How would you approach the adjuvant management of locally advanced pancreatic neuroendocrine tumor s/p resection with positive margins and positive lymph nodes (high lymph node ratio, + LVI, low grade and well differentiated)?  

We know that the factors of positive margins, positive lymph nodes and LVI all confer a heightened risk of relapse. It is critical to ensure good post-operative staging and I would suggest a multiphase CT, Gallium 68 Dotatate scan and Chromogrannin A. If there is no evidence of residual disease, we ...