Adjuvant therapy for gallbladder carcinoma: the Mayo Clinic Experience

PURPOSE

To analyze the effect of adjuvant chemoradiotherapy on gallbladder carcinoma.

METHODS AND MATERIALS

We retrospectively reviewed the records from consecutive patients who underwent R0 resection of gallbladder carcinoma between January 1, 1985, and December 31, 2004. Patients had either Stage I (T1-T2N0M0) or Stage II (T3N0M0 or T1-T3N1M0) disease. Patients undergoing adjuvant therapy received 5-fluorouracil chemotherapy concurrently with radiotherapy (median dosage, 50.4 Gy in 28 fractions). Adverse prognostic factors and the effect of adjuvant treatment on overall survival (OS) were evaluated.

RESULTS

A total of 73 patients were included in the analysis; of these, 25 received adjuvant chemoradiotherapy. On univariate analysis, no adverse prognostic factors for OS reached statistical significance, but trends were noted for Stage N1 vs. N0 (p = .06), Nx vs. N0 (p = .09), Stage T3 vs. T1-T2 (p = .06), and histologic findings other than adenocarcinoma (p = .13). The median OS for patients receiving adjuvant chemoradiotherapy vs. surgery alone was 4.8 years and 4.2 years, respectively (log-rank test, p = .56). However, a significantly greater percentage of patients receiving adjuvant chemoradiotherapy had Stage II disease (p <.001). In the multivariate Cox model, increasing T and N category and histologic findings other than adenocarcinoma were significant predictors of decreased OS. Additionally, adjuvant chemoradiotherapy was a significant predictor of improved OS after adjusting for these prognostic factors (hazard ratio for death, 0.3; 95% confidence interval, 0.13-0.69; p = .004).

CONCLUSION

After adjusting for the stage parameters and histologic findings, our data suggest that adjuvant chemoradiotherapy might improve OS for patients with gallbladder cancer.

Adjuvant radiotherapy and chemotherapy for pancreatic carcinoma: the Mayo Clinic experience (1975-2005)

PURPOSE

To determine prognostic factors and impact of adjuvant chemotherapy (CT) and radiotherapy (RT) on overall survival (OS) after resection of pancreatic adenocarcinoma.

PATIENTS AND METHODS

We performed a retrospective review 472 consecutive patients who underwent complete resection with negative margins (R0) for invasive carcinoma (T1-3N0-1M0) of the pancreas between 1975 and 2005 at the Mayo Clinic in Rochester, MN. Exclusion criteria included metastatic or unresectable disease at surgery, positive surgical margins, and indolent tumor types (islet cell tumors and mucinous cystadenocarcinoma). Median RT dose was 50.4 Gy in 28 fractions; 98% of RT patients also received concurrent fluorouracil-based CT.

RESULTS

Six patients died within 30 days of surgery. For the 466 surviving patients, median follow-up was 32.4 months; median OS was 21.6 months. Median OS after adjuvant CT-RT was 25.2 versus 19.2 months after no adjuvant therapy (P = .001). Two-year OS was 50% versus 39%, and 5-year OS was 28% versus 17%. Adverse prognostic factors identified by univariate and multivariate analysis included positive lymph nodes (risk ratio [RR] = 1.3; P < .001), high histologic grade (RR = 1.2; P < .001), and no adjuvant therapy (RR = 1.3; P < .001). Tumor extension beyond the pancreas was an adverse prognostic factor by univariate analysis alone (P = .03). Patients receiving adjuvant therapy had more adverse prognostic factors than those not receiving adjuvant therapy (P = .001).

CONCLUSION

This study represents one of the largest, single-institution, retrospective reviews of adjuvant therapy in patients after R0 resection of carcinoma of the pancreas. Overall survival was better in patients who received adjuvant CT-RT.

Experience with 208 resections for intraductal papillary mucinous neoplasm of the pancreas

HYPOTHESIS

Intraductal papillary mucinous neoplasm (IPMN) is an increasingly recognized disease of the pancreas. We report our experience with pancreatic resection for IPMN.

