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Søreide K, Stättner S, Hallet J. Surgery as a Principle and Technical Consideration for Primary Tumor Resection of Small Bowel Neuroendocrine Tumors. Ann Surg Oncol 2024; 31:1125-1137. [PMID: 38006527 PMCID: PMC10761444 DOI: 10.1245/s10434-023-14610-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/31/2023] [Indexed: 11/27/2023]
Abstract
Small bowel neuroendocrine tumors (SB-NETs) are increasingly identified and have become the most frequent entity among small bowel tumors. An increasing incidence, a high prevalence, and a prolonged survival with optimal modern multidisciplinary management makes SB-NETs a unique set of tumors to consider for surgical oncologists. The major goals of surgical treatment in the setting of SB-NET include control of tumor volume, control of endocrine secretion, and prevention of locoregional complications. Key considerations include assessment of multifocality and resection of mesenteric nodal masses with the use of mesenteric-sparing approaches and acceptance of R1 margins if necessary to clear disease while avoiding short bowel syndrome. A description through eight steps for consideration is presented to allow for systematic surgical planning and execution of resection. Moreover, some controversies and evolving considerations to the surgical principles and technical procedures remain. The role of primary tumor resection in the presence of (unresectable) liver metastasis is still unclear. Reports of feasibility of minimally invasive surgery are emerging, with undetermined selection criteria for appropriateness or long-term outcomes. Resection of SB-NETs should be considered in all patients fit for surgery and should follow principles to achieve surgical oncological control that is appropriate for the stage and tumor burden, considering the age and comorbidity of the individual patient.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway.
- Gastrointestinal Translational Research Group, Laboratory for Molecular Medicine, Stavanger University Hospital, Stavanger, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Vöcklabruck, Austria
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Susan Leslie Clinic for Neuroendocrine Tumors - Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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2
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Howe JR. Metastatic small bowel neuroendocrine tumours: surgical management of the primary. Br J Surg 2023; 110:1293-1295. [PMID: 37566464 DOI: 10.1093/bjs/znad247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 08/13/2023]
Affiliation(s)
- James R Howe
- Surgical Oncology and Endocrine Surgery, Roy J. and Lucille A. Carver University of Iowa College of Medicine, Iowa City, Iowa, USA
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3
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Søreide K, Hallet J, Jamieson NB, Stättner S. Optimal surgical approach for digestive neuroendocrine neoplasia primaries: Oncological benefits versus short and long-term complications. Best Pract Res Clin Endocrinol Metab 2023; 37:101786. [PMID: 37328324 DOI: 10.1016/j.beem.2023.101786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
The rising incidence and the accumulating prevalence of neuroendocrine neoplasia (NEN) in the population makes this a common, prevalent and a clinically relevant disease group. Surgical resection represents the only potentially curative treatment for digestive NENs. Thus, resection should in principle be considered for all patients with NEN, although taking the patients age, relevant comorbidity, and performance status into account for operability. Patients with insulinomas, NEN of the appendix and rectal NENs are usually cured by surgery alone. However, less than a third of patients are amendable to curative surgery alone at time of diagnosis. Furthermore, recurrence is common and may occur years after primary surgery, hence the long follow-up time recommended in most NENs (>10 years). As many patients with NENs present with locoregional or metastatic disease, there is considerable debate regarding the role of debulking surgery in these settings. However, good long-term survival can be achieved in a considerable proportion of patients, with 50-70% alive up to 10 years after surgery. Location and grade are the main determinants of long-term survival. Here we present considerations to surgery for primary neuroendocrine tumors in the digestive tract.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Gastrointestinal Translational Research Group, Laboratory for Molecular Medicine, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Susan Leslie Clinic for Neuroendocrine Tumors - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Nigel B Jamieson
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, University of Glasgow, Glasgow, Scotland, UK
| | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Salzkammergutklinikum, Vöcklabruck, Austria
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4
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Kupietzky A, Dover R, Mazeh H. Surgical aspects of small intestinal neuroendocrine tumors. World J Gastrointest Surg 2023; 15:566-577. [PMID: 37206065 PMCID: PMC10190731 DOI: 10.4240/wjgs.v15.i4.566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/25/2023] [Accepted: 03/27/2023] [Indexed: 04/22/2023] Open
Abstract
Small intestinal neuroendocrine tumors (NETs) are a heterogeneous group of epithelial tumors with a predominant neuroendocrine differentiation. Although NETs are usually considered rare neoplasms, small intestinal NETs are the most common primary malignancy of the small bowel, with an increasing prevalence worldwide during the course of the past few decades. The indolent nature of these tumors often leads to a delayed diagnosis, resulting in over one-third of patients presenting with synchronous metastases. Primary tumor resection remains the only curative option for this type of tumor. In this review article, the various surgical aspects for the excision of small intestinal NETs are discussed.
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Affiliation(s)
- Amram Kupietzky
- Department of Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91240, Israel
| | - Roi Dover
- Department of Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91240, Israel
| | - Haggi Mazeh
- Department of Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91240, Israel
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Symons R, Daly D, Gandy R, Goldstein D, Aghmesheh M. Progress in the Treatment of Small Intestine Cancer. Curr Treat Options Oncol 2023; 24:241-261. [PMID: 36826686 DOI: 10.1007/s11864-023-01058-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 02/25/2023]
Abstract
OPINION STATEMENT Small intestine cancer is rare, accounting for approximately 3% of all gastrointestinal malignancies. The most common histological subtypes include adenocarcinoma, neuroendocrine tumours (NETs) and gastrointestinal stromal tumours (GISTs). In localised disease, surgery remains the mainstay of treatment and the best approach to improve survival. Current treatment for small intestine adenocarcinoma (SIA) is extrapolated from small studies and data from colorectal cancer (CRC). There is limited evidence to guide therapy in the adjuvant setting. However, there are small phase II studies in the advanced setting providing evidence for the role of chemotherapy and immunotherapy. There is also limited evidence assessing the efficacy of targeted therapies. Small intestine NETs are rare, with evidence for somatostatin analogue therapy, particularly in the low to intermediate-grade well-differentiated tumours. Poorly differentiated NETs are generally managed with chemotherapy but have worse outcomes compared with well-differentiated NETs. The management of small intestine GISTs is largely targeting KIT mutations with imatinib. Recent trials have provided evidence for effective therapies in imatinib-resistant tumours and the potential role of immunotherapy. The aim of this article was to review the evidence for the current management and recent advances in the management of small intestine adenocarcinoma, NETs and GISTs.
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Affiliation(s)
- Rebecca Symons
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, High St, Randwick, Sydney, NSW, 2031, Australia
| | - Daniel Daly
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, High St, Randwick, Sydney, NSW, 2031, Australia.,University of New South Wales, Randwick, NSW, Australia
| | - Robert Gandy
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, High St, Randwick, Sydney, NSW, 2031, Australia.,University of New South Wales, Randwick, NSW, Australia
| | - David Goldstein
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, High St, Randwick, Sydney, NSW, 2031, Australia.,University of New South Wales, Randwick, NSW, Australia
| | - Morteza Aghmesheh
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, High St, Randwick, Sydney, NSW, 2031, Australia.
