ACR Appropriateness Criteria® Staging and Follow-Up of Pancreatic Neuroendocrine Tumors

Accurate staging and appropriate follow-up imaging of pancreatic neuroendocrine tumors (PNET) are essential for guiding management and optimizing outcomes. This document provides evidence-based recommendations for the imaging evaluation of patients with PNET across six clinical variants: local staging, staging for metastatic disease, surveillance postresection, follow-up after treatment of liver-dominant and non-liver dominant disease, and follow-up of untreated disease. Contrast-enhanced CT is usually appropriate in most scenarios and commonly used as the first-line imaging modality in assessing tumor size, locoregional extent, vascular involvement, and metastatic spread. MRI is also usually appropriate, particularly for liver evaluation. MRI with hepatobiliary contrast agents and diffusion-weighted imaging improves detection and characterization of liver metastases, especially in liver-dominant disease. DOTATATE PET/CT is usually appropriate for staging and treatment planning in patients with suspected or known metastatic disease. FDG-PET/CT is reserved for select cases, such as high-grade tumors. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.