DESIGN

Retrospective review from 1992 through 2005 with additional independent histopathologic confirmation.

SETTING

Mayo Clinic Rochester, a tertiary care center.

PATIENTS

All patients who underwent primary resection for pancreatic IPMN.

MAIN OUTCOME MEASURES

Disease-specific operative outcomes, survival, and recurrence patterns.

RESULTS

Of 208 patients (mean age, 66 years) with IPMN of the pancreas, 168 underwent partial pancreatectomy, and 40 underwent total pancreatectomy; 88 were classified as having adenoma, 38 as having borderline neoplasm, 19 as having carcinoma in situ, and 63 as having invasive carcinoma. The prevalence of a malignant neoplasm was 64% in patients with main duct IPMN compared with 18% in patients with branch duct IPMN. Re-resection of the initial pancreatic margin was necessary in 21% of patients. Final negative margins were achieved in 89% of patients. Five-year survival with noninvasive IPMN was 94%. Patients with invasive IPMN had a similar 5-year survival compared with a matched cohort with ductal adenocarcinoma (31% vs 24%; P = .26). In patients with invasive IPMN, 58% experienced disease recurrence. In patients with noninvasive IPMN, 10% experienced disease recurrence after partial pancreatectomy and 0% experienced disease recurrence after total pancreatectomy.

CONCLUSIONS

Patients with main duct IPMN or high-risk branch duct IPMN should be considered for targeted pancreatectomy. Invasive IPMN behaves as aggressively as ductal adenocarcinoma, but resection seems to provide the only potential for cure. Even with negative resection margins, the pancreatic remnant harbors a risk of recurrence and, thus, careful long-term surveillance is warranted.

Sulfatase 2 up-regulates glypican 3, promotes fibroblast growth factor signaling, and decreases survival in hepatocellular carcinoma

It has been shown that the heparin-degrading endosulfatase, sulfatase 1 (SULF1), functions as a liver tumor suppressor, but the role of the related sulfatase, sulfatase 2 (SULF2), in liver carcinogenesis remains to be elucidated. We investigated the effect of SULF2 on liver tumorigenesis. Expression of SULF2 was increased in 79 (57%) of 139 hepatocellular carcinomas (HCCs) and 8 (73%) of 11 HCC cell lines. Forced expression of SULF2 increased HCC cell growth and migration, whereas knockdown of SULF2 using short hairpin RNA targeting SULF2 abrogated HCC cell proliferation and migration in vitro. Because SULF1 and SULF2 desulfate heparan sulfate proteoglycans (HSPGs) and the HSPG glypican 3 (GPC3) is up-regulated in HCC, we investigated the effects of SULF2 on GPC3 expression and the association of SULF2 with GPC3. SULF2-mediated cell growth was associated with increased binding of fibroblast growth factor 2 (FGF2), phosphorylation of extracellular signal-regulated kinase and AKT, and expression of GPC3. Knockdown of GPC3 attenuated FGF2 binding in SULF2-expressing HCC cells. The effects of SULF2 on up-regulation of GPC3 and tumor growth were confirmed in nude mouse xenografts. Moreover, HCC patients with increased SULF2 expression in resected HCC tissues had a worse prognosis and a higher rate of recurrence after surgery.

CONCLUSION

In contrast to the tumor suppressor effect of SULF1, SULF2 has an oncogenic effect in HCC mediated in part through up-regulation of FGF signaling and GPC3 expression.

Association of MicroRNA expression in hepatocellular carcinomas with hepatitis infection, cirrhosis, and patient survival

PURPOSE

MicroRNA (miRNA) is a new class of small, noncoding RNA. The purpose of this study was to determine if miRNAs are differentially expressed in hepatocellular carcinoma (HCC).

EXPERIMENTAL DESIGN

More than 200 precursor and mature miRNAs were profiled by real-time PCR in 43 and 28 pairs of HCC and adjacent benign liver, respectively, and in normal liver specimens.