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Castle JT, Levy BE, Chauhan A. Pediatric Neuroendocrine Neoplasms: Rare Malignancies with Incredible Variability. Cancers (Basel) 2022; 14:cancers14205049. [PMID: 36291833 PMCID: PMC9599522 DOI: 10.3390/cancers14205049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/07/2022] [Accepted: 10/13/2022] [Indexed: 11/16/2022] Open
Abstract
Neuroendocrine neoplasms (NENs) encompass a variety of neuroendocrine tumors (NETs) and neuroendocrine carcinomas (NECs) which can arise anywhere in the body. While relatively rare in the pediatric population, the incidence of NENs has increased in the past few decades. These neoplasms can be devastating if not diagnosed and treated early, however, symptoms are variable and can be indolent for many years. There is a reported median of 10 years from the appearance of the first symptoms to time of diagnosis. Considering some of these neoplasms have a mortality rate as high as 90%, it is crucial healthcare providers are aware of NENs and remain vigilant. With better provider education and easily accessible resources for information about these neoplasms, awareness can be improved leading to earlier disease recognition and diagnosis. This manuscript aims to provide an overview of both the most common NENs as well as the rarer NENs with high lethality in the pediatric population. This review provides up to date evidence and recommendations, encompassing recent changes in classification and advances in treatment modalities, including recently completed and ongoing clinical trials.
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Affiliation(s)
- Jennifer T. Castle
- Department of Surgery, Markey Cancer Center, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA
| | - Brittany E. Levy
- Department of Surgery, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA
| | - Aman Chauhan
- Department of Internal Medicine-Medical Oncology, Markey Cancer Center, University of Kentucky, 800 Rose Street, Lexington, KY 40536, USA
- Correspondence: or
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McGuinness MJ, Woodhouse B, Harmston C, Parker K, Kramer N, Findlay M, Print C, Merrie A, Lawrence B. Survival of patients with small bowel neuroendocrine neoplasms in Auckland, Aotearoa New Zealand. ANZ J Surg 2022; 92:1748-1753. [PMID: 35762209 PMCID: PMC9541869 DOI: 10.1111/ans.17851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/30/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
Background Small intestinal Neuroendocrine Neoplasms (SI‐NENs) are the most common primary malignancy of the small bowel. The aim of this study is to define the survival of patients with an SI‐NEN in Auckland, Aotearoa New Zealand (AoNZ). Methods A retrospective study of all patients diagnosed with a jejunal or ileal SI‐NEN in the Auckland region between 2000 and 2012 was performed. The New Zealand NETwork! Registry was searched to identify the study cohort. Retrospective data collection was performed to collect stage, survival and follow up data. Results One hundred and seven patients were included in the study. The mean age of patients was 62.8 years (SD 11.9). The 5 and 10‐year disease‐specific survival for all patients was 66.1% (95% CI 56.5–75.7%) and 61.8% (95% CI 51.8–71.8%), respectively. Ten‐year disease‐specific survival was 100% for stage I and II, 74% (95%CI 61.7–84.4%) for stage III and 33.9% (95%CI 16.9–35.6%) for stage IV SI‐NEN. Eleven of 40 (27.5%) patients with stage III disease had recurrence and 3 of 7 (42.8%) patients with stage IV disease had recurrence. In patients with stage IV disease, neither primary resection (HR 2.25, 95% CI 0.92–5.5) nor distant resection (HR 1.72, 95% CI 0.63–4.7) were significantly associated with a disease‐specific or overall survival benefit. Conclusion This study demonstrates that stage at SI‐NEN diagnosis is associated with survival, but resection of the primary or distant metastases in patients with stage IV disease is not. There was no recurrence in patients with stage I or II disease after complete resection.
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Affiliation(s)
- Matthew J. McGuinness
- Faculty of Medical and Health Sciences and Maurice Wilkins Centre University of Auckland Auckland New Zealand
- Whangārei Hospital, Northland District Health Board Whangārei New Zealand
| | - Braden Woodhouse
- Faculty of Medical and Health Sciences and Maurice Wilkins Centre University of Auckland Auckland New Zealand
| | - Christopher Harmston
- Faculty of Medical and Health Sciences and Maurice Wilkins Centre University of Auckland Auckland New Zealand
- Whangārei Hospital, Northland District Health Board Whangārei New Zealand
| | - Kate Parker
- Planning, Funding and Outcomes Waitematā District Health Board Waitakere New Zealand
| | - Nicole Kramer
- Department of Pathology North Shore Hospital, Waitematā District Health Board Waitakere New Zealand
| | - Michael Findlay
- Faculty of Medical and Health Sciences and Maurice Wilkins Centre University of Auckland Auckland New Zealand
| | - Cristin Print
- Faculty of Medical and Health Sciences and Maurice Wilkins Centre University of Auckland Auckland New Zealand
| | - Arend Merrie
- Faculty of Medical and Health Sciences and Maurice Wilkins Centre University of Auckland Auckland New Zealand
- Auckland City Hospital, Auckland District Health Board Auckland New Zealand
| | - Ben Lawrence
- Faculty of Medical and Health Sciences and Maurice Wilkins Centre University of Auckland Auckland New Zealand
- Auckland City Hospital, Auckland District Health Board Auckland New Zealand
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Mou Y, Wang ZY, Tan CL, Chen YH, Liu XB, Ke NW. The Role of Primary Tumor Resection in Patients With Pancreatic Neuroendocrine Tumors With Liver Metastases. Front Oncol 2022; 12:838103. [PMID: 35350567 PMCID: PMC8957911 DOI: 10.3389/fonc.2022.838103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/10/2022] [Indexed: 02/05/2023] Open
Abstract
Background Liver metastases (LMs) are common in advanced pancreatic neuroendocrine tumor (PNET) patients. Currently, the benefit of primary tumor resection (PTR) in the setting of PNET patients with liver metastases is still controversial in several guidelines. Methods Data were extracted from the Surveillance, Epidemiology and End Results (SEER) database to evaluate this issue. The main index of interest in our study was overall survival time. Results Information on 536 PNET patients with liver metastases from the SEER database was identified. A total of 214 patients (PTR group) received primary tumor resection, and more than half of them (132 patients) had synchronous LM resection. The other 322 PNET patients (non-PTR group) with liver metastases did not receive primary tumor resection. A significant survival benefit was gained from PTR when compared with non-PTR patients, both in OS (72.93 ± 2.7 vs. 36.80 ± 2.22 months) and 3- or 5-year survival rates (75.1% vs. 28.9% and 67.9% vs. 22.3%, respectively). No difference was found between PTR alone and PTR with synchronous LM resection. From univariate and multivariate analyses, younger age (<65 years) and good or moderate tumor differentiation may be more important when considering primary tumor resection. However, we found that all grades of tumor differentiation could result in a better overall survival time after primary tumor resection. Conclusion Our study suggested that primary tumor resection in pancreatic neuroendocrine patients with liver metastases could result in a longer survival time. Primary tumor resection with synchronous liver metastasis resection was not related to a better survival benefit. This treatment strategy may routinely be taken into consideration in these patients.
