department of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, Milan 20132, Lombardy, Italy. sara.massironi@libero.it
Received: July 21, 2026 Revised: July 29, 2026 Accepted: September 4, 2026 Published online: October 16, 2026 Processing time: 86 Days and 14.7 Hours
Abstract
The growing use of cross-sectional imaging and endoscopic ultrasound (EUS) has led to more frequent detection of small pancreatic neuroendocrine neoplasms, particularly non-functioning lesions ≤ 2 cm. Active surveillance is appropriate for many low-risk tumors, whereas pancreatic surgery may be associated with substantial morbidity. EUS-guided ablation has therefore emerged as a pancreas-preserving option between surveillance and surgical resection. We conducted a narrative review of EUS-guided treatments for small pancreatic neuroendocrine neoplasms, focusing on pretreatment assessment, technical approaches, patient selection, radiological outcomes, safety, and emerging indications. Ethanol ablation and radiofrequency ablation are the most extensively studied techniques. Technical success approaches 100% in most series. Complete radiological response has generally ranged from approximately 50%-70% after ethanol ablation and 80%-90% after radiofrequency ablation, often after more than one treatment session. Clinical efficacy is particularly high in insulinomas, with symptom resolution reported in more than 90% of patients. Comparative studies suggest lower short-term morbidity and shorter hospitalization than surgery, although local recurrence may occur and long-term oncological outcomes remain insufficiently defined. EUS-guided ablation is promising for carefully selected patients, particularly those with insulinomas, but should not yet be considered a routine alternative to surgery or active surveillance, as prospective comparative studies and standardized outcome definitions are still needed.
Core Tip: Small pancreatic neuroendocrine neoplasms pose a therapeutic dilemma because surveillance may expose selected patients to tumor progression and psychological burden, whereas pancreatic surgery carries substantial morbidity. Endoscopic ultrasound-guided ethanol injection and radiofrequency ablation offer a pancreas-preserving intermediate strategy. This review summarizes current techniques, clinical outcomes, safety considerations, and proposed selection criteria, emphasizing that endoscopic ultrasound-guided ablation should currently be reserved for carefully selected patients treated in expert multidisciplinary centers.
