European Journal of Radiology 141 (2021) 109803

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European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

Research article

Prediction of non-functioning pancreatic neuroendocrine tumor grades

with fractal analysis of preoperative contrast-enhanced computed
tomography images
Akira Nakano a, *, Koichi Hayano b, Toru Tochigi b, Taro Mashiko a, Yoshihito Masuoka a,
Seiichiro Yamamoto a, Soji Ozawa a, Toshio Nakagohri a
a
Department of Surgery, Tokai University Hospital, 143 Shimokasuya, Isehara, Kanagawa, 259-1143, Japan
b
Department of Frontier Surgery, Chiba University Hospital, 1-8-1 Inohana, Chiba 260-8677, Japan

A R T I C L E I N F O A B S T R A C T

Keywords: Purpose: To assess intra-tumoral heterogeneity (ITH) via fractal analysis of preoperative contrast-enhanced
Pancreatic neuroendocrine tumor computed tomography (CT) images to predict pathological grades in non-functioning pancreatic neuroendo­
Intratumoral heterogeneity crine tumors (NF-PNETs) and verify its impact on patient survival.
Contrast-enhanced -computed tomography
Methods: This retrospective study enrolled 40 patients with NF-PNET resected in our institution during a period
Fractal analysis
Non-functioning tumor
from July 2005 to December 2018, except functioning tumors, unidentified tumors in CT, patients without
Ki-67 labeling index preoperative contrast-enhanced CT. CT images were analyzed using plugin software for calculating fractal
dimension (FD), and the maximum value was denoted as “FDmax,” and compared with pathological grades and
patient survival between G1 and G2/3 group separating according to two different Ki-67 index thresholds (3%
and 5%). All CT images were acquired in three-phases and arterial phase images were examined.
Results: Ki-67 index and FDmax showed a direct correlation with significance (p < 0.01). The mean FDmax of the
G2/3 tumor group was significantly higher than that of the G1 tumor group (p < 0.01 in both 3% and 5%
thresholds). In the ROC analysis, FDmax showed 0.773 of AUC, and cut-off value of 1.036 reported 62.5 %
sensitivity, 90.0 % specificity, 86.2 % PPV, and 70.6 % NPV to distinguish G2/3 patients. The high-FD (≥1.036)
group showed a significantly shorter disease-free survival (DFS) than the low-FD group (p = 0.0128). In
multivariate analysis of prognostic factors, high FD was the only significant factor for DFS (HR, 5.793; 95 % CI:
1.213− 27.664; p = 0.028).
Conclusions: The tumor’s FDmax using CE-CT analysis might be a potential biomarker for preoperative prediction
of G2/3 tumors, and predicting recurrence.

1. Introduction
Pancreatic neuroendocrine tumors (PNETs) are heterogeneous tu­
mors originating from the neuroendocrine cells in the pancreas ac­
counting for approximately 10 % of all pancreatic tumors [1]. In recent
years, the use of advanced imaging techniques including computed to­
mography (CT) and magnetic resonance imaging have resulted in an
increased detection rate of incidental PNETs [2]. All PNETs were
considered for surgery in Japan; however, with the 2019 revision of
clinical practice guidelines, small, non-functioning, low-grade tumors
can now be followed-up [3]. The recent guidelines from the European
Neuroendocrine Tumor Society have advocated the possibility of a
conservative approach for patient management [4]. However, preop­
erative assessment of malignant potential in PNETs remains challenging.
PNETs and their pathological grades are often diagnosed with endo­
scopic ultrasound-guided fine-needle aspiration (EUS-FNA)

