Duodenal neuroendocrine tumors (DNETs) account for 2%–3% of all gastrointestinal neuroendocrine tumors and approximately 3% of primary malignant duodenal tumors [1]. They are generally incidental and indolent, although a sizable proportion of them are functionally gastrinomas and can cause reflux and duodenal ulceration secondary to increased gastric acid [2]. DNETs are categorized into two primary types: periampullary DNETs and non-ampullary DNETs (NADNETs). According to the National Comprehensive Cancer Network guidelines, endoscopic resection (ER) should be the primary treatment option for localized tumor whenever feasible [3]. The European Neuroendocrine Tumor Society guidelines recommend ER for tumors ≤10 mm, surgical treatment for tumors ≥2 cm, those with submucosal invasion or metastasis, and periampullary neuroendocrine, however, the optimal treatment approach for lesions measuring 10 to 20 mm remains controversial [4]. To date, most studies on endoscopic treatment of NADNETs have been small-scale retrospective studies, with inconsistent treatment outcomes and a lack of long-term prognostic data [5-8]. A recent Chinese multicenter prospective study including 78 patients with NADNETs reported a favorable long-term outcome in endoscopic treatment [9].
In this issue of the Korean Journal of Helicobacter and Upper Gastrointestinal Research, Jeong et al. [10] evaluated the short- and long-term therapeutic outcomes of endoscopic or surgical treatments in patients with NADNETs. This single center retrospective study included 55 patients between 2009 to 2022, and the patients were classified as 21 ER group (median 9 [3–25] mm), 28 surgery group (median 12.5 [5–30] mm), and 6 observation group who did not have detectable residual tumors after initial biopsy group (median 5 [3–7] mm) during the median follow-up period of 42, 48, and 42.5 months, respectively. During the follow-up period, no recurrences were observed in any of the groups, and three cases in the ER group experienced perforations; 2 underwent primary repair surgery and 1 recovered with conservative treatment. In particular, the study reported detailed information of 7 margin-positive cases in the endoscopic and surgical resection group, and there was no recurrence even with no additional surgery. Although guidelines recommend surgical resection in patients with positive resection margin, it is possible that elderly patients with comorbidities refuse surgery in clinical practice. Thus, this study provides a comprehensive analysis of recurrence and complications of NADNETs treated with various modality during the relatively long period of follow-up, although it has limitations from single center retrospective study and small number of large size tumor in ER group. These findings are expected to assist clinicians in determining treatment modality for incidentally detected NADNETs in the future. The short- and long-term outcomes of endoscopic treatment may vary depending on the location and size of the lesion, as well as the operator’s expertise. Therefore, large-scale, prospective, multicenter studies are needed to establish clear indications for endoscopic treatment of NADNETs.
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