RESULTS

Several miRNAs including miR-199a, miR-21, and miR-301 were differentially expressed in the tumor compared with adjacent benign liver. A large number of mature and precursor miRNAs were up-regulated in the adjacent benign liver specimens that were both cirrhotic and hepatitis-positive compared with the uninfected, noncirrhotic specimens (P < 0.01). Interestingly, all of the miRNAs in this comparison had increased expression and none were decreased. The expression of 95 randomly selected mRNAs was not significantly altered in the cirrhotic and hepatitis-positive specimens, suggesting a preferential increase in the transcription of miRNA. Comparing the miRNA expression in the HCC tumors with patient's survival time revealed two groups of patients; those with predominantly lower miRNA expression and poor survival and those with predominantly higher miRNA expression and good survival (P < 0.05). A set of 19 miRNAs significantly correlated with disease outcome. A number of biological processes including cell division, mitosis, and G(1)-S transition were predicted to be targets of the 19 miRNAs in this group.

CONCLUSION

We show that a global increase in the transcription of miRNA genes occurs in cirrhotic and hepatitis-positive livers and that miRNA expression may prognosticate disease outcome in HCC.

Association of MicroRNA expression in hepatocellular carcinomas with hepatitis infection, cirrhosis, and patient survival

PURPOSE

MicroRNA (miRNA) is a new class of small, noncoding RNA. The purpose of this study was to determine if miRNAs are differentially expressed in hepatocellular carcinoma (HCC).

EXPERIMENTAL DESIGN

More than 200 precursor and mature miRNAs were profiled by real-time PCR in 43 and 28 pairs of HCC and adjacent benign liver, respectively, and in normal liver specimens.

RESULTS

Several miRNAs including miR-199a, miR-21, and miR-301 were differentially expressed in the tumor compared with adjacent benign liver. A large number of mature and precursor miRNAs were up-regulated in the adjacent benign liver specimens that were both cirrhotic and hepatitis-positive compared with the uninfected, noncirrhotic specimens (P < 0.01). Interestingly, all of the miRNAs in this comparison had increased expression and none were decreased. The expression of 95 randomly selected mRNAs was not significantly altered in the cirrhotic and hepatitis-positive specimens, suggesting a preferential increase in the transcription of miRNA. Comparing the miRNA expression in the HCC tumors with patient's survival time revealed two groups of patients; those with predominantly lower miRNA expression and poor survival and those with predominantly higher miRNA expression and good survival (P < 0.05). A set of 19 miRNAs significantly correlated with disease outcome. A number of biological processes including cell division, mitosis, and G(1)-S transition were predicted to be targets of the 19 miRNAs in this group.

CONCLUSION

We show that a global increase in the transcription of miRNA genes occurs in cirrhotic and hepatitis-positive livers and that miRNA expression may prognosticate disease outcome in HCC.

Role of hepatic resection for patients with carcinoid heart disease

OBJECTIVE

To evaluate the effects of resection of hepatic carcinoid metastases on progression and prognosis of carcinoid heart disease.

PATIENTS AND METHODS

From our database of 265 consecutive patients diagnosed as having carcinoid heart disease from January 1, 1980, through December 31, 2005, we calculated survival from first diagnosis of cardiac involvement. Hepatic resection during follow-up was entered as a time-dependent covariable in a multivariable analysis. In patients with serial echocardiograms more than 1 year apart without intervening cardiac surgery, a previously validated cardiac severity score was calculated. A score increase that exceeded 25% was considered relevant progression.

RESULTS

Hepatic resection was performed in 31 patients (12%) during follow-up. Five-year survival was significantly higher in these patients (86.5%; 95% confidence interval [CI], 73.5%-100.0%) than in patients without hepatic resection (29.0%; 95% CI, 23.3%-36.1%; univariable hazard ratio for hepatic resection, 0.25; 95% CI 0.12-0.53; P<.001). Hepatic resection remained strongly associated with improved prognosis in multivariable analysis (hazard ratio, 0.31; 95% CI, 0.14-0.66; P=.003). Among 77 patients (29%) with serial echocardiograms, 10 (13%) underwent hepatic resection during follow-up; resection was independently associated with decreased risk of cardiac progression (odds ratio, 0.29; 95% CI, 0.06-0.75; P=.03).