Abbreviations: CT, Computed tomography; PNETs, Pancreatic neuroendocrine tumors; NF-PNETs, Non-functioning pancreatic neuroendocrine tumors; ITS,
Intratumoral heterogeneity; EUS-FNA, Endoscopic ultrasound-guided fine needle aspiration; FD, Fractal dimension; FDmax, Maximum value of fractal dimension; LN,
Lymph node; HPF, High power field; ROI, Region of interest; AUC, Area under the curve; ROC, Receiver operating characteristic; OS, Overall survival; DFS, Disease-
free survival; NEC, Neuroendocrine carcinoma; DPM1, Positive dissected peripancreatic tissue margin; MST, Median survival time.
* Corresponding author.
E-mail addresses: nakano@chiba-u.jp (A. Nakano), k-hayano@chiba-u.jp (K. Hayano), tochigi@chiba-u.jp (T. Tochigi), mt334592@tsc.u-tokai.ac.jp (T. Mashiko),
y-masu@is.icc.u-tokai.ac.jp (Y. Masuoka), seiyamamoto@tsc.u-tokai.ac.jp (S. Yamamoto), sozawa@tokai.ac.jp (S. Ozawa), nakagori@tokai-u.jp (T. Nakagohri).

https://doi.org/10.1016/j.ejrad.2021.109803
Received 11 December 2020; Received in revised form 26 April 2021; Accepted 26 May 2021
Available online 29 May 2021
0720-048X/© 2021 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
A. Nakano et al.
preoperatively. The corresponding rates of the resected specimens with
grades ranged from 70 to 90%. However, the majority of accurately
diagnosed PNETs are small, NET G1 tumors [5]; As a matter of fact, poor
diagnostic accuracy was reported in G2/3 and large-sized tumors owing
to intratumoral heterogeneity (ITH) [6]. Likewise, Previous studies
investigated the CT characteristics of PNETs, such as ductal dilation,
ill-defined margins, or poor enhancement, for predicting pathological
grade of the PNETs [7]. However, accurate prediction is still limited by
CT alone.
ITH is one of the topics which recently gains attention as a biomarker
representing a malignant potential of the tumor itself, leading to cancer
progression or chemo-resistance which affects prognosis. Some previous
reports has demonstrated that ITH of tumor correlated with treatment
response or prognosis in hepatocellular carcinoma, and gastric cancer
[8,9]. These reports indicated that high ITH significantly associated with
progression of disease and worse outcomes. Fractal analysis, mathe­
matical methods for analyzing the value of complexity within the region
of interest (ROI) to provide a measure of intralesional heterogeneity, has
recently been in the spotlight as a useful method for quantifying ITH.
However, a few reports have been published, as for quantitative analysis
on PNETs, with various outcomes [10–12].
To the best of our knowledge, there have been no previous reports
regarding quantitative imaging analysis for predicting grades of PNETs,
particularly focusing on non-functioning tumors. This is an important
point because only non-functioning PNETs have treatment options
(resection or observation). Therefore, our aim of the study is to inves­
tigate the usefulness of fractal analysis of contrast-enhanced CT images
for preoperative prediction of pathological grades of NF-PNETs and
evaluate its impact on patients prognosis, which may be helpful infor­
mation for the determination of treatment option.
2. Materials and methods
2.1. Patient selection
This study was approved by the Institutional Review Board of our
hospital. The review board waived the requirement for informed consent
due to the retrospective study design. We checked all histologically
proven PNET cases during a period from July 2005 to December 2018
and identified 66 patients with PNETs who were considered for inclu­
sion in this retrospective study. We excluded patients who did not un­
dergo preoperative contrast-enhanced CT (n = 4), patient’s tumor not
identified (n = 11), and a patient with an R2 resection with multiple
Fig. 1. Flow diagram of the included patients. PNETs.
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European Journal of Radiology 141 (2021) 109803
liver metastases (n = 1). Among remaining 50 patients, we excluded 10
patients with functioning tumors. Finally, 40 NF-PNETs patients were
examined in our present study (Fig. 1).
2.2. CT imaging protocol
CT images were obtained using different 64-multiple detector scan­
ners (SOMATOM Definition Edge [Siemens Healthiness, Tokyo, Japan];
SOMATOM Definition Flash; and SOMATOM Force). All scans began at
the cranial liver end and continued to the caudal pancreas end, but
delayed-phase imaging was performed from the chest to the pelvis. The
imaging parameters were as follows: tube voltage, 120 kVp; tube cur­
rent, 200− 250 mA; slice thickness, 3 mm; slice interval, 1 mm; beam
collimation, 0.625 mm × 128; helical pitch, 0.6; and tube current,
automatic tube current modulation. For contrast-enhanced CT scan, a
non-ionic contrast material with an iodine concentration of 300 mg/mL
(Omnipaque, Daiichi Sankyo, Tokyo, Japan) was administered intrave­
nously at a dose of 2.0 mL/kg (in a fixed duration of 30 s). Bolus tracking
technique was used for the arterial phase scan. The enhanced images
were obtained at arterial phase (30–35 s) and portal phase (60− 70 s),
and delayed phase (120 s). The slice thickness of reconstruction was set
at 2.0 mm for diagnostic reading. As post-processing, we performed
multi-view reconstruction and maximum intensity projection.
2.3. CT image processing and fractal analysis at tumor sites
All CT images were digitally reconstructed using the ImageJ software
(version 1.52; National Institutes of Health). We used the arterial phase
of CT images because tumors showed the most distinct outline by their
hyper-vascular nature [13]. Region of interest (ROI) was manually
drawn in consensus by two observers (＞ 10 years of clinical experienced
surgeons who were blind to all patient information other than their lo­
cations) around the peripheral boundary of the primary pancreatic
lesion, avoiding adjacent vessels and calcifications. After images con­
taining generated ROI were loaded into ImageJ (where each pixel was
assigned a gray-scale value, range, 0–255), the analysis was performed
using FracLac (version 2.5), a plugin software for ImageJ, specially
designed for fractal analysis estimating the complexity of geometrical
patterns automatically from recursive procedures. We adopted the
“differential” box-counting method to analyze a gray-scale image, which
is a collection of disparate values, and to calculate the measured index of
heterogeneity, fractal dimension (FD). The analysis is based on the
following equation: NL = KL-FD, where, L: box size, NL: number of boxes
A. Nakano et al. European Journal of Radiology 141 (2021) 109803

