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Clift AK, Thomas R, Frilling A. Developments in interventional management of hepatic metastases from neuroendocrine tumours. Best Pract Res Clin Endocrinol Metab 2023; 37:101798. [PMID: 37468404 DOI: 10.1016/j.beem.2023.101798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Neuroendocrine tumours commonly metastasise to the liver, particularly those arising from the intestinal tract and pancreas. Whilst surgery offers the only approach with intent to cure, the vast majority of patients with neuroendocrine liver metastases are ineligible. Liver-directed interventional therapies seek to exploit the patho-anatomy of the blood supply of hepatic metastases to deliver therapy to liver deposits. This may involve percutaneous ablation, bland embolization, or the selective infusion of chemotherapeutics, targeted agents or radiolabelled embolic material. Retrospective case series evidence has characterised objective response rates, disease control rates, and longer-term outcomes associated with each approach. Recent advances in this field include ongoing comparative trials of different techniques, but more importantly, combinations of interventional liver-directed therapies and other systemic therapy in multimodal treatment concepts.
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Affiliation(s)
- Ashley Kieran Clift
- Cancer Research UK Oxford Centre, University of Oxford, Oxford, United Kingdom; Department of Surgery & Cancer, Imperial College London, London, United Kingdom.
| | - Robert Thomas
- Department of Imaging, Imperial College Healthcare NHS Trust, London, United Kingdom.
| | - Andrea Frilling
- Department of Surgery & Cancer, Imperial College London, London, United Kingdom.
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2
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Sulciner ML, Clancy TE. Surgical Management of Pancreatic Neuroendocrine Tumors. Cancers (Basel) 2023; 15:cancers15072006. [PMID: 37046665 PMCID: PMC10093271 DOI: 10.3390/cancers15072006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 03/30/2023] Open
Abstract
Pancreatic neuroendocrine tumors (PNETs) are relatively uncommon malignancies, characterized as either functional or nonfunctional secondary to their secretion of biologically active hormones. A wide range of clinical behavior can be seen, with the primary prognostic indicator being tumor grade as defined by the Ki67 proliferation index and mitotic index. Surgery is the primary treatment modality for PNETs. While functional PNETs should undergo resection for symptom control as well as potential curative intent, nonfunctional PNETs are increasingly managed nonoperatively. There is increasing data to suggest small, nonfunctional PNETs (less than 2 cm) are appropriate follow with nonoperative active surveillance. Evidence supports surgical management of metastatic disease if possible, and occasionally even surgical management of the primary tumor in the setting of widespread metastases. In this review, we highlight the evolving surgical management of local and metastatic PNETs.
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Grozinsky‐Glasberg S, Davar J, Hofland J, Dobson R, Prasad V, Pascher A, Denecke T, Tesselaar MET, Panzuto F, Albåge A, Connolly HM, Obadia J, Riechelmann R, Toumpanakis C. European Neuroendocrine Tumor Society (ENETS) 2022 Guidance Paper for Carcinoid Syndrome and Carcinoid Heart Disease. J Neuroendocrinol 2022; 34:e13146. [PMID: 35613326 PMCID: PMC9539661 DOI: 10.1111/jne.13146] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/17/2022] [Accepted: 04/18/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Simona Grozinsky‐Glasberg
- Neuroendocrine Tumor Unit, ENETS Center of Excellence, Department of Endocrinology and Metabolism, Hadassah Medical Organization and Faculty of MedicineHebrew University of JerusalemJerusalemIsrael
| | - Joseph Davar
- Carcinoid Heart Disease Clinic, Department of CardiologyRoyal Free Hospital & University College LondonLondonUK
| | - Johannes Hofland
- Department of Internal Medicine, Section of Endocrinology, ENETS Center of ExcellenceErasmus MC and Erasmus Cancer InstituteRotterdamThe Netherlands
| | - Rebecca Dobson
