Endoscopic Ultrasound-Guided Radiofrequency Ablation for Pancreatic Cystic Neoplasms and Neuroendocrine Tumors

Pancreatic lesions, including pancreatic cystic neoplasms (PCNs) and pancreatic neuroendocrine tumors (pNETs), represent a heterogeneous group of diseases with variable biological behavior, ranging from benign and indolent entities to lesions with significant malignant potential. Their detection has markedly increased over the past two decades, primarily due to the widespread use of high-resolution imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI). Incidental pancreatic cystic lesions are currently identified in up to 20% of abdominal imaging studies performed for unrelated indications, with prevalence rising with age. Consequently, the clinical burden associated with these lesions is expected to increase substantially in aging populations.

The management of pancreatic lesions remains challenging and requires a careful balance between the risk of malignant transformation and the morbidity associated with intervention. PCNs encompass both non-neoplastic lesions (e.g., pseudocysts) and neoplastic entities, including intraductal papillary mucinous neoplasms (IPMNs), mucinous cystic neoplasms (MCNs), serous cystadenomas (SCNs), and solid pseudopapillary neoplasms (SPNs). Among these, IPMNs and MCNs are associated with a well-documented risk of malignant progression. IPMNs, in particular, are classified into main duct, branch duct, and mixed types, with varying degrees of risk depending on morphological features and histopathological grade. However, accurate prediction of malignant potential in individual lesions remains difficult in routine clinical practice, as histological confirmation is often not feasible without surgical resection.

Similarly, pNETs constitute a rare but increasingly recognized group of pancreatic tumors, accounting for approximately 3% of all pancreatic malignancies. These tumors exhibit diverse biological behavior and may be functional (hormone-secreting) or non-functional. Functional tumors, such as insulinomas or gastrinomas, often present with clinical syndromes related to hormone excess, while non-functional tumors are frequently detected incidentally. Tumor grading, based on proliferative indices such as Ki-67, and tumor size are key determinants of prognosis and management. Current guidelines generally recommend surgical resection for functional tumors and for non-functional tumors ≥2 cm in size. However, the optimal management of small (≤2 cm), asymptomatic non-functional pNETs remains controversial, as many of these lesions demonstrate indolent behavior and low risk of progression.

Surgical resection, including procedures such as pancreaticoduodenectomy or distal pancreatectomy, remains the standard of care for many pancreatic lesions with suspected or confirmed malignancy. However, these procedures are technically demanding and associated with considerable morbidity (20-30%) and mortality (1-3%) even in specialized centers. Postoperative complications may include pancreatic fistula, delayed gastric emptying, hemorrhage, and long-term endocrine and exocrine insufficiency. These risks are particularly relevant in elderly patients and those with significant comorbidities. Furthermore, accumulating evidence suggests that a substantial proportion of patients undergoing surgery for PCNs ultimately have low-grade or benign disease, raising concerns about overtreatment.

On the other hand, conservative management strategies based on long-term imaging surveillance are associated with their own limitations, including cumulative healthcare costs, radiation exposure (in the case of CT), and significant psychological burden for patients living with an untreated pancreatic lesion of uncertain malignant potential. Therefore, there is a clear unmet clinical need for minimally invasive treatment options that can effectively manage selected pancreatic lesions while minimizing procedural risk.