at size L needed to cover the object being studied, and log K: obtained
from the y-intercept using linear regression (log-log plot of NL vs. L). The
minimum box size was set as 2 × 2 pixels and was gradually increased
during the sampling period until the maximum size (45 %) of the total
area selected was reached.
The 3D analysis was performed by determining ROIs using the same
method on every axial CT image containing tumor lesion to cover the
entire tumor volume. FD was calculated for each slice, and ITH was
represented by the highest FD value among calculated FDs, designated
as FDmax. To ensure reproducibility, the measurement was performed
three times, and the median was used as the representative value
(Fig. 2).
2.4. Surgical procedures and pathologic evaluation
Pancreatic parenchyma resections with lymph node dissection are
the standard procedures performed in our institution. Pan­
creaticoduodenectomy (PD) (n = 18), distal pancreatectomy (DP)
(n = 8), and total pancreatectomy (n = 3) were performed depending
on the tumor location. For patients with small (≤ 2 cm) lesions and
without lymph node(LN) enlargement, tumor enucleation (n = 6) or
middle pancreatectomy (n = 5) were performed. Simultaneous hepa­
tectomy (n = 3) and concomitant portal vein resection (n = 3) were also
performed.
For each patient, pathological tumor grade evaluation was done
according to the 2017 WHO classification, including Ki-67 proliferation
index and the number of mitosis [i.e., NET G1: Ki-67 ≤ 2%, < 2 mitotic
counts/10 HPF; NET G2: Ki-67 3–20 %, mitotic count 2–20/10 HPFs;
NEC G3: Ki-67 > 20 %, mitotic count > 20/10 HPF] [14].
2.5. Categorical assignment of patients for comparison
To assess the accuracy and precision of FDmax in detecting high-
grade tumors, patients were divided, depending on their postoperative
pathological analysis, into G1 and G2/3 groups according to the Ki-67
index, with two different cut-offs (≥ 3% and ≥ 5%). For the assess­
ment of the prognostic impact of FDmax, patients were divided into the
high-FD and low-FD groups based on the optimal cut-off value
calculated in the receiver operating characteristic (ROC) curve analysis.
2.6. Statistical analyses
IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk,
NY, USA) was used for statistical analyses. Continuous variables were
represented as means ± SD or medians and range, and categorical var­
iables as numbers and percentages. The Mann-Whitney test was used to
compare quantitative variables, and the X2 test was used to compare
categorical variables of each group. The relationship between FDmax
and Ki-67 was tested with a Pearson correlation. Cut-off values were
obtained to determine the performance of FDmax and tumor size in
differentiating the tumors, using ROC curve analysis. Overall survival
(OS) and disease-free survival (DFS) were measured from the date of
operation to the date of last clinical follow-up or death from any cause.
Survival curves were plotted using the Kaplan–Meier method, and the
log-rank test was used to assess differences between groups. Univariate
and multivariable Cox regression analyses, with a manual backward
stepwise elimination procedure, were performed to assess the effect of
each variable on survival. A p-value < 0.05 was considered statistically
significant.
3. Results
3.1. Patient characteristics
Characteristics of 40 patients (male, n = 21; female, n = 19) with
NF-PNETs are summarized in Table 1. The median age was 61 years
(range, 36–80), median tumor size, 23.5 mm (range, 4–150), and Ki-67
index values, range 0.5–40 %. Based on the WHO 2017 classification,
patients’ tumors were graded as NET G1 (n = 20), NET G2 (n = 19), and
NEC G3 (n = 1).
All patients received R0 surgery except one (R1, with positive
dissected peripancreatic tissue margin (DPM1)). LN metastasis was
Table 1
Clinical characteristics and surgical outcomes of patients undergoing surgery.
Factors 　 n (%)