- Department of CardiologyLiverpool Heart and Chest HospitalLiverpoolUK
| | - Vikas Prasad
- Department of Nuclear MedicineUniversity UlmUlmGermany
| | - Andreas Pascher
- Department of General, Visceral and Transplantation SurgeryUniversity Hospital MuensterMuensterGermany
| | - Timm Denecke
- Department of Diagnostic and Interventional RadiologyLeipzig University Medical CenterLeipzigGermany
| | | | - Francesco Panzuto
- Digestive Disease Unit, Department of Medical‐Surgical Sciences and Translational MedicineSapienza University of Rome, ENETS Center of ExcellenceRomeItaly
| | - Anders Albåge
- Department of Cardiothoracic Surgery and Anesthesiology, University Hospital, and Department of Surgical SciencesUppsala UniversityUppsalaSweden
| | - Heidi M. Connolly
- Department of Cardiovascular DiseasesMayo ClinicRochesterMinnesotaUSA
| | | | | | - Christos Toumpanakis
- Centre for Gastroenterology, Neuroendocrine Tumour Unit, ENETS Centre of ExcellenceRoyal Free HospitalLondonUK
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Survival According to Therapy Regimen for Small Intestinal Neuroendocrine Tumors. J Clin Med 2022; 11:jcm11092358. [PMID: 35566487 PMCID: PMC9104547 DOI: 10.3390/jcm11092358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/14/2022] [Accepted: 04/16/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction: Scarce data exist for therapy regimens other than somatostatin analogues (SSA) and peptide receptor radiotherapy (PRRT) for siNET. We analyzed real world data for differences in survival according to therapy. Patients and methods: Analysis of 145 patients, diagnosed between 1993 and 2018 at a single institution, divided in treatment groups. Group (gr.) 0: no treatment (n = 10), gr 1: TACE and/or PRRT (n = 26), gr. 2: SSA (n = 32), gr. 3: SSA/PRRT (n = 8), gr. 4: chemotherapy (n = 8), gr. 5: not metastasized (at diagnosis), surgery only (n = 53), gr. 6 = metastasized (at diagnosis), surgery only (n = 10). Results: 45.5% female, median age 60 years (range, 27–84). A total of 125/145 patients with a resection of the primary tumor. For all patients, 1-year OS (%) was 93.8 (95%-CI: 90–98), 3-year OS = 84.3 (CI: 78–90) and 5-year OS = 77.5 (CI: 70–85). For analysis of survival according to therapy, only stage IV patients (baseline) that received treatment were included. Compared with reference gr. 2 (SSA only), HR for OS was 1.49 (p = 0.47) for gr. 1, 0.72 (p = 0.69) for gr. 3, 2.34 (p = 0.19) for gr. 4. The 5 y OS rate of patients whose primary tumor was resected (n = 125) was 73.1%, and without PTR was 33.3% (HR: 4.31; p = 0.003). Individual patients are represented in swimmer plots. Conclusions: For stage IV patients in this analysis (limited by low patient numbers in co. 3/4), multimodal treatment did not significantly improve survival over SSA treatment alone. A resection of primary tumor significantly improves survival.
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Kohno S. Diagnosis and Surgical Treatment of Gastroenteropancreatic Neuroendocrine Neoplasms: A Literature Review. CANCER DIAGNOSIS & PROGNOSIS 2022; 2:115-125. [PMID: 35399177 PMCID: PMC8962810 DOI: 10.21873/cdp.10085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/31/2022] [Indexed: 06/14/2023]
Abstract
This review aimed to highlight the characteristics and surgical treatments of tumours, and answer questions regarding the assessment of gastrointestinal neuroendocrine neoplasms (NENs) and optimal therapy. NENs comprise tumours that can produce hormones and cause a secretory syndrome. The diagnostic method and accuracy differ depending on the site of occurrence; hence, the relevant scientific society has created NEN treatment guidelines for each organ. Gastroenteric pancreatic (GEP) NENs have been unified and classified together according to the 2019 World Health Organization classification. Treatment is based on complete tumour resection, and when metastatic or primary lesions cannot be completely resected, lesions and symptoms are treated. Except for surgery for NENs, chemotherapy, molecularly targeted drugs, transarterial chemoembolization, etc., have also been confirmed as treatments. GEP NEN treatment methods will continue to advance and change because of surgery and other advances in treatment and diagnostic methods.
