Staging and Follow-up of Pancreatic Neuroendocrine Tumors

Variant: 1 Adult. Local staging of pancreatic neuroendocrine tumor.

Procedure	Appropriateness Category	Relative Radiation Level
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
DOTATATE PET/CT skull base to mid-thigh	Usually Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Appropriate	☢☢☢☢
US abdomen endoscopic	May Be Appropriate	O
MRI abdomen without and with IV contrast	May Be Appropriate (Disagreement)	O
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate (Disagreement)	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
FDG-PET/CT skull base to mid-thigh	May Be Appropriate	☢☢☢☢
MRI abdomen without IV contrast	Usually Not Appropriate	O
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢

Variant: 2 Adult. Staging of pancreatic neuroendocrine tumor. Evaluation for metastatic disease.

Procedure	Appropriateness Category	Relative Radiation Level
MRI abdomen and pelvis without and with IV contrast	Usually Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
DOTATATE PET/CT skull base to mid-thigh	Usually Appropriate	☢☢☢
CT chest abdomen pelvis with IV contrast	Usually Appropriate	☢☢☢☢
MRI abdomen and pelvis without IV contrast	May Be Appropriate	O
CT abdomen and pelvis without and with IV contrast	May Be Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	May Be Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	May Be Appropriate	☢☢☢☢
US abdomen endoscopic	Usually Not Appropriate	O
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 3 Adult. Pancreatic neuroendocrine tumor. Imaging after surgical resection, no suspected or known recurrence. Surveillance.

Procedure	Appropriateness Category	Relative Radiation Level
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
CT chest abdomen pelvis with IV contrast	Usually Appropriate	☢☢☢☢
MRI abdomen and pelvis without and with IV contrast	May Be Appropriate (Disagreement)	O
MRI abdomen and pelvis without IV contrast	May Be Appropriate	O
DOTATATE PET/CT skull base to mid-thigh	May Be Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	May Be Appropriate (Disagreement)	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	May Be Appropriate	☢☢☢☢
US abdomen endoscopic	Usually Not Appropriate	O
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 4 Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Liver dominant disease.

Procedure	Appropriateness Category	Relative Radiation Level
MRI abdomen and pelvis without and with IV contrast	Usually Appropriate	O
CT abdomen and pelvis without and with IV contrast	Usually Appropriate	☢☢☢☢
CT chest abdomen pelvis with IV contrast	Usually Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	Usually Appropriate	☢☢☢☢
MRI abdomen and pelvis without IV contrast	May Be Appropriate (Disagreement)	O
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate (Disagreement)	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate (Disagreement)	O
CT abdomen and pelvis with IV contrast	May Be Appropriate (Disagreement)	☢☢☢
DOTATATE PET/CT skull base to mid-thigh	May Be Appropriate (Disagreement)	☢☢☢
US abdomen endoscopic	Usually Not Appropriate	O
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Variant: 5 Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Non-liver dominant disease.

Procedure	Appropriateness Category	Relative Radiation Level
MRI abdomen and pelvis without and with IV contrast	Usually Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
DOTATATE PET/CT skull base to mid-thigh	Usually Appropriate	☢☢☢
CT chest abdomen pelvis with IV contrast	Usually Appropriate	☢☢☢☢
MRI abdomen and pelvis without IV contrast	May Be Appropriate	O
MRI abdomen without and with IV contrast with MRCP	May Be Appropriate (Disagreement)	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
CT abdomen and pelvis without and with IV contrast	May Be Appropriate	☢☢☢☢
CT chest abdomen pelvis without and with IV contrast	May Be Appropriate	☢☢☢☢
FDG-PET/CT skull base to mid-thigh	May Be Appropriate	☢☢☢☢
US abdomen endoscopic	Usually Not Appropriate	O
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢
CT chest abdomen pelvis without IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 6 Adult. Pancreatic neuroendocrine tumor. Follow-up imaging of untreated disease.