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Affiliation(s)
| | | | | | | | - Xu-Bao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Neng-Wen Ke
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
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9
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Yan H, Yin L, Han H, Jin Y, Liu Z. Relationship between Primary Tumor Resection for Metastatic Small Intestine Neuroendocrine Tumors and Survival: A Propensity Score-Matched Analysis. J INVEST SURG 2022; 35:1239-1247. [PMID: 34991432 DOI: 10.1080/08941939.2021.2024306] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND At present, it has been controversial whether primary tumor resection (PTR) can bring survival advantage to patients with metastatic small intestine neuroendocrine tumors (SI-NETs). To answer this question, we conducted a retrospective cohort study to evaluate the effect of PTR on the survival of patients with metastatic SI-NETs. METHODS Information on SI-NETs patients from 2004 to 2015 was extracted from Surveillance, Epidemiology, and End Results (SEER) databases. Demographics, tumor characteristics, treatment, and survival were compared. Propensity score-matched (PSM) was used 1:1 in the filtered queue. Cox proportional hazard regression model was used to evaluate the correlation between PTR and treatment results. RESULTS Before PSM, survival analysis showed that PTR significantly prolonged the survival of metastatic SI-NETs patients. After PSM, there was no significant difference in overall survival (OS) and cancer-specific survival (CSS) between the PTR group and the non-PTR group. Multivariate analysis showed no significant difference in OS and CSS between the two groups (p > 0.05). CONCLUSION Our study shows that OS and CSS are comparable between the PTR group and the non-PTR group. Thus, we believe that PTR should not be actively performed on such patients. Meanwhile, it is undeniable that properly selected patients may also benefit from PTR. Therefore, prospective randomized controlled trials are still needed to verify the effect of PTR on patients in the future.
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Affiliation(s)
- Haihao Yan
- Medical Center for Digestive Diseases, Second Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Linlin Yin
- Medical Center for Digestive Diseases, Second Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Hao Han
- Medical Center for Digestive Diseases, Second Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Ye Jin
- Medical Center for Digestive Diseases, Second Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Zheng Liu
- Medical Center for Digestive Diseases, Second Affiliated Hospital, Nanjing Medical University, Nanjing, China
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Nagel I, Herrmann K, Lahner H, Rischpler C, Weber F. Combined medical therapy, nuclear medicine therapy and other therapies in metastatic neuroendocrine tumor. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00156-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Neoplasia neuroendocrina metastásica de origen desconocido: de la incertidumbre en el diagnóstico por imagen a la precisión de la cirugía radioguiada laparoscópica. Rev Esp Med Nucl Imagen Mol 2022; 41 Suppl 1:S29-S30. [DOI: 10.1016/j.remnie.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Van Den Heede K, Chidambaram S, Van Slycke S, Brusselaers N, Warfvinge CF, Ohlsson H, Nordenström E, Almquist M. Effect of primary tumour resection without curative intent in patients with metastatic neuroendocrine tumours of the small intestine and right colon: meta-analysis. Br J Surg 2021; 109:191-199. [DOI: 10.1093/bjs/znab413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 10/31/2021] [Indexed: 12/13/2022]
Abstract
Abstract
Background
Patients with small intestinal neuroendocrine tumours (siNETs) usually present with advanced disease. Primary tumour resection without curative intent is controversial in patients with metastatic siNETs. The aim of this meta-analysis was to investigate survival after primary tumour resection without curative intent compared with no resection in patients with metastatic siNETs.
Methods
A systematic literature search was performed, using MEDLINE® (PubMed), Embase®, Web of Science, and the Cochrane Library up to 25 February 2021. Studies were included if survival after primary tumour resection versus no resection in patients with metastatic siNETs was reported. Results were pooled in a random-effects meta-analysis, and are reported as hazard ratios (HRs) with 95 per cent confidence intervals. Sensitivity analyses were undertaken to enable comment on the impact of important confounders.
Results
After screening 3659 abstracts, 16 studies, published between 1992 and 2021, met the inclusion criteria, with a total of 9428 patients. Thirteen studies reported HRs adjusted for important confounders and were included in the meta-analysis. Median overall survival was 112 (i.q.r. 82–134) months in the primary tumour resection group compared with 60 (74–88) months in the group without resection. Five-year overall survival rates were 74 (i.q.r. 67–77) and 44 (34–45) per cent respectively. Primary tumour resection was associated with improved survival compared with no resection (HR 0.55, 95 per cent c.i. 0.47 to 0.66). This effect remained in sensitivity analyses.
Conclusion
Primary tumour resection is associated with increased survival in patients with advanced, metastatic siNETs, even after adjusting for important confounders.
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Affiliation(s)
- Klaas Van Den Heede
- Department of Surgery, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of General and Endocrine Surgery, OLV Clinic Aalst, Aalst, Belgium
| | - Swathikan Chidambaram
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Endocrine Surgery, Hammersmith Hospital, London, UK
| | - Sam Van Slycke
- Department of General and Endocrine Surgery, OLV Clinic Aalst, Aalst, Belgium
- Department of Head and Skin, University Hospital Ghent, Ghent, Belgium
- Department of General Surgery, AZ Damiaan, Ostend, Belgium
| | - Nele Brusselaers
- Centre for Translational Microbiome Research Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
- Department of Family Medicine and Population Health, Global Health Institute, University of Antwerp, Wilrijk, Belgium
| | - Carl Fredrik Warfvinge
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Oncology and Pathology, Lund University, Lund, Sweden
| | - Håkan Ohlsson
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Surgery, Ystad Hospital, Ystad, Sweden
| | - Erik Nordenström
- Department of Surgery, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Martin Almquist
- Department of Surgery, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
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Resection of Primary Gastrointestinal Neuroendocrine Tumor Among Patients with Non-Resected Metastases Is Associated with Improved Survival: A SEER-Medicare Analysis. J Gastrointest Surg 2021; 25:2368-2376. [PMID: 33403563 DOI: 10.1007/s11605-020-04898-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/19/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The objective of this study was to analyze whether primary tumor resection (PTR) among patients with stage IV gastrointestinal neuroendocrine tumor (GI-NET) and unresected metastases was associated with improved outcomes. METHODS Patients diagnosed with stage IV GI-NETs were identified in the linked SEER-Medicare database from 2004 to 2015. Overall survival (OS) of patients who did versus did not undergo PTR was examined using bivariate and multivariable cox regression analysis as well as propensity score matching (PSM). RESULTS Among 2219 patients with metastatic GI-NETs, 632 (28.5%) underwent PTR, whereas 1587 (71.5%) did not. The majority of individuals had a NET in the pancreas (n = 969, 43.6%); the most common site of metastatic disease was the liver (n = 1064, 47.9%). Patients with stage IV small intestinal NETs most frequently underwent PTR (62.6%) followed by individuals with colon NETs (56.5%). After adjusting for all competing factors, PTR remained independently associated with improved OS (HR = 0.65, 95% CI: 0.56-0.76). Following PSM (n = 236 per group), patients who underwent PTR had improved OS (median OS: 1.3 years vs 0.8 years, p = 0.016). While PTR of NETs originating from stomach, small intestine, colon, and pancreas was associated with improved OS, PTR of rectal NET did not yield a survival benefit. CONCLUSION Primary GI-NET resection was associated with a survival benefit among individuals presenting with metastatic GI-NET with unresected metastases. Resection of primary GI-NET among patients with stage IV disease and unresected metastases should only be performed in selected cases following multi-disciplinary evaluation.