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Affiliation(s)
- Shuzo Kohno
- Department of Surgery, The Jikei University Katsushika Medical Center, Tokyo, Japan
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Lee L, Ramos-Alvarez I, Jensen RT. Predictive Factors for Resistant Disease with Medical/Radiologic/Liver-Directed Anti-Tumor Treatments in Patients with Advanced Pancreatic Neuroendocrine Neoplasms: Recent Advances and Controversies. Cancers (Basel) 2022; 14:cancers14051250. [PMID: 35267558 PMCID: PMC8909561 DOI: 10.3390/cancers14051250] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/08/2022] [Accepted: 02/23/2022] [Indexed: 12/14/2022] Open
Abstract
Simple Summary Tumor resistance, both primary and acquired, is leading to increased complexity in the nonsurgical treatment of patients with advanced panNENs, which would be greatly helped by reliable prognostic/predictive factors. The importance in identifying resistance is being contributed to by the increased array of possible treatments available for treating resistant advanced disease; the variable clinical course as well as response to any given treatment approach of patients within one staging or grading system, the advances in imaging which are providing increasing promising results/parameters that correlate with grading/outcome/resistance, the increased understanding of the molecular pathogenesis providing promising prognostic markers, all of which can contribute to selecting the best treatment to overcome resistance disease. Several factors have been identified that have prognostic/predictive value for identifying development resistant disease and affecting overall survival (OS)/PFS with various nonsurgical treatments of patients with advanced panNENs. Prognostic factors identified for patients with advanced panNENs for both OS/PFSs include various clinically-related factors (clinical, laboratory/biological markers, imaging, treatment-related factors), pathological factors (histological, classification, grading) and molecular factors. Particularly important prognostic factors for the different treatment modalities studies are the recent grading systems. Most prognostic factors for each treatment modality for OS/PFS are not specific for a given treatment option. These advances have generated several controversies and new unanswered questions, particularly those related to their possible role in predicting the possible sequence of different anti-tumor treatments in patients with different presentations. Each of these areas is reviewed in this paper. Abstract Purpose: Recent advances in the diagnosis, management and nonsurgical treatment of patients with advanced pancreatic neuroendocrine neoplasms (panNENs) have led to an emerging need for sensitive and useful prognostic factors for predicting responses/survival. Areas covered: The predictive value of a number of reported prognostic factors including clinically-related factors (clinical/laboratory/imaging/treatment-related factors), pathological factors (histological/classification/grading), and molecular factors, on therapeutic outcomes of anti-tumor medical therapies with molecular targeting agents (everolimus/sunitinib/somatostatin analogues), chemotherapy, radiological therapy with peptide receptor radionuclide therapy, or liver-directed therapies (embolization/chemoembolization/radio-embolization (SIRTs)) are reviewed. Recent findings in each of these areas, as well as remaining controversies and uncertainties, are discussed in detail, particularly from the viewpoint of treatment sequencing. Conclusions: The recent increase in the number of available therapeutic agents for the nonsurgical treatment of patients with advanced panNENs have raised the importance of prognostic factors predictive for therapeutic outcomes of each treatment option. The establishment of sensitive and useful prognostic markers will have a significant impact on optimal treatment selection, as well as in tailoring the therapeutic sequence, and for maximizing the survival benefit of each individual patient. In the paper, the progress in this area, as well as the controversies/uncertainties, are reviewed.
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Affiliation(s)
- Lingaku Lee
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804, USA; (L.L.); (I.R.-A.)
- National Kyushu Cancer Center, Department of Hepato-Biliary-Pancreatology, Fukuoka 811-1395, Japan
| | - Irene Ramos-Alvarez
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804, USA; (L.L.); (I.R.-A.)
| | - Robert T. Jensen
- Digestive Diseases Branch, NIDDK, NIH, Bethesda, MD 20892-1804, USA; (L.L.); (I.R.-A.)