Procedure	Appropriateness Category	Relative Radiation Level
MRI abdomen and pelvis without and with IV contrast	Usually Appropriate	O
MRI abdomen without and with IV contrast with MRCP	Usually Appropriate	O
CT abdomen and pelvis with IV contrast	Usually Appropriate	☢☢☢
CT abdomen and pelvis without and with IV contrast	Usually Appropriate	☢☢☢☢
MRI abdomen and pelvis without IV contrast	May Be Appropriate	O
MRI abdomen without IV contrast with MRCP	May Be Appropriate	O
DOTATATE PET/CT skull base to mid-thigh	May Be Appropriate (Disagreement)	☢☢☢
US abdomen endoscopic	Usually Not Appropriate	O
CT abdomen and pelvis without IV contrast	Usually Not Appropriate	☢☢☢
FDG-PET/CT skull base to mid-thigh	Usually Not Appropriate	☢☢☢☢

Panel Members

Joseph H. Yacoub, MD^a; Motoyo Yano, MD, PhD^b; Kevin J. Chang, MD^c; Emily Bergsland, MD^d; Priya R. Bhosale, MD^e; Brooks D. Cash, MD^f; Victoria Chernyak, MD, MS^g; Ayushi Gupta, MD^h; Julie Hallet, MD, MScⁱ; Jason Halpern, MD^j; Michael Magnetta, MD^k; Craig F. Noronha, MD^l; Tamer Refaat, MD, PhD, MS^m; Elena K. Korngold, MDⁿ.

Summary of Literature Review

Introduction/Background

Discussion of Procedures by Variant

Variant 1: Adult. Local staging of pancreatic neuroendocrine tumor.

Variant 1: Adult. Local staging of pancreatic neuroendocrine tumor.
A. CT abdomen and pelvis with IV contrast

Variant 1: Adult. Local staging of pancreatic neuroendocrine tumor.
B. CT abdomen and pelvis without and with IV contrast

Variant 1: Adult. Local staging of pancreatic neuroendocrine tumor.
C. CT abdomen and pelvis without IV contrast

Variant 1: Adult. Local staging of pancreatic neuroendocrine tumor.
D. DOTATATE PET/CT skull base to mid-thigh

Variant 1: Adult. Local staging of pancreatic neuroendocrine tumor.
E. FDG-PET/CT skull base to mid-thigh

Variant 1: Adult. Local staging of pancreatic neuroendocrine tumor.
F. MRI abdomen without and with IV contrast

Variant 1: Adult. Local staging of pancreatic neuroendocrine tumor.
G. MRI abdomen without and with IV contrast with MRCP

Variant 1: Adult. Local staging of pancreatic neuroendocrine tumor.
H. MRI abdomen without IV contrast

Variant 1: Adult. Local staging of pancreatic neuroendocrine tumor.
I. MRI abdomen without IV contrast with MRCP

Variant 1: Adult. Local staging of pancreatic neuroendocrine tumor.
J. US abdomen endoscopic

Variant 2: Adult. Staging of pancreatic neuroendocrine tumor. Evaluation for metastatic disease.

Variant 2: Adult. Staging of pancreatic neuroendocrine tumor. Evaluation for metastatic disease.
A. CT abdomen and pelvis with IV contrast

Variant 2: Adult. Staging of pancreatic neuroendocrine tumor. Evaluation for metastatic disease.
B. CT abdomen and pelvis without and with IV contrast

Variant 2: Adult. Staging of pancreatic neuroendocrine tumor. Evaluation for metastatic disease.
C. CT abdomen and pelvis without IV contrast

Variant 2: Adult. Staging of pancreatic neuroendocrine tumor. Evaluation for metastatic disease.
D. CT chest abdomen pelvis with IV contrast

Variant 2: Adult. Staging of pancreatic neuroendocrine tumor. Evaluation for metastatic disease.
E. CT chest abdomen pelvis without and with IV contrast

Variant 2: Adult. Staging of pancreatic neuroendocrine tumor. Evaluation for metastatic disease.
F. CT chest abdomen pelvis without IV contrast

Variant 2: Adult. Staging of pancreatic neuroendocrine tumor. Evaluation for metastatic disease.
G. DOTATATE PET/CT skull base to mid-thigh

Variant 2: Adult. Staging of pancreatic neuroendocrine tumor. Evaluation for metastatic disease.
H. FDG-PET/CT skull base to mid-thigh

Variant 2: Adult. Staging of pancreatic neuroendocrine tumor. Evaluation for metastatic disease.
I. MRI abdomen and pelvis without and with IV contrast

Variant 2: Adult. Staging of pancreatic neuroendocrine tumor. Evaluation for metastatic disease.
J. MRI abdomen and pelvis without IV contrast

Variant 2: Adult. Staging of pancreatic neuroendocrine tumor. Evaluation for metastatic disease.
K. US abdomen endoscopic

Variant 3: Adult. Pancreatic neuroendocrine tumor. Imaging after surgical resection, no suspected or known recurrence. Surveillance.