CONCLUSION

Despite the limitations of this retrospective nonrandomized study, our data suggest that patients with carcinoid heart disease who undergo hepatic resection have decreased cardiac progression and improved prognosis. Eligible patients should be considered for hepatic surgery.

Hepatic resection for colorectal metastases: value for risk scoring systems?

INTRODUCTION

Predictors of outcome in patients with metastatic colorectal cancer remain inconsistent. We aimed to identify predictors of outcome in these patients, to develop a prognostic scoring system, and to assess the general applicability of the current major risk scoring systems.

MATERIALS AND METHODS

Following IRB approval, medical records of 662 consecutive patients undergoing resection of colorectal metastases to the liver during 1960 to 1995 were reviewed. Clinicopathologic and outcome data were assessed from records and mailed questionnaire. Clinicopathologic variables were tested using univariate and multivariate analyses; best-fit models were then generated to study the effect of each independent risk factor on outcome. To validate existing scoring models, our independent data set was applied to those scores. The relative concordance probability estimates were calculated for these models and compared with that of the proposed Mayo model.

RESULTS

The overall and disease-specific 5-year survival rates were 37% and 42%, respectively. The probability of recurrence at any site was 65% at 5 years. Perioperative blood transfusion and positive hepatoduodenal nodes were the major determinants of survival and recurrence. To assess the general applicability of the proposed risk scoring systems, we imported the data from our patient population into 3 other scoring systems. Neither survival nor recurrence among our patients was stratified discretely by any of the scoring systems. Based on probability estimates, all models were only marginally better than chance alone in predicting outcome.

CONCLUSION

Broad application of risk scoring systems for patients with metastatic colorectal cancer has limited clinical value and refinement and external validation should be undertaken before utilization.

Inferior vena cava stenting: a safe and effective treatment for intractable ascites in patients with polycystic liver disease

We performed a retrospective study of seven patients with polycystic liver disease who underwent stenting of the inferior vena cava for intractable ascites. All patients had symptomatic ascites and inferior vena cava stenosis demonstrable by venography. The mean pressure gradient across the inferior vena cava stenosis before stenting was 14.5 mm Hg (range 6-25 mm Hg) and significantly decreased to a mean pressure gradient of 2.8 mm Hg (range 0-6 mm Hg, p = 0.008) after stenting. Two patients also had stenting of hepatic venous stenoses after unsuccessful inferior vena cava stenting. After a mean follow-up of 12.2 months (range 0.5-39.1 months), five of the seven patients have had maintained clinical improvement, defined as decreased symptoms, diuretic requirements, and frequency of paracentesis. Four patients have required no further intervention. The other patient was lost in follow-up. Patients with clinical improvement had an overall larger mean pressure gradient before stenting (19.2 vs. 9.8 mm Hg) and a larger Delta pressure gradient (15.8 vs. 7.8 mm Hg) compared to those in whom stenting was unsuccessful. These results suggest inferior vena cava stenting is safe and effective and should be considered as a first-line intervention in the treatment of medically intractable ascites in select patients with polycystic liver disease.

Right hepatectomy for living liver donation vs right hepatectomy for disease: intraoperative and immediate postoperative comparison

HYPOTHESIS

Perioperative events of patients undergoing living donor (LD) right hepatectomy are similar to those of patients undergoing right hepatectomy for disease (DZ).

DESIGN

Institutional review board-approved retrospective case-control study.

SETTING

Eight hundred-bed tertiary care referral center.

PATIENTS AND METHODS

We matched 40 patients who had LD with 40 patients who had DZ. Perioperative events (anesthesia, surgical events, transfusion, hemodynamic events, complications, and length of hospital stay) were compared using the signed rank test and exact McNemar test where appropriate.

MAIN OUTCOME MEASURES

Intraoperative time, transfusion requirements, postoperative complications, and hospital length of stay.

