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Reply to the letter to the editor

We thank Dr Rimbas and his colleagues for their interest in our case series on endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) of nonfunctional pancreatic neuroendocrine tumors (NFpNETs) ≤2 cm in 27 patients. Regarding the rate of complications, Rimbas and colleagues questioned whether EUS-RFA treatment was justified in lesions with a size of 9–10 mm. Adverse events occurred during the first nine procedures. In the absence of significant technical modifications, we suggest that there is a learning curve effect with a better proficiency after a certain number of procedures. As such, the morbidity rate today might be lower than reported in our case series. The morbidity rate of pancreatic surgery, in contrast, is considerable. Therefore, current guidelines consider surveillance as a reasonable alternative strategy for G1 or low-grade G2 pNETs ≤2 cm. However, several observational studies showed that approximately one-fifth of small NFpNETs progressed during follow-up, and the rate of secondary surgery ranges between 3% and 25%, with potential high morbidity and without alternative curative treatment by EUS-RFA. As a result, we are not convinced that endoscopic treatment should be reserved for pancreatic head lesions. More prospective studies are needed, but the technique is very promising. As the risk of malignancy in small NFpNETs is estimated to be 5–8%, careful patient selection is mandatory, and patients with metastatic lymph nodes have to be excluded, as is the case for parenchymalsparing surgery. In conclusion, we think that EUS-RFA is the current treatment of choice for G1 pNETs ≤2 cm, as it has an excellent efficacy and an acceptable safety profile, whereas surveillance of these potentially malignant lesions is associated with considerable costs and patient anxiety. Authors declare no conflict of interest for this article.