Variant 3: Adult. Pancreatic neuroendocrine tumor. Imaging after surgical resection, no suspected or known recurrence. Surveillance.
A. CT abdomen and pelvis with IV contrast

Variant 3: Adult. Pancreatic neuroendocrine tumor. Imaging after surgical resection, no suspected or known recurrence. Surveillance.
B. CT abdomen and pelvis without and with IV contrast

Variant 3: Adult. Pancreatic neuroendocrine tumor. Imaging after surgical resection, no suspected or known recurrence. Surveillance.
C. CT abdomen and pelvis without IV contrast

Variant 3: Adult. Pancreatic neuroendocrine tumor. Imaging after surgical resection, no suspected or known recurrence. Surveillance.
D. CT chest abdomen pelvis with IV contrast

Variant 3: Adult. Pancreatic neuroendocrine tumor. Imaging after surgical resection, no suspected or known recurrence. Surveillance.
E. CT chest abdomen pelvis without and with IV contrast

Variant 3: Adult. Pancreatic neuroendocrine tumor. Imaging after surgical resection, no suspected or known recurrence. Surveillance.
F. CT chest abdomen pelvis without IV contrast

Variant 3: Adult. Pancreatic neuroendocrine tumor. Imaging after surgical resection, no suspected or known recurrence. Surveillance.
G. DOTATATE PET/CT skull base to mid-thigh

Variant 3: Adult. Pancreatic neuroendocrine tumor. Imaging after surgical resection, no suspected or known recurrence. Surveillance.
H. FDG-PET/CT skull base to mid-thigh

Variant 3: Adult. Pancreatic neuroendocrine tumor. Imaging after surgical resection, no suspected or known recurrence. Surveillance.
I. MRI abdomen and pelvis without and with IV contrast

Variant 3: Adult. Pancreatic neuroendocrine tumor. Imaging after surgical resection, no suspected or known recurrence. Surveillance.
J. MRI abdomen and pelvis without IV contrast

Variant 3: Adult. Pancreatic neuroendocrine tumor. Imaging after surgical resection, no suspected or known recurrence. Surveillance.
K. US abdomen endoscopic

Variant 4: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Liver dominant disease.

Variant 4: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Liver dominant disease.
A. CT abdomen and pelvis with IV contrast

Variant 4: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Liver dominant disease.
B. CT abdomen and pelvis without and with IV contrast

Variant 4: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Liver dominant disease.
C. CT abdomen and pelvis without IV contrast

Variant 4: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Liver dominant disease.
D. CT chest abdomen pelvis with IV contrast

Variant 4: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Liver dominant disease.
E. CT chest abdomen pelvis without and with IV contrast

Variant 4: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Liver dominant disease.
F. CT chest abdomen pelvis without IV contrast

Variant 4: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Liver dominant disease.
G. DOTATATE PET/CT skull base to mid-thigh

Variant 4: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Liver dominant disease.
H. FDG-PET/CT skull base to mid-thigh

Variant 4: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Liver dominant disease.
I. MRI abdomen and pelvis without and with IV contrast

Variant 4: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Liver dominant disease.
J. MRI abdomen and pelvis without IV contrast

Variant 4: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Liver dominant disease.
K. MRI abdomen without and with IV contrast with MRCP

Variant 4: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Liver dominant disease.
L. MRI abdomen without IV contrast with MRCP

Variant 4: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Liver dominant disease.
M. US abdomen endoscopic

Variant 5: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Non-liver dominant disease.