Sex Male 21(52.5)

Female 19(47.5)
Age, years Median (range) 61 (36–80)
Tumor location Head 22(0.55)
Body 10(25.0)
Tail 5(12.5)
Overlapping 3(7.5)
Size of tumor (mm) Median (range) 23.5 (4–150)
Grading NET G1 20(50)
NET G2 19(47.5)
NEC G3 1(2.5)
T-stage (UICC) T1 17(42.5)
T2 7(17.5)
T3 10(25.0)
T4 6(15.0)
LN metastasis (+) 8(20.0)
(-) 32(80.0)
Liver metastasis Positive 3(7.5)
UICC Stage I 16(40.0)
II 13(32.5)
III 8(20.0)
Ⅳ 3(7.5)
Resectability R0 39(97.5)
R1 1(2.5)
Lymphatic invasion (+) 13(32.5)
(-) 27(67.5)
Vascular invasion (+) 16(40.0)
(-) 24(60.0)
Perineural invasion (+) 10(25.0)
　 (-) 30(75.0)

Abbreviations: NET, neuroendocrine tumor; NEC, neuroendocrine carcinoma;

Fig. 2. An Example for Determination of maximum value of fractal dimension. UICC, Union for International Cancer Control.

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A. Nakano et al. European Journal of Radiology 141 (2021) 109803

observed in eight patients (20.0 %). Liver metastasis was observed in

three patients preoperatively, and all of them were resected with
simultaneous hepatectomy. Six T4 cases were also included, and they
underwent curative surgery with combined resection of adjacent organs.