RESULTS

There was a significant difference in surgical time between the LD and DZ groups (median, 4.1 vs 3.3 hours; P = .001). There was also a significant difference in anesthesia time between the LD and DZ groups (median, 5.6 vs 4.2 hours; P<.001). The level of autologous transfusion was higher in the LD group (median, 1.3 vs 0 U in the DZ group; P<.001), and that of packed red blood cell transfusion was lower in the LD group (mean, 0 vs 0.5 U; P = .008). There was no other significant intraoperative difference. Postoperative hemoglobin levels were significantly higher in the LD group (median, 12.6 vs 11.8 g/dL; P = .03). Comparison of the number of complications in the immediate postoperative period revealed no other significant differences.

CONCLUSIONS

The LD procedure took longer to perform because of the time required for hilar dissection. The difference in intraoperative transfusions is attributable to use of cell salvage and retransfusion of salvaged blood for all donors; this was not routine for DZ procedures. Perioperative outcomes were similar in all other respects. The LD procedure has similar outcomes to those of the DZ procedure.

Outcomes of primary liver cancer in children: an appraisal of experience

INTRODUCTION

Hepatoblastoma (HB) and hepatocellular carcinoma (HCC) are the most common primary liver cancers in children. Recent advances in management of pediatric liver cancer have improved disease-specific survival (DSS). This is a review of our experience with childhood liver malignancy over the past 3 decades.

MATERIALS AND METHODS

A retrospective chart review from 1975 to 2005 identified patients who were 18 years old or younger with a histologically confirmed diagnosis of primary liver cancer. Patients were staged according to the Children's Cancer Group and Pediatric Oncology Group (CCG/POG) system. Patients were followed up prospectively through clinic visits and mail correspondence. Standard statistical methods were used for comparison, risk, and survival analyses.

RESULTS

Fifty-two patients were confirmed to have primary liver cancers, where 24 (46%) patients had HB, 22 (42%) had HCC, 3 (6%) had sarcomas, and 3 (6%) had other histologies. Mean ages at presentation for HB and HCC were 3.2 and 13.1 years old, respectively. The most common presentations were abdominal mass (67%) and pain (40%). Most patients underwent major liver resection (n = 45, 87%), including: lobectomy (n = 25, 48%), and trisegmentectomy (n = 11, 21%). Three patients underwent liver transplantation (n = 3, 6%) for advanced local disease. Forty-five (87%) received primary or neoadjuvant and/or adjuvant chemotherapy. Patients had the following CCG/POG stages: I (n = 31, 60%), II (n = 6, 11.5%), III (n = 9, 17%), and IV (n = 6, 11.5%). Complete gross resection (stage I and II) was achieved in 37 (71%) patients. The perioperative mortality and morbidity rates were 0% and 29%, respectively. Patients with complete resection had significantly better 5-year DSS and median survival compared with incomplete gross resection: 62% vs 9% and 216 vs 18 months, P < .001. Patients treated during the period 1995-2005 had better 5-year DSS and median survival compared with those treated during 1975-1994: 68% vs 32% and 117 vs 27 months, P = .032. All 3 patients who underwent transplantation for conventionally unresectable disease are alive without disease recurrence (follow-up period, 1-15 years).

CONCLUSION

Complete resection of the pediatric primary liver tumors remains the cornerstone of treatment to achieve cure. Major liver resection can be performed with minimal perioperative mortality and morbidity. Patients with HB appeared to have better survival compared with patients with HCC, and there was significant improvement in the DSS of children treated in the recent decade. Liver transplantation in conjunction with chemotherapy may have an increasing role in the management of locally advanced primary liver cancers.

Risk factors for mortality after surgery in patients with cirrhosis

BACKGROUND & AIMS

Current methods of predicting risk of postoperative mortality in patients with cirrhosis are suboptimal. The utility of the Model for End-stage Liver Disease (MELD) in predicting mortality after surgery other than liver transplantation is unknown. The aim of this study was to determine the risk factors for postoperative mortality in patients with cirrhosis.

