Radioligand therapy, vascular deprivation and surgical resection as a step-up-approach for locally advanced pancreatic neuroendocrine bleeding mass

Background Surgery for symptomatic non-functioning pancreatic neuroendocrine tumors (NF-PanNETs) represents the only definitive curative treatment option and improves the overall survival rate. The new frontier in locally advanced NF-PanNETs treatment is Radioligand therapy (RLT) in a neoadjuvant setting. Acute gastrointestinal bleeding is a rare complication that requires immediate treatment with a multidisciplinary approach. Case presentation We present a case of a 36-year-old male diagnosed with locally advanced non-functioning PanNET in the pancreatic body-tail diagnosed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). RLT, proposed to reduce mass dimension in the planning of surgical resection, was performed to obtain a downstaging tumor and enabling access to radical surgery. For the acute onset of hemorrhagic shock caused by lower gastrointestinal bleeding, tumor endovascular embolization was performed using microspheres and gelatin sponge. On vascular deprivation day 4, a posterior radical antegrade modular pancreatosplenectomy (P-RAMPS), left lateral duodenectomy (III and IV portion) and resection of the left colic flexure were performed. Reconstruction of intestinal continuity was ensured by isoperistaltic side-to-side duodeno-jejuno and colo-colic anastomosis. The patient had a short hospital stay with quick recovery and a good outcome at 6 months follow-up after the surgery. Conclusions Symptomatic non-functioning PanNETs are infrequent slow-growing tumors and some of them may present in advanced stages with local involvement of surrounding structures. Our case suggests that a step-up-approach for locally advanced pancreatic neuroendocrine bleeding mass is mandatory and aggressive surgical management is a mainstay.