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high mortality if left untreated [4]. In the case of our patient, a diagnosis of probable gastrinoma was made due to gastrin levels of 743, chromogranin of 1874, and multiple ulcers extending into the second and third parts of the duodenum.

Currently, surgical resection is widely recognized as the standard treatment for local and metastatic PNETs [8]. Local, low-grade tumors are considered for parenchyma sparing resection, whereas pancreaticoduodenectomy is recognized as necessary in metastatic disease, as observed in our patient with lesions located in the pancreas, liver, and regional lymph nodes [7,8]. Although the mortality rate associated with pancreaticoduodenectomy has significantly decreased in the last several decades, there is still a 35% morbidity rate [17,18]. In the short-term postoperative period, common morbidities include delayed gastric emptying, pancreatic fistula, and surgical site infection [19]. Endocrine and exocrine insufficiencies, with incidences of 36% and 20% respectively, are frequent long-term complications that can impact patient quality of life [20].

For our patient with a primary mass in the head of the pancreas, enlarged peripancreatic lymph nodes, and right liver lobe mass, pancreaticoduodenectomy was offered as first-line treatment. The patient had concerns about radical surgery, potential complications, and long-term side effects and wished to pursue alternative therapies. After discussion about the risks and benefits, it was decided to perform IRE on the pancreas lesion, peripancreatic and portal lymph node removal, and major hepatectomy. The patient was advised that if tumor regrowth occurred, pancreaticoduodenectomy would ultimately be required. At the 6-month scan in May 2022, the patient remained tumor free although frequent monitoring will continue.

Up to this point, there are very few reports of IRE as a surgical treatment for PNETs. A 2016 case report discusses three patients with small (<2 cm), low-grade PNETs who were treated with IRE, all of whom remained disease free after 12-month follow-up [21]. There were no reports found during literature review of IRE use for PNETs with regional lymphadenopathy or distant metastasis. Previous studies on IRE as a treatment for unresectable locally advanced pancreatic adenocarcinomas showed promising results [22]. PNETs are much less common than other pancreatic cancers and have the propensity to be slow growing, leading to more favorable outcomes and longer survival time [4]. Because of this, there is an opportunity to continue considering less radical surgical options such as IRE as a primary treatment modality in future cases.

Conclusion

IRE is a new nonthermal ablative technology that has shown promising potential for the treatment of pancreatic cancers, though its use has not yet been broadly studied for PNETs. Pancreaticoduodenectomy is currently the standard treatment for pancreatic head PNETs with resectable metastases, but the procedure has a high morbidity risk and potential long-term complication rate. This is the first report that we know of using IRE for treatment of a probable gastrinoma with metastasis to the liver. Conclusions are limited based on this single case report. Further studies are warranted to evaluate the efficacy of IRE as a primary surgical treatment for PNETs.

Declarations

## Ethical Consent

Not applicable.

## Funding

No funding.

## Conflicts of Interest

The authors have no conflicts of interest to disclose.

## Authors' contributions

All authors read and approved the final manuscript.