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Abstract
Small bowel neuroendocrine tumors (SBNETS) are slow-growing neoplasms with a noted propensity toward metastasis and comparatively favorable prognosis. The presentation of SBNETs is varied, although abdominal pain and obstructive symptoms are the most common presenting symptoms. In patients with metastases, hypersecretion of serotonin and other bioactive amines results in diarrhea, flushing, valvular heart disease, and bronchospasm, termed carcinoid syndrome. The treatment of SBNETs is multimodal and includes surgery, liver-directed therapy, somatostatin analogues, targeted therapy, and peptide receptor radionuclide therapy.
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Niederle B, Selberherr A, Niederle MB. How to Manage Small Intestine (Jejunal and Ileal) Neuroendocrine Neoplasms Presenting with Liver Metastases? Curr Oncol Rep 2021; 23:85. [PMID: 34018081 PMCID: PMC8137632 DOI: 10.1007/s11912-021-01074-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Small intestinal neuroendocrine neoplasms (siNENs) are slowly growing tumours with a low malignant potential. However, more than half of the patients present with distant metastases (stage IV) and nearly all with locoregional lymph node (LN) metastases at the time of surgery. The value of locoregional treatment is discussed controversially. RECENT FINDINGS In stage I to III disease, locoregional surgery was currently shown to be curative prolonging survival. In stage IV disease, surgery may prolong survival in selected patients with the chance to cure locoregional disease besides radical/debulking liver surgery. It may improve the quality of life and may prevent severe local complications resulting in a state of chronic malnutrition and severe intestinal ischaemia or bowel obstruction. Locoregional tumour resection offers the opportunity to be curative or to focus therapeutically on liver metastasis, facilitating various other therapeutic modalities. Risks and benefits of the surgical intervention need to be balanced individually.
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Affiliation(s)
- Bruno Niederle
- Department of General Surgery, Divison of Visceral Surgery, Medical University of Vienna, Waehringer Gürtel 18-20, A-1090 Vienna, Austria
| | - Andreas Selberherr
- Department of General Surgery, Divison of Visceral Surgery, Medical University of Vienna, Waehringer Gürtel 18-20, A-1090 Vienna, Austria
| | - Martin B. Niederle
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Waehringer Gürtel 18-20, A-1090 Vienna, Austria
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Sanz Viedma S, Alors Ruiz J, Roldán de la Rua J, Ortega Lozano S, Osorio Fernández D, Suárez Muñoz MA. Metastatic neuroendocrine neoplasia of unknown origin: From uncertainty in diagnostic imaging to the accuracy of radioguided laparoscopic surgery. Rev Esp Med Nucl Imagen Mol 2021; 41:S2253-654X(21)00069-X. [PMID: 33875402 DOI: 10.1016/j.remn.2021.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/26/2021] [Accepted: 02/27/2021] [Indexed: 10/21/2022]
Affiliation(s)
- S Sanz Viedma
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga (IBIMA), Málaga, España.
| | - J Alors Ruiz
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de la Victoria, Málaga, España
| | - J Roldán de la Rua
- Unidad de Cirugía HBP, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Málaga, España
| | - S Ortega Lozano
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de la Victoria, Málaga, España
| | - D Osorio Fernández
- Unidad de Cirugía HBP, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Málaga, España
| | - M A Suárez Muñoz
- Unidad de Cirugía HBP, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Málaga, España
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17
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Frilling A, Clift AK, Frampton AE, Bomanji J, Kaemmerer D, Al-Nahhas A, Alsafi A, Kidd M, Modlin IM, Hoersch D, Baum RP. A combination of surgery, theranostics, and liquid biopsy - a personalised oncologic approach to treatment of patients with advanced metastatic neuroendocrine neoplasms. Int J Med Sci 2021; 18:2166-2175. [PMID: 33859524 PMCID: PMC8040427 DOI: 10.7150/ijms.51740] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 01/14/2021] [Indexed: 01/29/2023] Open
Abstract
Rationale: Neuroendocrine neoplasia (NEN) of small bowel (SBNEN) frequently present with metastatic disease. Theranostics (molecular imaging followed by targeting therapy) allow for personalised medicine. Liquid biopsies enable precise identification of residual disease and real-time monitoring of therapeutic response. Our aim was to determine the clinical utility of a combination of surgery, theranostics, and a multigene blood measurement in metastasised SBNEN. Methods: Inclusion criteria were SBNEN, G1/G2 NEN, initial tumour diagnosis, stage IV NEN, positivity on 68Ga somatostatin analogue PET/CT, eligible for surgery, and 177Lu peptide receptor radionuclide therapy (PRRT). Blood samples for NETest were collected longitudinally. Progression-free survival (PFS) and overall survival (OS) were calculated. NETest results were assessed prior to surgery and during clinical follow-up. Results: A surgical cohort of 39 SBNEN patients met eligibility criteria. Thirty-two patients underwent ileal resection and 7 right hemicolectomy. The mean number of 177Lu PRRT cycles was 4. Mortality was nil. Surgical morbidity was 10.3%. Transient grade 1/2 toxicity occurred in 41% (PRRT). NETest scores (n=9 patients) decreased in 100% following treatment and correlated with diminished tumour volume and disease stabilization following surgery and PRRT. Median follow-up: 78 months. Median PFS and OS: 42.7 and 110 months, respectively. Progression-free survival at 1-, 3-, and 5-years was 79.4%, 57.1% and 40.5%, respectively. Overall survival at 1-, 3-, and 5-years was 97.4%, 97.4%, and 94.1%, respectively. Conclusions: Surgery combined with 177Lu PRRT is safe and provides favourable PFS and OS in selected patients with advanced SBNEN. Liquid biopsy (NETest) has the potential to accurately delineate disease status.