METHODS

Patients with cirrhosis (N = 772) who underwent major digestive (n = 586), orthopedic (n = 107), or cardiovascular (n = 79) surgery were studied. Control groups of patients with cirrhosis included 303 undergoing minor surgical procedures and 562 ambulatory patients. Univariate and multivariable proportional hazards analyses were used to determine the relationship between risk factors and mortality.

RESULTS

Patients undergoing major surgery were at increased risk for mortality up to 90 days postoperatively. By multivariable analysis, only MELD score, American Society of Anesthesiologists class, and age predicted mortality at 30 and 90 days, 1 year, and long-term, independently of type or year of surgery. Emergency surgery was the only independent predictor of duration of hospitalization postoperatively. Thirty-day mortality ranged from 5.7% (MELD score, <8) to more than 50% (MELD score, >20). The relationship between MELD score and mortality persisted throughout the 20-year postoperative period.

CONCLUSIONS

MELD score, age, and American Society of Anesthesiologists class can quantify the risk of mortality postoperatively in patients with cirrhosis, independently of the procedure performed. These factors can be used in determining operative mortality risk and whether elective surgical procedures can be delayed until after liver transplantation.

The utility of Lens culinaris agglutinin-reactive alpha-fetoprotein in the diagnosis of hepatocellular carcinoma: evaluation in a United States referral population

BACKGROUND & AIMS

The percentage of Lens culinaris agglutinin-reactive (alpha)-fetoprotein (AFP-L3%) is proposed as a diagnostic and prognostic marker for hepatocellular carcinoma (HCC). We evaluated the utility of AFP-L3% for diagnosis of HCC in a US referral population.

METHODS

This retrospective study included 272 patients: 166 with HCC and 106 with benign liver disease (chronic liver disease, 77; benign liver mass, 29). The AFP-L3% was measured using a clinical auto-analyzer.

RESULTS

The AFP-L3% is not reported for a total alpha-fetoprotein (AFP) less than 10 ng/mL, and all patients with an AFP greater than 200 ng/mL had HCC; thus the AFP-L3% was noninformative for these patients. In patients with a total AFP of 10-200 ng/mL, an AFP-L3% greater than 10% had a sensitivity of 71% and a specificity of 63% for diagnosis of HCC. An AFP-L3% greater than 35% had a reduced sensitivity of 33%, but an increased specificity of 100%. The high specificity of the AFP-L3% cut-off of 35% allowed the confident diagnosis of an additional 10% of HCCs not diagnosed using an AFP cut-off of 200 ng/mL. After adjustment for AFP level, no association was observed between AFP-L3% and tumor size, stage, vascular invasion, grade, or survival.

CONCLUSIONS

Patients with indeterminate total AFP values of 10-200 ng/mL present a diagnostic dilemma. We found that an AFP-L3% greater than 35% has 100% specificity for HCC in these patients. AFP-L3%, used in combination with AFP, may be a clinically useful adjunct marker for the diagnosis of HCC.

Hepatic resection in the treatment of hilar cholangiocarcinoma

HC is an uncommon--although readily recognizable-clinical entity. Although current hepatobiliary imaging has improved, accurate staging of HC preoperatively is difficult. In patients who have potentially resectable HC, careful preoperative preparation with biliary drainage, portal vein embolization, or both is indicated because major hepatic resection has become an essential component of surgical treatment, and these interventions may reduce perioperative risks. Currently, lobar or extended lobar hepatic and bile duct resection, regional lymphadenectomy, and Roux-en-Y hepaticojejunostomy are the treatments of choice for HC. Whether major vascular resection coupled with these procedures or hepatic transplantation in selected patients will improve overall survival is unknown. Finally, current outcomes dictate investigation of effective adjuvant therapy.

