Liver-directed surgery of neuroendocrine metastases: What is the optimal strategy?

Abstract

Introduction Neuroendocrine tumors (NETs) frequently metastasize to the liver. Surgical debulking offers symptomatic relief and improved survival. However, the frequent presence of multifocal, bilobar disease and high recurrence rates introduce doubt regarding their optimal management. Parenchyma-sparing debulking (PSD) procedures (ablation, enucleation, wedge resections) may offer similar survival improvements as resection, while minimizing morbidity and preserving functional liver tissue. Methods Clinicopathologic variables from 228 patients with small bowel (SBNETs) or pancreatic NETs (PNETs) managed surgically at one institution were collected. Liver-directed surgery (LDS) was carried out when significant debulking was deemed feasible. Survival was assessed using the Kaplan-Meier method. Results 108 PNET and SBNET patients underwent LDS with primarily PSD procedures. Nearly two-thirds of patients achieved 70% cytoreduction and 84% had concurrent resection of their primary. The median number of lesions treated was 6 (range 1–36). There were no 30-day operative mortalities. The 30-day major complication rate was 13.0%. Patients that achieved 70% cytoreduction enjoyed improved progression free (median 3.2 years) and overall survival (median not reached). Conclusion PSD procedures are safe and can achieve significant cytoreduction, which is associated with improved survival. Lowering the debulking target threshold to 70% may benefit NET patients by increasing eligibility for cytoreduction.

Appropriate Use Criteria for Somatostatin Receptor PET Imaging in Neuroendocrine Tumors

“…Uptake on SSTR PET can be predictive of therapeutic response to PRRT (42), and it is likely that SSTR PET will prove to be a more accurate selection tool than 111 In-pentetreotide for PRRT, although criteria for positive disease have yet to be developed for SSTR PET. Published series reporting on surgical cytoreduction of NET liver metastases have demonstrated that, although it is not curative, it improved survival compared with historic controls (e.g., all patients with NET metastases from large national databases) (43)(44)(45)(46)(47). The conventional wisdom is that surgical debulking "sets the clock back" but does not cure patients; thus, the presence of extrahepatic disease is not necessarily an absolute contraindication.…”

Update on Surgical Management of Small Bowel Neuroendocrine Tumors

“…Denucleation or parenchymal-sparing hepatectomy is currently the most preferable approach for many surgeons (45,46). Combining surgery and RFA or MWA may be a feasible approach for preserving postoperative liver function.…”

“…In contrast to liver metastases from other types of cancer, surgical intervention in metastatic liver disease from NENs does not necessitate an R0 resection, although this would be the optimal approach (46,47). The rationale behind this approach is that these types of metastases are not invasive, meaning that denucleation is an acceptable approach when R0 resection is not possible.…”

Nowotwory neuroendokrynne jelita cienkiego i wyrostka robaczkowego — zasady postępowania (rekomendowane przez Polską Sieć Guzów Neuroendokrynnych)

“…The preferred treatment of intestinal NENs is partial or multiple resection with lymphadenectomy, as a radical treatment, or palliative, cytoreductive surgery reducing the tumour mass by approximately 90% [3]. If possible, the primary tumour site should be removed, even if the disease is generalised, with concurrent resection or enucleation of the hepatic metastatic lesions [74]. Treatment of aNENs depends primarily on the tumour size and the intensity of infiltration of the primary tumour [75][76][77].…”

“…Goblet cell carcinoid, MiNEN and NEC G3 are not classified as NEN; they should be treated according to the recommendations regarding adenocarcinoma [5,32,71,76]; 8. In NENs of the appendix with hepatic metastases, the recommended management is right--sided hemicolectomy including removal of the metastases (anatomical and non-anatomical resections) [74].…”