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Affiliation(s)
- Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ashley K. Clift
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Adam E. Frampton
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jamshed Bomanji
- Department of Nuclear Medicine, University College London Hospitals, London, UK
| | - Daniel Kaemmerer
- Department of General and Visceral Surgery, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Adil Al-Nahhas
- Department of Imaging and Nuclear Medicine, Imperial College London, London, UK
| | - Ali Alsafi
- Department of Imaging and Nuclear Medicine, Imperial College London, London, UK
| | | | - Irvin M. Modlin
- Gastroenterological and Endoscopic Surgery, Yale University School of Medicine, New Haven, USA
| | - Dieter Hoersch
- Department of Gastroenterology/Endocrinology, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Richard P. Baum
- CURANOSTICUM Wiesbaden-Frankfurt at DKD Helios Klinik, Wiesbaden, Germany
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18
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Selberherr A, Freermann S, Koperek O, Niederle MB, Riss P, Scheuba C, Niederle B. Neuroendocrine liver metastasis from the small intestine: Is surgery beneficial for survival? Orphanet J Rare Dis 2021; 16:30. [PMID: 33446229 PMCID: PMC7809808 DOI: 10.1186/s13023-021-01677-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neuroendocrine neoplasia of the small intestine (siNEN) are frequently diagnosed with liver metastases. The impact of the presence of liver metastases on overall survival and the necessity of surgery for liver metastasis is discussed controversially. The aim of this study is to evaluate and compare the overall long-term survival of patients with siNENs with and without liver metastasis at initial diagnosis and the possible benefit of surgical treatment as compared to active surveillance of metastases. 123 consecutive patients with siNENs were treated between 1965 and 2016. All clinical and histological records were reevaluated including analysis of the proliferation rates in all specimens. The 1-, 5-, 10- and 20-year overall survival was estimated by Kaplan-Meier analysis for patients with and without liver metastasis and according to the type of treatment (surgical vs. surveillance) of liver metastases if present. RESULTS The 1-, 5-, 10- and 20-year overall survival rate was 89.0%, 68.4%, 52.8% and 31.0% in patients without and 89.5%, 69.5%, 33.2% and 3.6% in those with liver metastases. No statistically significant differences were observed comparing the two groups. Within the group of patients with liver metastases, the type of treatment (surgical vs. surveillance) was in favor of patients undergoing surgery. Multivariate analysis showed that the presence of liver metastases upon diagnosis was an individual risk factor associated with worse survival. CONCLUSION The presence of liver metastasis at initial diagnosis does not have a statistically significant influence on survival. Surgery for hepatic metastasis seems to show a benefit for overall survival and may be indicated especially in patients symptomatic due to high tumor burden and serotonin hypersecretion to reduce hormone activity.
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Affiliation(s)
- Andreas Selberherr
- Section "Endocrine Surgery", Division of General Surgery, Department of Surgery, Medical University, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Simon Freermann
- Section "Endocrine Surgery", Division of General Surgery, Department of Surgery, Medical University, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Oskar Koperek
- Department of Pathology, Medical University, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Martin B Niederle
- Department of Anesthesiology, Medical University, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Philipp Riss
- Section "Endocrine Surgery", Division of General Surgery, Department of Surgery, Medical University, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Christian Scheuba
- Section "Endocrine Surgery", Division of General Surgery, Department of Surgery, Medical University, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Bruno Niederle
- Section "Endocrine Surgery", Division of General Surgery, Department of Surgery, Medical University, Währinger Gürtel 18-20, 1090, Vienna, Austria
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19
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Lim JY, Pommier RF. Clinical Features, Management, and Molecular Characteristics of Familial Small Bowel Neuroendocrine Tumors. Front Endocrinol (Lausanne) 2021; 12:622693. [PMID: 33732215 PMCID: PMC7959745 DOI: 10.3389/fendo.2021.622693] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 01/21/2021] [Indexed: 12/14/2022] Open
Abstract
Small bowel neuroendocrine tumors are rare tumors with an increasing incidence over the last several decades. Early detection remains challenging because patients commonly develop symptoms late in the disease course, often after the tumors have metastasized. Although these tumors were thought to arise from sporadic genetic mutations, large epidemiological studies strongly support genetic predisposition and increased risk of disease in affected families. Recent studies of familial small bowel neuroendocrine tumors have identified several novel genetic mutations. Screening for familial small bowel neuroendocrine tumors can lead to earlier diagnosis and improved patient outcomes. This review aims to summarize the current knowledge of molecular changes seen in familial small bowel neuroendocrine tumors, identify clinical features specific to familial disease, and provide strategies for screening and treatment.
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20
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Gangi A, Anaya DA. Surgical Principles in the Management of Small Bowel Neuroendocrine Tumors. Curr Treat Options Oncol 2020; 21:88. [PMID: 32862334 DOI: 10.1007/s11864-020-00784-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OPINION STATEMENT Small bowel neuroendocrine tumors (SB NETs) are increasing in frequency and becoming more common in surgical practice. It is often difficult to make the diagnosis of a SB NET at an early stage, as the primary tumor tends to be small and patients are asymptomatic until there is regional or distant metastasis, when they develop abdominal pain, partial obstruction, or bleeding and/or develop carcinoid syndrome. Despite this advanced presentation at the time of diagnosis, patients with metastatic SB NETs, as compared to other gastrointestinal malignancies, have favorable survival, which can be improved by appropriate surgical interventions. With the lack of randomized studies, there is reasonable controversy surrounding the optimal management of patients with SB NETs. As such, treatment of these patients is driven primarily by physician experience and available data based predominantly on retrospective studies. Based on this, current recommendations advocate for patients with SB NETs (localized or metastatic) to be managed at experienced centers by a multidisciplinary team. Eligible patients should undergo surgical resection of primary and regional disease as outlined in this article. Additionally, patients with metastatic disease should be evaluated on a case by case basis to evaluate surgical options that may mitigate bowel symptoms (i.e., pain, intestinal angina, obstruction) and carcinoid symptoms (flushing, diarrhea, hemodynamic instability) and prolong survival. Unlike other gastrointestinal malignancies, aggressive surgical management of these patients, even in the context of unresectable metastatic disease, can improve patients' symptoms and long-term survival. The principles outlined in this article are geared to guide appropriate management of SB NET patients with improvement in quality of life and overall survival outcomes.
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Affiliation(s)
- Alexandra Gangi
- Division of Surgical Oncology, Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel A Anaya
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL, 33612, USA.
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21
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Role of Primary Tumor Resection for Metastatic Small Bowel Neuroendocrine Tumors. World J Surg 2020; 45:213-218. [PMID: 32797281 DOI: 10.1007/s00268-020-05727-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2020] [Indexed: 12/21/2022]
Abstract
While small bowel resection is well established as standard of care for curative-intent management of localized and loco-regional small bowel neuroendocrine tumors (SB-NETs), resection of the primary tumor in the setting of metastatic disease is debated. This review addresses the role of primary tumor resection for stage IV well-differentiated grade 1 and 2 SB-NETs. While survival benefits have been reported for primary tumor resection in the setting of metastatic disease, these studies are limited by selection bias and thus controversial. The main clinical benefits of primary tumor resection for stage IV disease involve the prevention of potentially debilitating complications associated with mesenteric fibrosis, including intestinal obstruction, mesenteric ischemia and angina, venous congestion, malabsorption, and malnutrition. Patients with metastases undergoing initial resection of the primary SB-NETs appear to have fewer episodes of care and re-intervention for loco-regional complications than those who do not undergo resection. As recommended by the NANETS and ENETS guidelines, resection of the primary tumor for stage IV SB-NETs should be strongly considered to avoid future loco-regional complications and potentially to improve survival. All patients with stage IV SB-NETs should be assessed by a surgeon experienced in the management of NETs to consider surgical therapies, including resection of the primary tumor despite metastatic disease.
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22
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[Gastroenteropancreatic neuroendocrine neoplasms-Heterogeneity, management and perspectives of treatment and research]. Internist (Berl) 2020; 61:875-890. [PMID: 32676723 DOI: 10.1007/s00108-020-00832-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The term neuroendocrine neoplasms (NEN) encompasses a molecularly and biologically very heterogeneous group of tumors, which have in common their origin in neuroendocrine cells. The also very heterogeneous subgroup of gastroenteropancreatic neuroendocrine neoplasms (GEP-NEN) is the best classified and investigated group. This article provides a systematic review of the current classification, diagnostics and treatment options of GEP-NEN. In order to achieve a better overview, it was consciously decided not to use an approach based on the primary localization. Instead, a thematic organization according to classification, clinical phenotype, diagnostics and treatment was chosen.