- Correspondence: ; Tel.: +1-301-496-4201
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Linch F, Thompson S, Fleming C, Vella A, Andrews J. Hepatic Artery Embolization for Palliation of Symptomatic Hypoglycemia in Patients With Hepatic Insulinoma Metastases. J Endocr Soc 2021; 5:bvab149. [PMID: 34877442 PMCID: PMC8643969 DOI: 10.1210/jendso/bvab149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Indexed: 12/03/2022] Open
Abstract
Context Insulinoma is a pancreatic neuroendocrine tumor that causes hyperinsulinemic hypoglycemia. Symptomatic hypoglycemia related to hepatic insulinoma metastases may be addressed with liver-directed therapies such as hepatic artery embolization. Objective This work aimed to determine the safety and effectiveness of bland hepatic artery embolization (HAE) for palliation of symptomatic hypoglycemia in patients with hepatic insulinoma metastases refractory to medical management. Methods An institutional review board–approved retrospective review was undertaken of all patients with a tissue (n = 18) or imaging (n = 2) diagnosis of hepatic insulinoma metastases and symptomatic hyperinsulinemic hypoglycemia refractory to medical management who underwent bland HAE at a single center between January 1, 1998 and November 1, 2020. Twenty patients (10 women, 10 men; mean age, 56 years; range, 18-84 years) were identified who individually underwent 1 (n = 7), 2 (n = 5), 3 (n = 5), 4 (n = 2), or 5 (n = 1) HAEs, for an overall total of 45 HAEs. Post-HAE hypoglycemia recurrence was defined as onset of adrenergic symptoms (eg, sweating, weakness, tremor), neuroglycopenic symptoms (eg, confusion, loss of consciousness), and/or documented serum glucose of less than 50 mg/dL, in the absence of an alternative explanation. Median time to first hypoglycemia recurrence, hypoglycemia-free survival (HFS), and overall survival (OS) were calculated using Kaplan-Meier method. Results Before HAE, all patients experienced adrenergic or neuroglycopenic symptoms alleviated by glucose intake, and 60% (n = 12) of patients had documented serum glucose of less than 50 mg/dL within 1 week of the first treatment. Median post-HAE follow-up was 9.4 months (mean, 26 months; range, 0.1-190 months). Postprocedural hypoglycemic symptom relief after the first HAE was reported in 100% (n = 20) of patients before discharge or at follow-up. Post-HAE hypoglycemia recurrence occurred in 60% (n = 12) of patients with a median time to first hypoglycemia recurrence of 2 months (mean, 14 months; range, 0.2-60 months). After the first HAE, median HFS was 14.5 months, and median OS was 16 months. One patient experienced labile postprocedure blood glucose levels requiring intensive care unit admission for intravenous dextrose. Otherwise, no major procedure-related complications occurred. Conclusion Bland HAE is a safe, effective, and repeatable procedure for palliation of symptomatic hypoglycemia in patients with hepatic insulinoma metastases refractory to medical management.
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Affiliation(s)
- Forrest Linch
- Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott Thompson
- Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Chad Fleming
- Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adrian Vella
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota, USA
| | - James Andrews
- Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Clift AK, Frilling A. Liver-Directed Therapies for Neuroendocrine Neoplasms. Curr Oncol Rep 2021; 23:44. [PMID: 33721122 DOI: 10.1007/s11912-021-01030-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW To comprehensively synthesise and appraise the available evidence regarding therapies for metastatic neuroendocrine neoplasms that exploit the hepatic vasculature to deliver therapy to liver metastases. RECENT FINDINGS Various techniques including transarterial embolisation/chemoembolisation (TAE/TACE) and selective internal radiotherapy (SIRT, also termed radioembolisation [RE]) have been examined in patents with neuroendocrine liver metastases. Variations in the radioactive agents for selective internal radiotherapy (SIRT) have been explored, such as the use of Holmium-166, in addition to more established agents such as Yttrium-90. Recent trials have examined the safety and efficacy of combining liver-targeted therapy with systemic treatments, such as peptide receptor radionuclide therapy. More retrospective case series of liver-directed modalities will not provide additional knowledge. Randomised clinical trials have begun to compare the efficacy of different forms of liver-directed therapies, and also their combination with systemic treatment. Their results are expected to guide optimal treatment sequencing within multimodal concepts.
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Affiliation(s)
- Ashley Kieran Clift
- CRUK Oxford Centre, University of Oxford, Oxford, UK.,Department of Surgery & Cancer, Imperial College London, London, UK
| | - Andrea Frilling
- Department of Surgery & Cancer, Imperial College London, London, UK. .,Department of Surgery and Cancer, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK.
