Surgical management of pancreatic neuroendocrine tumours

Pancreatic neuroendocrine neoplasms (PanNENs) are increasingly encountered in surgical practice, with rising incidence and prevalence1,2. As such, all surgeons, whether they specialize in pancreatic surgery or not, will encounter PanNENs more and more often. A solid understanding of their biology, treatment options, and evolving management strategies is therefore essential. PanNENs encompass all neuroendocrine lesions of the pancreas, with the WHO classifying them as either well-differentiated neuroendocrine tumours (NETs) or poorly differentiated neuroendocrine carcinomas (NECs). Well-differentiated NETs are further stratified by grade based on Ki-67 index: grade 1 (G1) (<3%), grade 2 (G2) (3–20%), and grade 3 (G3) (>20%). This BJS Commission primarily addresses mainly non-functional (NF) pancreatic neuroendocrine tumours (PanNETs), with occasional mention of pancreatic neuroendocrine carcinomas (PanNECs) or functional tumours where most relevant. The pace of discovery in PanNETs has accelerated dramatically in recent years. What is clear is that they represent a unique disease for which different thinking patterns are needed. PanNETs are distinct from pancreatic adenocarcinoma, characterized by different growth patterns and prolonged survival (even in the presence of metastatic disease). They also present significant heterogeneity in presentation, functional status, genetic background, and disease extent. Importantly, they differ meaningfully from small intestinal NETs, despite often being grouped together in clinical studies—a practice that has led to misleading extrapolations. Surgery remains a cornerstone of PanNET management, yet practice patterns vary widely due to a fragmented evidence base, limited standardization, and a preponderance of single-institution (and single-surgeon) data3. Meanwhile, systemic therapies have advanced significantly, both in terms of novel agents and evidence from large-scale randomized trials, which has offered new opportunities for integrated, multidisciplinary care4–12. These developments challenge surgeons to remain current, adapt to new evidence, and leverage improved systemic options in clinical decision-making. This BJS Commission does not attempt to provide an exhaustive review of PanNETs. Instead, it focuses on key clinical dilemmas that commonly arise in practice and areas where evidence is evolving rapidly and where emerging developments are likely to shape surgical management in the years to come.