3.2. Correlation between Ki-67 index of tumor and FDmax

The mean FDmax of the 40 patients was 0.948 and ranged from
0.519 to 1.402. Fig. 3 is a scatter plot showing the relationship between
FDmax and Ki-67 values; a direct correlation was observed between
FDmax and Ki-67 measurements, with a statistical significance
(r = 0.538, p < 0.01). Fig. 4 shows a comparison of the distribution of
FDmax values in the G1 and G2/3 groups. When 3% was used as the
threshold for Ki-67 values to separate the two groups, the mean FDmax
of the G2/3 tumor group (1.05 ± 0.22) was higher than that of the G1
tumor group (0.84 ± 0.18), and a significant difference was observed
between the two groups (p < 0.01). Similarly, when 5% was used as the
threshold for Ki-67 values, the mean FDmax of the G2/3 tumor group
(1.08 ± 0.19) was higher than that of the G1 tumor group (0.83 ± 0.39),
and a significant difference was observed between the two groups Fig. 4. CT images of the two categorical groups. a) CT image of a G1 group
(p < 0.01) (Table 2). An example measurement is shown in Fig. 5. tumor b) CT image of a G2/3 group tumor, showing high values compared with
Fig. 5a is a CE-CT image of a uniformly stained G1 group tumor with a that of G1 tumor.
Ki-67 index of 1.0 % and FDmax of 1.0086. Fig. 5b is an image of a
heterogeneously stained G2/3 group tumor, with a Ki-67 index of 10.0
Table 2
% and FDmax of 1.036, which was higher than that of the G1 group
Comparison of the mean FD with two different categorical cut-offs.
tumor in both indices.
n Mean FDmax

3.3. Diagnostic performance of FDmax on CE-CT in differentiating G2/3 Grades, cut-off 3%

tumors from G1 tumors
The ROC curve test for FDmax showed an area under the curve (AUC)
of 0.773 (95 %CI: 0.621–0.924, p = 000) in the identification of the G2/
3 group when threshold Ki-67 index of 3% was used for separating the
G1 group and G2/3 group. The optimal cut-off value of 1.036 reported
60.0 % sensitivity, 90.0 % specificity, 86.7 % PPV and 70.6 % NPV, 75.0
% accuracy, respectively. When threshold of Ki-67 index was 5%, AUC
increased up to 0.833 (95 %CI: 0.699–0.967), and the optimal cut-off
value of 1.036 (same as threshold of 3%) reported 66.7 % sensitivity,
90.9 % specificity, 86.7 % PPV, and 76.9 % NPV, 80.0 % accuracy,
respectively (Fig. 6).
For comparison, ROC analysis was performed using the maximum
tumor diameter as a parameter. When threshold of Ki-67 index 3%, ROC
curve test for tumor diameter showed an AUC of 0.709 (95 %CI:
0.546–0.871), and the optimal cut-off value of 45 mm reported 50.0 %
sensitivity; 90.0 % specificity, 83.3 % PPV, and 64.3 % NPV, 70.0 %
Histological grades
G1 group 20 0.84 ± 0.18
G2/3 group 20 1.05 ± 0.22
Grades, cut-off 5%
Histological grades
G1 group 24 0.83 ± 0.39
G2/3 group 16 1.08 ± 0.19
Abbreviations: FDmax, maximum value of fractal dimension.
accuracy. When a threshold ≥ 5%, AUC was 0.753 (95 %CI:
0.598–0.907) and the optimal cut-off value of 29 mm reported 55.6 %
sensitivity, 86.4 % specificity, 76.9 % PPV, 70.4 % NPV, and 72.5 %
accuracy, respectively. The results of comparison between FDmax and
tumor diameter for predicting histological grading are shown in Table 3.
3.4. Correlation between prognosis and FDmax
To evaluate the impact of FDmax on prognosis, patients were divided
into high FD (FDmax≥1.036, n = 14) and low FD (FDmax<1.036,
n = 26) groups based on the optimal cutoff value. The survival curves of
each group are shown in Fig. 7; there was no significant difference in OS
between the high-FD and low-FD groups (HR = 1.363, 95 % CI:
0.082–22.524, p = 0.829). Median survival time (MST) was not avail­
able in both groups. DFS showed significantly shorter survival time in
the high-FD group compared to the low-FD group (MST = 76 months vs.
NA, p = 0.0128).
The results of univariate and multivariate analysis of prognostic
factors are shown in Table 4. in OS, there were no significant prognostic
factors in univariate analysis, and therefore multivariate analysis was
not performed. In DFS, high FD (HR, 5.793; 95 % CI: 1.213− 27.664;
p = 0.028), positive lymphatic invasion (HR, 3.582; 95 % CI:
1.002–12.804; p = 0.049), and positive vascular invasion (HR, 5.229;
95 % CI: 1.095–24.961; p = 0.038), were significant factors in univari­
ate analysis. In multivariate analysis, high FD remained the only sig­
nificant factor for DFS (HR, 5.793; 95 % CI: 1.213− 27.664; p = 0.028).