Variant 5: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Non-liver dominant disease.
A. CT abdomen and pelvis with IV contrast

Variant 5: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Non-liver dominant disease.
B. CT abdomen and pelvis without and with IV contrast

Variant 5: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Non-liver dominant disease.
C. CT abdomen and pelvis without IV contrast

Variant 5: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Non-liver dominant disease.
D. CT chest abdomen pelvis with IV contrast

Variant 5: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Non-liver dominant disease.
E. CT chest abdomen pelvis without and with IV contrast

Variant 5: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Non-liver dominant disease.
F. CT chest abdomen pelvis without IV contrast

Variant 5: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Non-liver dominant disease.
G. DOTATATE PET/CT skull base to mid-thigh

Variant 5: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Non-liver dominant disease.
H. FDG-PET/CT skull base to mid-thigh

Variant 5: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Non-liver dominant disease.
I. MRI abdomen and pelvis without and with IV contrast

Variant 5: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Non-liver dominant disease.
J. MRI abdomen and pelvis without IV contrast

Variant 5: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Non-liver dominant disease.
K. MRI abdomen without and with IV contrast with MRCP

Variant 5: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Non-liver dominant disease.
L. MRI abdomen without IV contrast with MRCP

Variant 5: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging after treatment. Non-liver dominant disease.
M. US abdomen endoscopic

Variant 6: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging of untreated disease.

Variant 6: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging of untreated disease.
A. CT abdomen and pelvis with IV contrast

Variant 6: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging of untreated disease.
B. CT abdomen and pelvis without and with IV contrast

Variant 6: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging of untreated disease.
C. CT abdomen and pelvis without IV contrast

Variant 6: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging of untreated disease.
D. DOTATATE PET/CT skull base to mid-thigh

Variant 6: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging of untreated disease.
E. FDG-PET/CT skull base to mid-thigh

Variant 6: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging of untreated disease.
F. MRI abdomen and pelvis without and with IV contrast

Variant 6: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging of untreated disease.
G. MRI abdomen and pelvis without IV contrast

Variant 6: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging of untreated disease.
H. MRI abdomen without and with IV contrast with MRCP

Variant 6: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging of untreated disease.
I. MRI abdomen without IV contrast with MRCP

Variant 6: Adult. Pancreatic neuroendocrine tumor. Follow-up imaging of untreated disease.
J. US abdomen endoscopic