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23
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Cloyd JM, Wiseman JT, Pawlik TM. Surgical management of pancreatic neuroendocrine liver metastases. J Gastrointest Oncol 2020; 11:590-600. [PMID: 32655938 PMCID: PMC7340805 DOI: 10.21037/jgo.2019.11.02] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 11/13/2019] [Indexed: 12/12/2022] Open
Abstract
Pancreatic neuroendocrine tumors (PNET) are a heterogeneous group of neoplasms that vary in their clinical presentation, behavior and prognosis. The most common site of metastasis is the liver. Surgical resection of neuroendocrine liver metastases (NELM) is thought to afford the best long-term outcomes when feasible. Initial preoperative workup should include surveillance for carcinoid syndrome, screening for evidence of liver insufficiency, and performance of imaging specific to neuroendocrine tumors such as a somatostatin receptor positron emission tomography scan. Standard surgical principles apply to hepatic surgery for NELM, namely prioritizing low central venous pressure anesthesia, minimizing blood loss, knowledge of liver anatomy, generous use of intraoperative ultrasound, as well as safe parenchymal transection techniques and practices to avoid bile leakage. Knowledge of established prognostic factors may assist with patient selection, which is important for optimizing short- and long-term outcomes of hepatic resection. Adjunct therapies such as concomitant liver ablation are used frequently and are generally safe when used appropriately. For patients with synchronous resectable NELM, resection of the primary either in a staged or combined fashion is recommended. Primary tumor resection in the setting of unresectable metastatic disease is more controversial, however generally recommended if morbidity is acceptable. For patients who are not surgical candidates, due to either patient performance status or burden of liver disease, several liver-directed therapies such as transarterial embolization, chemoembolization, and radioembolization are available to assist with locoregional control, extend progression-free survival (PFS), and improve symptoms of carcinoid syndrome. Multiple systemic therapy options exist for patients with metastatic PNET which are often prioritized for those patients with advanced or progressive disease. A systematic approach in a multi-disciplinary setting is likely to result in the best long-term outcomes for patients with pancreatic NELM. Ongoing research is needed to determine the optimal patient selection for hepatic surgery as well as the ideal treatment sequencing for those patients with NELM.
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Affiliation(s)
- Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner, Columbus, OH, USA
| | - Jason T Wiseman
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner, Columbus, OH, USA
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24
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Ma ZY, Gong YF, Zhuang HK, Zhou ZX, Huang SZ, Zou YP, Huang BW, Sun ZH, Zhang CZ, Tang YQ, Hou BH. Pancreatic neuroendocrine tumors: A review of serum biomarkers, staging, and management. World J Gastroenterol 2020; 26:2305-2322. [PMID: 32476795 PMCID: PMC7243647 DOI: 10.3748/wjg.v26.i19.2305] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 03/27/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023] Open
Abstract
Pancreatic neuroendocrine tumors (pNETs) are a heterogeneous group of tumors with complicated treatment options that depend on pathological grading, clinical staging, and presence of symptoms related to hormonal secretion. With regard to diagnosis, remarkable advances have been made: Chromogranin A is recommended as a general marker for pNETs. But other new biomarker modalities, like circulating tumor cells, multiple transcript analysis, microRNA profile, and cytokines, should be clarified in future investigations before clinical application. Therefore, the currently available serum biomarkers are insufficient for diagnosis, but reasonably acceptable in evaluating the prognosis of and response to treatments during follow-up of pNETs. Surgical resection is still the only curative therapeutic option for localized pNETs. However, a debulking operation has also been proven to be effective for controlling the disease. As for drug therapy, steroids and somatostatin analogues are the first-line therapy for those with positive expression of somatostatin receptor, while everolimus and sunitinib represent important progress for the treatment of patients with advanced pNETs. Great progress has been achieved in the combination of systematic therapy with local control treatments. The optimal timing of local control intervention, planning of sequential therapies, and implementation of multidisciplinary care remain pending.
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Affiliation(s)
- Zu-Yi Ma
- Department of General Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
- Shantou University of Medical College, Shantou 515000, Guangdong Province, China
| | - Yuan-Feng Gong
- Department of General Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Hong-Kai Zhuang
- Department of General Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
- Shantou University of Medical College, Shantou 515000, Guangdong Province, China
| | - Zi-Xuan Zhou
- Department of General Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Shan-Zhou Huang
- Department of General Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Yi-Ping Zou
- Department of General Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
- Shantou University of Medical College, Shantou 515000, Guangdong Province, China
| | - Bo-Wen Huang
- Department of General Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Zhong-Hai Sun
- Department of General Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
- Shantou University of Medical College, Shantou 515000, Guangdong Province, China
| | - Chuan-Zhao Zhang
- Department of General Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
| | - Yun-Qiang Tang
- Department of Hepatobiliary Surgery, the Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou 510080, Guangdong Province, China
| | - Bao-Hua Hou
- Department of General Surgery, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, Guangdong Province, China
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25
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Gangi A, Manguso N, Gong J, Crystal JS, Paski SC, Hendifar AE, Tuli R. Midgut Neuroendocrine Tumors with Liver-only Metastases: Benefit of Primary Tumor Resection. Ann Surg Oncol 2020; 27:4525-4532. [PMID: 32394299 DOI: 10.1245/s10434-020-08510-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Management of metastatic midgut neuroendocrine tumors (MNET) remains controversial. The benefits of resecting the primary tumor are not clear and advocated only for select patients. This study aimed to determine whether resection of the primary MNET in patients with untreated liver-only metastases has an impact on survival. METHODS This retrospective study reviewed data of the National Cancer Database from 2004 to 2015 for patients with liver-only metastatic MNETs and compared those who received resection of their primary MNET with those who did not. Patient demographics, tumor characteristics, and clinical outcomes were compared between the groups. The primary outcome was overall survival (OS) after adjustment for patient, demographic, and tumor-related factors. RESULTS The study identified 1952 patients with a median age of 63 years (range, 18-90 years). The median primary tumor size was 2.4 cm (range, 0.1-20 cm). Of these patients, 1295 (66%) underwent resection of the primary tumor and 667 (34%) did not. The patients who underwent resection were younger (median age, 63 vs 65 years; p < 0.001) and had smaller primary tumors (median, 2.3 vs 3.0 cm; p < 0.001). The patients with clinical T1 or T2 tumors were significantly less likely to undergo resection than those with stage T3 or T4 tumors (58.5% vs 89.7%; p < 0.001). The median follow-up period was 43 months (range, 1-83 months). In the entire cohort, 483 deaths occurred, with a 5-year OS of 61%. The 5-year OS rate was 49% for the patients who underwent resection and 66% for those who did not (p < 0.001). When the patients were grouped according to T stage, no OS difference between resection and no resection for stages T1 (p = 0.07) and T2 (p = 0.40) was identified. However, the 5-year OS rate was significantly better for the resected patient cohort with T3 (67.5% vs 37.2%; p < 0.001) or T4 (59.8% vs 21.5%; p < 0.001) tumors. CONCLUSIONS The patients with treatment-naïve liver-only metastatic MNET had improved OS when the primary tumor was resected, particularly those with clinical stage T3 or T4 tumors. These patients may benefit from surgical resection of their primary tumor.