Hepatic resection for metachronous metastases from ovarian carcinoma

Recently, several authors have reported that optimal primary cytoreduction of both hepatic and extrahepatic disease is not only feasible but improves survival. However, the role of hepatic resection in combination with secondary cytoreduction for epithelial ovarian cancer is unclear. Patients with recurrent ovarian cancer and metachronous intrahepatic metastases are often evaluated by a multidisciplinary team at the Mayo Clinic comprising pelvic and hepatobiliary surgeons for consideration of cytoreductive surgery. The purpose of this report is to update the outcome of cytoreductive surgery including hepatic resection for patients with metastatic ovarian carcinoma.

Liver transplantation for gastroenteropancreatic neuroendocrine cancers: Defining selection criteria to improve survival

Liver transplantation for gastroenteropancreatic neuroendocrine cancer (GEP) is controversial. The aim of this study was to assess patient outcomes after liver transplantation for hepatic metastases from GEP. Medical records of patients who underwent liver transplantation for GEP were reviewed. Immunohistochemistry for assessing the Ki67 proliferation index was performed on explanted liver tissue. Nineteen patients who underwent liver transplantation had a mean follow-up of 22 months with a range of 0 to 84 months. There was 1 intraoperative death, and 3 patients had disease recurrence after liver transplantation leading to death in 1 patient. Overall estimated 1-year survival for 17 patients included in the treatment protocol (mean follow-up, 15 months) was 87% with an estimated 1-year recurrence-free rate (conditional on survival) of 77%. Three of 11 patients with pancreatic islet cell GEP developed disease recurrence, whereas all 8 patients with carcinoid GEP remain free of disease. Analysis of the Ki67 proliferation index in 18 patients did not differentiate those with recurrence from those without disease recurrence. In conclusion, liver transplantation for patients with hepatic metastases from GEP is a viable therapeutic option in highly selected patients.

Treatment of neuroendocrine cancer metastatic to the liver: the role of ablative techniques

Carcinoid tumors and islet cell neoplasms are neuroendocrine neoplasms with indolent patterns of growth and association with bizarre hormone syndromes. These tumors behave in a relatively protracted and predictable manner, which allows for multiple therapeutic options. Even in the presence of hepatic metastases, the standard of treatment for neuroendocrine malignancy is surgery, either with curative intent or for tumor cytoreduction, i.e., resection of 90% or more of the tumor volume. Image-guided ablation, as either an adjunct to surgery or a primary treatment modality, can be used to treat neuroendocrine cancer metastatic to the liver. Image-guided ablative techniques, including radiofrequency ablation, alcohol injection, and cryoablation, can be used in selected patients to debulk hepatic tumors and improve patient symptoms. Although long-term follow-up data are not available, the surgical literature indicates that significant ablative debulking may improve patient survival. In this review, we discuss metastatic neuroendocrine disease and its treatment options, especially image-guided ablative techniques.

Hepatic resection for noncolorectal, nonneuroendocrine metastases

Resection of certain hepatic metastases of noncolorectal, nonneuroendocrine (NCNNE) origin provides actual long-term (>5 years) survival. We conducted a retrospective outcome study at a single tertiary referral institution. Between January 1988 and October 1998, 64 consecutive patients underwent resection of hepatic metastases from NCNNE primary tumors. Overall and disease-free survival rates were correlated to clinicopathologic factors and operative morbidity and mortality. Thirteen patients underwent a right hepatectomy, 6 underwent a left hepatectomy, 3 had extended right and 2 extended left hepatectomy, 2 patients had segmentectomy, 24 underwent wedge resections, and 14 underwent a combination of these forms of resection. R0 resection was achieved in 56 patients (87.5%). The operative mortality was 1.5% (1 of 64). Actual 1-, 3-, and 5-year survivals were 81%, 43%, and 30%, respectively. The factor adversely associated with overall and disease-free survival was uniformly related to the interval between primary tumor resection and the development of hepatic metastases. A 1.5% operative mortality and an actual 5-year survival of 30% justifies hepatic resection, including major hepatic resection, for certain NCNNE metastases. The factor affecting prognosis in this highly select group of patients was the biological behavior of the tumor, with tumors that metastasize earlier having poorer survival rates.