Summary of Highlights

Gender Equality and Inclusivity Clause

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

References

1.	Konstantinoff KS, Morani AC, Hope TA, et al. Pancreatic neuroendocrine tumors: tailoring imaging to specific clinical scenarios. Abdom Radiol (NY) 2023;48:1843-53.
2.	Lee NJ, Hruban RH, Fishman EK. Pancreatic neuroendocrine tumor: review of heterogeneous spectrum of CT appearance. [Review]. Abdominal Radiology. 43(11):3025-3034, 2018 11.
3.	Dasari A, Shen C, Halperin D, et al. Trends in the Incidence, Prevalence, and Survival Outcomes in Patients With Neuroendocrine Tumors in the United States. JAMA Oncol 2017;3:1335-42.
4.	Xu Z, Wang L, Dai S, et al. Epidemiologic Trends of and Factors Associated With Overall Survival for Patients With Gastroenteropancreatic Neuroendocrine Tumors in the United States. JAMA Netw Open 2021;4:e2124750.
5.	Park HJ, Kim HJ, Kim KW, et al. Comparison between neuroendocrine carcinomas and well-differentiated neuroendocrine tumors of the pancreas using dynamic enhanced CT. European Radiology. 30(9):4772-4782, 2020 Sep.
6.	Balachandran A, Tamm EP, Bhosale PR, et al. Venous tumor thrombus in nonfunctional pancreatic neuroendocrine tumors. AJR Am J Roentgenol 2012;199:602-8.
7.	Liu C, Bian Y, Meng Y, et al. Preoperative Prediction of G1 and G2/3 Grades in Patients With Nonfunctional Pancreatic Neuroendocrine Tumors Using Multimodality Imaging. Academic Radiology. 29(4):e49-e60, 2022 04.
8.	Halfdanarson TR, Strosberg JR, Tang L, et al. The North American Neuroendocrine Tumor Society Consensus Guidelines for Surveillance and Medical Management of Pancreatic Neuroendocrine Tumors. Pancreas 2020;49:863-81.
9.	Lo GC, Kambadakone A. MR Imaging of Pancreatic Neuroendocrine Tumors. [Review]. Magnetic Resonance Imaging Clinics of North America. 26(3):391-403, 2018 Aug.
10.	Bian Y, Li J, Jiang H, et al. Tumor Size on Microscopy, CT, and MRI Assessments Versus Pathologic Gross Specimen Analysis of Pancreatic Neuroendocrine Tumors. AJR. American Journal of Roentgenology. 217(1):107-116, 2021 07.
11.	Choe J, Kim KW, Kim HJ, et al. What Is New in the 2017 World Health Organization Classification and 8th American Joint Committee on Cancer Staging System for Pancreatic Neuroendocrine Neoplasms?. [Review]. Korean Journal of Radiology. 20(1):5-17, 2019 01.
12.	Chauhan A, Chan K, Halfdanarson TR, et al. Critical updates in neuroendocrine tumors: Version 9 American Joint Committee on Cancer staging system for gastroenteropancreatic neuroendocrine tumors. CA Cancer J Clin 2024;74:359-67.
13.	Canellas R, Lo G, Bhowmik S, Ferrone C, Sahani D. Pancreatic neuroendocrine tumor: Correlations between MRI features, tumor biology, and clinical outcome after surgery. Journal of Magnetic Resonance Imaging. 47(2):425-432, 2018 02.
14.	Shah MH, Goldner WS, Halfdanarson TR, et al. NCCN Guidelines Insights: Neuroendocrine and Adrenal Tumors, Version 2.2018. J Natl Compr Canc Netw 2018;16:693-702.
15.	Chan JA, Geyer S, Zemla T, et al. Phase 3 Trial of Cabozantinib to Treat Advanced Neuroendocrine Tumors. N Engl J Med 2024.
16.	Kunz PL, Graham NT, Catalano PJ, et al. Randomized Study of Temozolomide or Temozolomide and Capecitabine in Patients With Advanced Pancreatic Neuroendocrine Tumors (ECOG-ACRIN E2211). J Clin Oncol 2023;41:1359-69.
17.	Sundin A, Arnold R, Baudin E, et al. ENETS Consensus Guidelines for the Standards of Care in Neuroendocrine Tumors: Radiological, Nuclear Medicine & Hybrid Imaging. Neuroendocrinology 2017;105:212-44.
18.	Kawamoto S, Johnson PT, Shi C, et al. Pancreatic neuroendocrine tumor with cystlike changes: evaluation with MDCT. AJR. American Journal of Roentgenology. 200(3):W283-90, 2013 Mar.
19.	Canellas R, Burk KS, Parakh A, Sahani DV. Prediction of Pancreatic Neuroendocrine Tumor Grade Based on CT Features and Texture Analysis. AJR. American Journal of Roentgenology. 210(2):341-346, 2018 Feb.
20.	Han S, Kim JH, Yoo J, Jang S. Prediction of recurrence after surgery based on preoperative MRI features in patients with pancreatic neuroendocrine tumors. European Radiology. 32(4):2506-2517, 2022 Apr.
21.	Luo Y, Dong Z, Chen J, et al. Pancreatic neuroendocrine tumours: correlation between MSCT features and pathological classification. Eur Radiol 2014;24:2945-52.
22.	LeGout JD, Bailey RE, Bolan CW, et al. Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion. [Review]. Radiographics. 40(7):2098-2116, 2020 Nov-Dec.
23.	Falconi M, Eriksson B, Kaltsas G, et al. ENETS Consensus Guidelines Update for the Management of Patients with Functional Pancreatic Neuroendocrine Tumors and Non-Functional Pancreatic Neuroendocrine Tumors. Neuroendocrinology 2016;103:153-71.