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Affiliation(s)
- Alexandra Gangi
- Division of Surgical Oncology, Department of Surgery, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Nicholas Manguso
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jun Gong
- Department of Gastrointestinal Malignancies, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jessica S Crystal
- Division of Surgical Oncology, Department of Surgery, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shirley C Paski
- Department of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Andrew E Hendifar
- Department of Gastrointestinal Malignancies, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Richard Tuli
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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26
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Scoville SD, Xourafas D, Ejaz AM, Tsung A, Pawlik T, Cloyd JM. Contemporary indications for and outcomes of hepatic resection for neuroendocrine liver metastases. World J Gastrointest Surg 2020; 12:159-170. [PMID: 32426095 PMCID: PMC7215975 DOI: 10.4240/wjgs.v12.i4.159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/21/2020] [Accepted: 03/05/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Although surgical resection is associated with the best long-term outcomes for neuroendocrine liver metastases (NELM), the current indications for and outcomes of surgery for NELM from a population perspective are not well understood.
AIM To determine the current indications for and outcomes of liver resection (LR) for NELM using a population-based cohort.
METHODS A retrospective review of the 2014-2017 American College of Surgeons National Surgical Quality Improvement Program and targeted hepatectomy databases was performed to identify patients who underwent LR for NELM. Perioperative characteristics and 30-d morbidity and mortality were analyzed.
RESULTS Among 669 patients who underwent LR for NELM, the median age was 60 (interquartile range: 51-67) and 51% were male. While the number of metastases resected ranged from 1 to 9, the most common (45%) number of tumors resected was one. The majority (68%) of patients had a largest tumor size of < 5 cm. Most patients underwent partial hepatectomy (71%) while fewer underwent a right or left hepatectomy or trisectionectomy. The majority of operations were open (82%) versus laparoscopic (17%) or robotic (1%). In addition, 30% of patients underwent intraoperative ablation while 45% had another concomitant operation including cholecystectomy (28.8%), bowel resection (20.2%), or partial pancreatectomy (3.4%). Overall 30-d morbidity and mortality was 29% and 1.3%, respectively. On multivariate analysis, American Society of Anesthesiologists class ≥ 3 [odds ratios (OR), OR = 2.089, 95% confidence intervals (CI): 1.197-3.645], open approach (OR = 1.867, 95%CI: 1.148-3.036), right hepatectomy (OR = 1.618, 95%CI: 1.014-2.582), and prolonged operative time of > 230 min (OR = 1.731, 95%CI: 1.168-2.565) were associated with higher 30-d morbidity while intraoperative ablation and concomitant procedures were not.
CONCLUSION LR for NELM was performed with relatively low postoperative morbidity and mortality. Concomitant procedures performed at the time of LR did not increase morbidity.
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Affiliation(s)
- Steven D Scoville
- Department of Surgery, Division of Surgical Oncology at The Ohio State University, James Cancer Center, Columbus, OH 43210, United States
- The Arthur G James Comprehensive Cancer Center and Solove Research Institute, The Ohio State University, Columbus, OH 43210, United States
| | - Dimitrios Xourafas
- Department of Surgery, Division of Surgical Oncology at The Ohio State University, James Cancer Center, Columbus, OH 43210, United States
- Department of Surgery, Harvard Medical School, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, United States
| | - Aslam M Ejaz
- Department of Surgery, Division of Surgical Oncology at The Ohio State University, James Cancer Center, Columbus, OH 43210, United States
- Department of Surgery, The Ohio State University, Columbus, OH 43210, United States
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology at The Ohio State University, James Cancer Center, Columbus, OH 43210, United States
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
| | - Timothy Pawlik
- Department of Surgery, Division of Surgical Oncology at The Ohio State University, James Cancer Center, Columbus, OH 43210, United States
- Department of Surgery, The Ohio State University, Columbus, OH 43210, United States
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology at The Ohio State University, James Cancer Center, Columbus, OH 43210, United States
- Department of Surgery, The Ohio State University, Columbus, OH 43210, United States
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, United States
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27
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Kasai Y, Mahuron K, Hirose K, Corvera CU, Kim GE, Hope TA, Shih BE, Warren RS, Bergsland EK, Nakakura EK. A novel stratification of mesenteric mass involvement as a predictor of challenging mesenteric lymph node dissection by minimally invasive approach for ileal neuroendocrine tumors. J Surg Oncol 2020; 122:204-211. [PMID: 32291778 DOI: 10.1002/jso.25930] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/09/2020] [Accepted: 03/31/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES We classified the extent of mesenteric mass (MM) involvement that predicts challenging mesenteric lymph node dissection (mLND) by minimally invasive surgery (MIS) for ileal neuroendocrine tumors (i-NETs). METHODS Patients who underwent surgery for i-NETs were retrospectively reviewed. MM involvement was classified as region-0: no MM; region-1: >2 cm from the origins of the ileocolic artery/vein; region-2: ≤2 cm from the origins; and region-3: more proximal superior mesenteric artery/vein. Logistic regression analysis was used to evaluate the predictive value of MM regions for gross positive mesenteric margin (mR2) and/or conversion among the MIS cohort. The open surgery cohort was used as a reference for mR2 rates. RESULTS Of 108 patients, 83 patients (77%) underwent MIS. MMs in region-2 and region-3 were independent risk factors for mR2 and/or conversion (odds ratio [95% confidence interval]: 4.25 [1.17-16.4] and 8.51 × 107 [11.0-], respectively, against regions-0 and 1]. mR2 rates of MIS and open surgery cohorts per region did not differ significantly (4% and 7% for regions-0 and 1; 17% and 25% for region-2; and 100% and 83% for region-3). CONCLUSIONS The novel stratification of MM regions was predictive of challenging mLND by MIS. Surgeons should have a low threshold for conversion for MMs in proximal regions.