Fig. 3. Correlation between Ki-67 index of tumor and FDmax. FDmax,

Maximum value of fractal dimension.

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A. Nakano et al. European Journal of Radiology 141 (2021) 109803

Fig. 5. Comparison of FDmax between categorical groups using different cut-offs. FDmax, Maximum value of fractal dimension.

Fig. 6. ROC curve to differentiate G2/3 group from G1 group. a) With Ki-67 index cutoff ≧ 3% b) With categorical cutoff ≧ 5%. ROC, Receiver operating
characteristic.

Table 3
Comparison of FDmax and tumor diameter for predicting histological grading.
Grades, cut-off 3% FDmax<1.036 FDmax≧1.036 Total Size<45 mm Size≧45 mm Total
Histological grades

G1 group 18 2 20 18 2 20
G2/3 group 8 12 20 10 10 28
Total 26 14 40 28 12 40
Grades, cut-off 5% Same as above Same as above Total Size<29 mm Size≧29 mm Total
Histological grades
G1 group 20 2 22 19 3 22
G2/3 group 6 12 18 8 10 18
Total 26 14 40 27 13 40

Abbreviations: FDmax, maximum value of fractal dimension.

4. Discussion aggressiveness [10]. However, only a single axial image of CT (which is

The present study aimed to assess the usefulness of fractal analysis on
CT images of PNETs patient for predicting tumor grades preoperatively,
to improve the management of NF-PNETs by intervening with CT fractal
analysis in the choice of treatment and the prediction of tumor aggres­
siveness, according to the correlation between parameters and outcome.
We found that maximum FD, as a representative of ITH, appears to be
higher in G2/3 tumors than in G1 tumors (P < 0,01), and high FD was a
significant risk factor in DFS. This is in accordance with Canellas et al.
findings that CT texture analysis parameters can have the potential to
predict tumor grades in PNETs (separating G1 and G2/3) and tumor
the largest cross-sectional area of tumors) was analyzed in their study. A
similar study by Choi et al., which compared 3D CT texture analysis in
G1 PNETs and G2-G3 PNETs, showed that lower Sphericity would
indicate a higher grade tumor [11]. In a study by M. Isabella et al. in
which texture analysis was performed on liver metastases of PNETs and
non-pancreatic NETs, Entropy, Kurtosis and Skewness have a significant
correlation with higher mortality risk and time to progression [12].
These reports included both functioning and non-functioning tumors.
Texture analysis is a suitable method for evaluating ITH, however,
multiple complex parameters may make it somewhat difficult to un­
derstand intuitively the significance of the result itself. In our study, we

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A. Nakano et al. European Journal of Radiology 141 (2021) 109803

Fig. 7. Correlation of FD with overall survival and disease free survival using the Kaplan–Meier analysis. FD, Fractal dimension.