24.	Hope TA, Bergsland EK, Bozkurt MF, et al. Appropriate Use Criteria for Somatostatin Receptor PET Imaging in Neuroendocrine Tumors. J Nucl Med 2018;59:66-74.
25.	Howe JR, Merchant NB, Conrad C, et al. The North American Neuroendocrine Tumor Society Consensus Paper on the Surgical Management of Pancreatic Neuroendocrine Tumors. Pancreas 2020;49:1-33.
26.	Ambrosini V, Campana D, Bodei L, et al. 68Ga-DOTANOC PET/CT clinical impact in patients with neuroendocrine tumors. J Nucl Med. 51(5):669-73, 2010 May.
27.	Jeon SK, Lee JM, Joo I, et al. Nonhypervascular Pancreatic Neuroendocrine Tumors: Differential Diagnosis from Pancreatic Ductal Adenocarcinomas at MR Imaging-Retrospective Cross-sectional Study. Radiology. 284(1):77-87, 2017 07.
28.	Yano M, Misra S, Salter A, Carpenter DH. Assessment of disease aggression in cystic pancreatic neuroendocrine tumors: A CT and pathology correlation study. Pancreatology 2017;17:605-10.
29.	Kim JH, Eun HW, Kim YJ, Han JK, Choi BI. Staging accuracy of MR for pancreatic neuroendocrine tumor and imaging findings according to the tumor grade. Abdominal Imaging. 38(5):1106-14, 2013 Oct.
30.	Takumi K, Fukukura Y, Higashi M, et al. Pancreatic neuroendocrine tumors: Correlation between the contrast-enhanced computed tomography features and the pathological tumor grade. Eur J Radiol. 84(8):1436-43, 2015 Aug.
31.	Arai T, Kobayashi A, Fujinaga Y, et al. Contrast-enhancement ratio on multiphase enhanced computed tomography predicts recurrence of pancreatic neuroendocrine tumor after curative resection. Pancreatology. 16(3):397-402, 2016 May-Jun.
32.	Guo C, Zhuge X, Wang Z, et al. Textural analysis on contrast-enhanced CT in pancreatic neuroendocrine neoplasms: association with WHO grade. Abdominal Radiology. 44(2):576-585, 2019 02.
33.	Pereira JA, Rosado E, Bali M, Metens T, Chao SL. Pancreatic neuroendocrine tumors: correlation between histogram analysis of apparent diffusion coefficient maps and tumor grade. Abdominal Imaging. 40(8):3122-8, 2015 Oct.
34.	Elias D, Lefevre JH, Duvillard P, et al. Hepatic metastases from neuroendocrine tumors with a "thin slice" pathological examination: they are many more than you think. Ann Surg 2010;251:307-10.
35.	NCCN Clinical Practice Guidelines in Oncology. Pancreatic Adenocarcinoma. Version 1.2024. Available at: https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf.
36.	d'Assignies G, Fina P, Bruno O, et al. High sensitivity of diffusion-weighted MR imaging for the detection of liver metastases from neuroendocrine tumors: comparison with T2-weighted and dynamic gadolinium-enhanced MR imaging. Radiology. 268(2):390-9, 2013 Aug.
37.	Morse B, Jeong D, Thomas K, Diallo D, Strosberg JR. Magnetic Resonance Imaging of Neuroendocrine Tumor Hepatic Metastases: Does Hepatobiliary Phase Imaging Improve Lesion Conspicuity and Interobserver Agreement of Lesion Measurements? Pancreas 2017;46:1219-24.
38.	Tirumani SH, Jagannathan JP, Braschi-Amirfarzan M, et al. Value of hepatocellular phase imaging after intravenous gadoxetate disodium for assessing hepatic metastases from gastroenteropancreatic neuroendocrine tumors: comparison with other MRI pulse sequences and with extracellular agent. Abdom Radiol (NY) 2018;43:2329-39.
39.	Korngold EK, Moreno C, Kim DH, et al. ACR Appropriateness Criteria® Staging of Colorectal Cancer: 2021 Update. J Am Coll Radiol 2022;19:S208-S22.
40.	Lavelle LP, O'Neill AC, McMahon CJ, et al. Is diffusion-weighted MRI sufficient for follow-up of neuroendocrine tumour liver metastases?. Clin Radiol. 71(9):863-8, 2016 Sep.
41.	Bhosale P, Kwek JW, Iyer R, Wei W, Bassett R, Kundra V. Follow-up of known carcinoid liver metastases: is respiratory-gated t(2) fast spin-echo enough?. Neuroendocrinology. 93(4):241-8, 2011.
42.	Galgano SJ, Iravani A, Bodei L, El-Haddad G, Hofman MS, Kong G. Imaging of Neuroendocrine Neoplasms: Monitoring Treatment Response-AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2022;218:767-80.
43.	Davenport MS, Viglianti BL, Al-Hawary MM, et al. Comparison of acute transient dyspnea after intravenous administration of gadoxetate disodium and gadobenate dimeglumine: effect on arterial phase image quality. Radiology 2013;266:452-61.
44.	National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Committee on National Statistics; Committee on Measuring Sex, Gender Identity, and Sexual Orientation. Measuring Sex, Gender Identity, and Sexual Orientation. In: Becker T, Chin M, Bates N, eds. Measuring Sex, Gender Identity, and Sexual Orientation. Washington (DC): National Academies Press (US) Copyright 2022 by the National Academy of Sciences. All rights reserved.; 2022.
45.	American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.