Comments on “Impact of tumor size and nodal status on recurrence of nonfunctional pancreatic neuroendocrine tumors ≤2 cm after curative resection: a multi‐institutional study of 392 cases”

We read with great interest the article by Dong et al. The authors evaluated the incidence and risk factors of lymph node metastasis (LNM), as well as outcomes of patients with resected small nonfunctional pancreatic neuroendocrine tumors (NF‐pNETs), and concluded that surgical resection with lymphadenectomy should be considered for patients with NF‐pNETs ≥1.5‐2.0 cm. Herein, we would like to raise the following comments: First, in this study, the authors reported a relatively low rate of enucleation (39 of 329, 9.9%) compared with the study by Sallinen et al (70 of 210, 33.3%). Related research and our previous study have demonstrated that enucleation is a suitable surgical method for appropriate patients which preserves pancreatic function and may be associated with excellent long‐term disease‐free survival rates in highly selected patients. Furthermore, for the 39 patients who underwent enucleation, for whom lymphadenectomy may not be routinely performed, there were 4 who had LNM. Therefore, enucleation with regional lymphadenectomy may be considered for selected patients with small NF‐pNETs, but further studies regarding this issue are needed. Second, the data from our institution also suggest that small NF‐pNETs (1‐2 cm) may show aggressive behavior such as LNM, Ki67 > 20%, or even distant metastasis. We agree that surgical resection with lymphadenectomy should be considered for selected patients and appreciate the authors’ work in evaluating the indication for surgery in patients with small NF‐pNETs. However, in our opinion, to assess the benefit of surgery and lymphadenectomy, the postoperative morbidity and mortality should be taken into consideration. It is noted that most patients (227 of 329, 58.7%) had at least one complication; roughly one‐third of these patients (87 of 227, 38.5%) experienced a Clavien‐Dindo III‐IV complication. And, the mortality data in this study were not presented. Our data showed that the incidence of pancreatic fistula (B and C) and Clavien‐Dindo III‐V complication after resection of small NF‐pNETs was 38% and 27%, which is a considerable proportion. Therefore, we think that surgeons should balance tumor progression and possible postoperative complications to make a decision before indications for surgery in patients with small NF‐pNETs are constructed. Overall, surgical resection with lymphadenectomy may need to be considered for selected patients with NF‐pNETs, and postoperative morbidity and mortality should be taken into consideration. More high‐quality studies are needed to evaluate the indication for surgery in patients with small NF‐pNETs.