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Affiliation(s)
- Yosuke Kasai
- Department of Surgery, University of California, San Francisco, San Francisco, California.,UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Kelly Mahuron
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Kenzo Hirose
- Department of Surgery, University of California, San Francisco, San Francisco, California.,UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Carlos U Corvera
- Department of Surgery, University of California, San Francisco, San Francisco, California.,UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Grace E Kim
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California.,Department of Pathology, University of California, San Francisco, San Francisco, California
| | - Thomas A Hope
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California.,Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Brandon E Shih
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Robert S Warren
- Department of Surgery, University of California, San Francisco, San Francisco, California.,UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Emily K Bergsland
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California.,Department of Medicine, University of CFACS, California, San Francisco, San Francisco, California
| | - Eric K Nakakura
- Department of Surgery, University of California, San Francisco, San Francisco, California.,UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
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Kasai Y, Mahuron K, Hirose K, Corvera CU, Kim GE, Hope TA, Shih BE, Warren RS, Bergsland EK, Nakakura EK. Prognostic impact of a large mesenteric mass >2 cm in ileal neuroendocrine tumors. J Surg Oncol 2019; 120:1311-1317. [DOI: 10.1002/jso.25727] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/14/2019] [Indexed: 12/17/2022]
Affiliation(s)
- Yosuke Kasai
- Department of SurgeryUniversity of California San Francisco California
- UCSF Helen Diller Family Comprehensive Cancer Center San Francisco California
| | - Kelly Mahuron
- Department of SurgeryUniversity of California San Francisco California
| | - Kenzo Hirose
- Department of SurgeryUniversity of California San Francisco California
- UCSF Helen Diller Family Comprehensive Cancer Center San Francisco California
| | - Carlos U. Corvera
- Department of SurgeryUniversity of California San Francisco California
- UCSF Helen Diller Family Comprehensive Cancer Center San Francisco California
| | - Grace E. Kim
- UCSF Helen Diller Family Comprehensive Cancer Center San Francisco California
- Department of PathologyUniversity of California San Francisco California
| | - Thomas A. Hope
- UCSF Helen Diller Family Comprehensive Cancer Center San Francisco California
- Department of Radiology and Biomedical ImagingUniversity of California San Francisco California
| | - Brandon E. Shih
- UCSF Helen Diller Family Comprehensive Cancer Center San Francisco California
| | - Robert S. Warren
- Department of SurgeryUniversity of California San Francisco California
- UCSF Helen Diller Family Comprehensive Cancer Center San Francisco California
| | - Emily K. Bergsland
- UCSF Helen Diller Family Comprehensive Cancer Center San Francisco California
- Department of MedicineUniversity of California San Francisco California
| | - Eric K. Nakakura
- Department of SurgeryUniversity of California San Francisco California
- UCSF Helen Diller Family Comprehensive Cancer Center San Francisco California
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29
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Weber F, Dralle H. Value of ileus-prophylactic surgery for metastatic neuroendocrine midgut tumours. Best Pract Res Clin Endocrinol Metab 2019; 33:101342. [PMID: 31628078 DOI: 10.1016/j.beem.2019.101342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Neuroendocrine tumours of the small intestine (SINET) are a rare disease. However, a rising incidence rate and excellent long-term survival, even in the setting of metastatic disease lead to a high prevalence of SINET of up to 11/100.000. At the time of diagnosis, most patients already suffer from metastatic disease. About one third of patients demonstrate localized or regional metastatic disease at time of presentation. For those patients the indication for curative surgery is not debated and 10-year cancer specific survival of almost 90% can be achieved. Due to major limitations of existing studies actually there is no sufficient evidence in favour of ileus-prophylactic palliative surgery for metastatic SINET. Until now the available evidence favouring an ileus-prophylactic palliative small bowel resection for stage IV SI-NET must be weighed against available high-level evidence from randomized trials that showed long-term survival under systemic therapy. Importantly, there is not a single study that indicates surgery for a symptomatic patient should be postponed. Because the majority of patients are symptomatic at the time of diagnosis, the rationale for an ileus-prophylactic palliative surgery is to operate before progression of mesenteric tumour mass and desmoplasia takes place and before intestinal obstruction and ischaemia occurs. To what extent a prophylactic palliative small bowel resection will provide a survival benefit in a situation where the mesenteric tumour mass cannot be resected radically is not clearly addressed by the current level of evidence.
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Affiliation(s)
- Frank Weber
- Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, Essen, Germany.
| | - Henning Dralle
- Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, Essen, Germany
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30
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Sahara K, Merath K, Tsilimigras DI, Hyer JM, Guglielmi A, Aldrighetti L, Weiss M, Fields RC, Poultsides GA, Maithel SK, Endo I, Pawlik TM, other members of the U.S. Neuroendo. Conditional disease‐free survival after curative‐intent liver resection for neuroendocrine liver metastasis. J Surg Oncol 2019; 120:1087-1095. [DOI: 10.1002/jso.25713] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/13/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Kota Sahara
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbus Ohio
- Department of Gastroenterological SurgeryYokohama City University School of MedicineYokohama Japan
| | - Katiuscha Merath
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbus Ohio
| | - Diamantis I. Tsilimigras
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbus Ohio
| | - J. Madison Hyer
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbus Ohio
| | | | | | - Matthew Weiss
- Department of SurgeryJohns Hopkins HospitalBaltimore Maryland
| | - Ryan C. Fields
- Department of SurgeryWashington University School of MedicineSt Louis Missouri
| | | | | | - Itaru Endo
- Department of Gastroenterological SurgeryYokohama City University School of MedicineYokohama Japan
| | - Timothy M. Pawlik
- Department of Surgery, Division of Surgical OncologyThe Ohio State University Wexner Medical Center and James Comprehensive Cancer CenterColumbus Ohio
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Tsilimigras DI, Squires MH, Cloyd JM, Pawlik TM. Treatment strategies for neuroendocrine liver metastases: an update. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1651639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Diamantis I. Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Malcolm H. Squires
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M. Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M. Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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32
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Zheng M, Li Y, Li T, Zhang L, Zhou L. Resection of the primary tumor improves survival in patients with gastro-entero-pancreatic neuroendocrine neoplasms with liver metastases: A SEER-based analysis. Cancer Med 2019; 8:5128-5136. [PMID: 31328428 PMCID: PMC6718577 DOI: 10.1002/cam4.2431] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/01/2019] [Accepted: 07/08/2019] [Indexed: 12/12/2022] Open
Abstract
Patients who suffer from gastro‐entero‐pancreatic neuroendocrine neoplasms (GEP‐NENs) often present with liver metastatic disease. The efficacy of primary tumor resection (PTR) for these patients remains controversial due to the relatively heterogeneous behavior of the primary tumor and the lack of clinical evidence. In this series, GEP‐NEN patients with liver metastases (LM) were selected from the Surveillance, Epidemiology, and End Results database between 2010 and 2015. A logistic regression model was used to analyze variables that were associated with PTR. A Cox proportional hazards model was used to identify independent prognostic risk factors. In total, 1547 patients were enrolled in our study, including 897 patients who underwent PTR. Resection of the primary tumor was associated with prolonged survival in all patients (5‐year overall survival (OS) rates: 57.0% vs 15.4%, P < .001), and improved 5‐year OS rates were observed in patients with gastric, small intestinal, colorectal, and pancreatic subtypes (39.7%, 73.3%, 24.6%, and 59.7%, respectively). On the multivariate analysis, PTR was an independent prognostic factor of prolonged OS (HR = 0.48, 95% CI: 0.39‐0.59, P < .001). Patients with a young age (≤60 years), small intestinal or colorectal NENs, a large primary tumor, lymph node (LN) metastases, and high tumor differentiation were more likely to undergo PTR. However, patients with colorectal NENs or a large primary tumor (≥4 cm) were at an increased risk of death independently in the PTR subgroup. The risk factors for OS also included old age, gastric tumor location, and poor differentiation. In conclusion, although PTR prolonged OS in all GEP‐NEN patients presenting with LM, surgical recipients should be considered carefully. Age, primary tumor site, size, and differentiation might help surgeons identify patients who could benefit from PTR.
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Affiliation(s)
- Mengzhen Zheng
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yan Li
- Xinxiang Medical University, Xinxiang, China
| | - Tong Li
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lianfeng Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lin Zhou
- Department of Gastroenterology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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