resection with LN dissection (PD/DP) should be performed with PNETs

Table 4 is still controversial, as LN metastasis occurs even in tumors with small
Univariate and multivariable Cox regression analysis of OS and DFS in relation
diameters [16]. Preoperative prediction of tumor malignant potential
to clinical and pathological features.
using fractal analysis may help to select an appropriate surgical
OS DFS approach.
Variables Multivariable In the prognostic comparison, there were no significant differences in
Univariate Univariate HR (95 % CI) p- OS in univariate analysis; this might be because the prognosis of radi­
P P value
cally resected PNETs was extremely good. PNETs sometimes have liver
Age ≥61 years 0.432 0.615 metastases, with a poor prognosis. Our study included three patients
Sex, female 0.448 0.651 with liver metastases (that were resected with simultaneous hepatec­
Size >23.5 mm 0.887 0.114
pT2.3.4 0.802 0.079
tomy). Their FDmax of primary lesions were 1.0093, 0.8353, and
N1 0.327 0.062 1.3243, respectively. It appears that FDmax of the primary lesion is not
pStage II/III/Ⅳ 0.774 0.082 significantly related to the presence of liver metastases. Two of them had
Lymphatic 0.577 0.049 eliminated in step2 a good prognosis without recurrence. One of them (with FDmax 1.3243)
invasion (+)
recurred with liver metastases, however, still alive for 84 months with
Vascular invasion 0.887 0.038 eliminated in step3
(+) repeated hepatectomy. This may be the reason why there was a signif­
Perineural 0.492 0.714 icant difference in DFS and not in OS.
invasion (+) The present study had some limitations. First, it was a retrospective,
Grade 2/3 0.493 0.108 single-center, and small-sized cohort study. Second, our cohort included
FDmax ≥1.036 0.829 0.028 5.793 0.028
(1.213− 27.664)
some cases in which synchronous liver metastases were resected (R0
surgery). Thirdly, three different CT scanner was used for imaging and
Abbreviations: FDmax, maximum value of fractal dimension; UICC, Union for this might make difference on the quality of imaging analysis. Further
International Cancer Control; OS, overall survival; DFS, disease-free survival; CI,
clinical application of fractal analysis in larger cohorts is expected to
confidence interval.
elucidate these relationships in the future.

focused on non-functioning tumors because only non-functioning PNETs 5. Conclusions

have treatment options. FDmax showed good accuracy in differentiating
G2/3 from G1 including large-sized PNETs in which EUS-FNA did not
demonstrate satisfactory accuracy for the diagnosis of pathological
grades. If the preoperative diagnostic results of EUS-FNA are supple­
mented with predictions derived from fractal analysis, and criteria are
created using these two factors, preoperative tumor grades can be
possibly predicted more accurately than with EUS-FNA alone.
In the present study, we adopted two different Ki-67 index cut-offs
for dividing tumors into groups, because cut-off values for separating
G1 and G2 have been a matter of debate in recent years, oscillating
between 3% and 5% [15]. An alternative grade classification of G2
thresholds > 5% might be more discriminatory than that of > 3% in
prognostically different groups of PNETs after surgery. In our study,
FDmax showed a favorable ability to distinguish G2/3 with both
thresholds. In this respect, the present study appears to have some sig­
nificance in the recent guideline regarding small NF-PNETs (in which a
non-surgical approach was proposed). Since pancreatic resection is a
highly invasive surgery, and most G1 tumors have slow-growing nature
without metastases, this preoperative analysis will help appropriate
selection of the patients with NF-PNETs who should be followed up.
Likewise, whether enucleation/simple pancreatic resection without LN
dissection (e.g., middle pancreatic resection) or standard pancreatic
FDmax of preoperative contrast-enhanced CT at tumor site showed a
significant correlation with Ki-67 labeling index and good performance
in differentiating NET G2/3 from NET G1 when used as a parameter; this
may help in identifying those patients who should not be treated by
observation. Moreover, our data indicated that FDmax could be an
influential parameter in predicting DFS.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Akira Nakano: Conceptualization, Methodology, Formal analysis,
Software, Writing - original draft. Koichi Hayano: Validation, Writing -
review & editing. Toru Tochigi: Writing - review & editing. Taro
Mashiko: Investigation, Resources, Data curation. Yoshihito Masuoka:
Investigation, Resources, Data curation. Seiichiro Yamamoto: Super­
vision. Soji Ozawa: Supervision. Toshio Nakagohri: Supervision.

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A. Nakano et al.
Declaration of Competing Interest
None.
Acknowledgements
We would like to thank Editage (www.editage.com) for English
language editing.
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