Management of Pancreatic Neuroendocrine Tumors Surgery During COVID-19 Pandemic
Overview
This retrospective cohort study from a high-volume pancreatic surgery center in Italy evaluated the impact of the COVID-19 pandemic on the management of non-functioning pancreatic neuroendocrine tumors (NF-PNETs). Findings revealed significant delays in surgery, increased use of preoperative oncological therapies, and changes in tumor characteristics at diagnosis during the pandemic period.
Background
The COVID-19 pandemic strained healthcare resources globally, leading to prioritization of urgent cancer surgeries and postponement of elective procedures. Pancreatic neuroendocrine tumors, especially NF-PNETs larger than 20 mm, typically require surgical intervention to improve prognosis. The pandemic disrupted standard management protocols, causing delays in diagnosis, treatment, and surgical scheduling. This study investigates these impacts in a tertiary referral center specializing in pancreatic surgery.
Data Highlights
Parameter
Pre-COVID-19 (Mar 2017-Mar 2020)
COVID-19 Era (Mar 2020-Mar 2023)
p-value
Number of patients
205
165
Preoperative oncological treatments (any)
Lower frequency
Higher frequency
<0.001
Suspected vascular infiltration at diagnosis
6%
15%
0.005
Metastatic lymphadenopathies at diagnosis
15%
24%
0.024
Median time from diagnosis to surgery (days)
182 (IQR 100–357)
382 (IQR 200–610)
<0.001
Waiting list duration (days)
60 (IQR 40–88)
103 (IQR 52–192)
<0.001
Median operative time (minutes)
383 (IQR 284–468)
400 (IQR 320–470)
Not significant
Major postoperative complications (Clavien-Dindo ≥3)
24%
13%
0.007
Median Ki67 index
3 (IQR 2–6)
4 (IQR 2–8)
0.03
Microvascular infiltration
Higher rate
Lower rate
<0.05
Lymphatic infiltration
Lower rate
Higher rate
<0.05
Key Findings
The median time from diagnosis to surgery nearly doubled during the COVID-19 era (182 to 382 days), indicating significant surgical delays.
Preoperative oncological treatments (“bridge therapies”) such as PRRT, somatostatin analogs, and chemotherapy were used more frequently during the pandemic (p < 0.001).
There was a higher prevalence of suspected vascular infiltration and metastatic lymphadenopathies at diagnosis during the COVID-19 period (15% vs. 6% and 24% vs. 15%, respectively).
Despite longer waiting times, major postoperative complications decreased during the pandemic (24% pre-COVID vs. 13% during COVID, p = 0.007).
The median Ki67 proliferation index was slightly higher during the pandemic (4 vs. 3, p = 0.03), suggesting possible changes in tumor biology or selection bias.
Pathology showed lower microvascular but higher lymphatic infiltration rates during the COVID-19 period (both p < 0.05).
Clinical Implications
The COVID-19 pandemic necessitated prioritization of pancreatic surgeries, leading to delays in NF-PNET treatment and increased reliance on neoadjuvant therapies. Clinicians should be aware of potential tumor progression risks due to surgical postponements and consider multidisciplinary approaches to optimize timing and treatment strategies. Despite delays, postoperative outcomes may improve with careful patient selection and perioperative management.
Conclusion
The pandemic significantly altered NF-PNET management by prolonging surgical wait times and increasing preoperative therapies, with observable changes in tumor characteristics at surgery. These findings highlight the need for adaptive strategies to maintain oncological care quality during healthcare crises.
References
Italian healthcare system impact during COVID-19
Oncological surgical activity disruptions and ethical considerations
Institutional management protocols for PNETs
North American Neuroendocrine Tumor Society guidelines during COVID-19
by Salvatore Paiella, Luca Landoni, Matteo De Pastena, Giovanni Elio, Fabio Casciani, Sara Cingarlini, Mirko D’Onofrio, Giulia Maistri, Ivan Ciatti, Massimiliano Tuveri, Maria Vittoria Davì, Claudio Luchini, Katia Donadello, Gessica Manzini, Giuseppe Malleo, Roberto Salvia