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Safety and Efficacy of Arterially Directed Liver Therapies in the Treatment of Hepatic Metastatic Ovarian Cancer: A Retrospective Single-Institution Study. J Vasc Interv Radiol 2021; 32:853-860. [PMID: 33636309 DOI: 10.1016/j.jvir.2020.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 11/04/2020] [Accepted: 11/08/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To evaluate the safety and efficacy of 2 locoregional therapies (LRTs) including hepatic artery embolization (HAE) and transarterial radioembolization (TARE) in the treatment of patients with metastatic ovarian cancer to the liver. MATERIAL AND METHODS From October 2010 to May 2019, the data of 15 consecutive patients (median age, 54 years ± 9.8; range, 35-78 years) with hepatic metastatic ovarian cancer who were treated with either HAE (n = 6; 40%) or TARE (n = 9; 60%) were reviewed. The most common histopathologic type was epithelial ovarian carcinoma (80%). The most common chemotherapy regimens used prior to embolization included carboplatin, paclitaxel, cisplatin, and bevacizumab. Patients received a mean of 4 lines ± 3 (range, 1-9) of chemotherapy. All patients with serous carcinoma were resistant to platinum at the time of embolization. Indications for embolization were progression of disease to the liver while receiving chemotherapy in 14 (93.3%) patients and palliative pain control in 1 patient. RESULTS The overall response rates at 1, 3, and 6 months were 92.4%, 85.6%, and 70%, respectively. Median overall survival from the time of LRT was 9 (95% confidence interval [CI], 4-14) months. Median local tumor progression was 6.4 months ± 5.03 (95% CI, 3.3-9.5). No grade 3-5 adverse events were detected in either group. CONCLUSIONS HAE and TARE were well tolerated in patients with metastatic ovarian cancer to the liver and possibly ensured prolonged disease control in heavily treated, predominantly in patients resistant to platinum. Larger numbers are needed to verify these data.
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Kanabar R, Barriuso J, McNamara MG, Mansoor W, Hubner RA, Valle JW, Lamarca A. Liver Embolisation for Patients with Neuroendocrine Neoplasms: Systematic Review. Neuroendocrinology 2021; 111:354-369. [PMID: 32172229 DOI: 10.1159/000507194] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/12/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Liver embolisation is one of the treatment options available for patients diagnosed with neuro-endocrine neoplasms (NEN). It is still uncertain whether the benefits of the various types of embolisation treatments truly outweigh the complications in NENs. This systematic review assesses the available data relating to liver embolisation in patients with NENs. METHODS Eligible studies (identified using MEDLINE-PubMed) were those reporting data on NEN patients who had undergone any type of liver embolisation. The primary end points were best radiological response and symptomatic response; secondary end-points included progression-free survival (PFS), overall survival (OS) and toxicity. RESULTS Of 598 studies screened, 101 were eligible: 16 were prospective (15.8%). The eligible studies included a total of 5,545 NEN patients, with a median of 39 patients per study (range 5-214). Pooled rate of partial response was 36.6% (38.9% achieved stable disease) and 55.2% of patients had a symptomatic response to therapy when pooled data were analysed. The median PFS and OS were 18.4 months (95% CI 15.5-21.2) and 40.7 months (95% CI 35.2-46.2) respectively. The most common toxicities were found to be abdominal pain (48.8%) and nausea (48.1%). Outcome did not significantly vary depending on the type of embolisation performed. CONCLUSION Liver embolisation provides adequate symptom relief for patients with carcinoid syndrome and is also able to reach partial response in a significant proportion of patients and a reasonable PFS. Quality of studies was limited, highlighting the need of further prospective studies to confirm the most suitable form of liver embolisation in NENs.
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Affiliation(s)
- Rahul Kanabar
- Manchester Medical School, The University of Manchester, Manchester, United Kingdom,
| | - Jorge Barriuso
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Mairéad G McNamara
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Was Mansoor
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Richard A Hubner
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Juan W Valle
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Angela Lamarca
- Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
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Sartori S, Bianchi L, Di Vece F, Tombesi P. Liver-directed therapies for liver metastases from neuroendocrine neoplasms: Can laser ablation play any role? World J Gastroenterol 2020; 26:3118-3125. [PMID: 32684730 PMCID: PMC7336329 DOI: 10.3748/wjg.v26.i23.3118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 02/06/2023] Open
Abstract
Aggressive cytoreduction can prolong survival in patients with unresectable liver metastases (LM) from neuroendocrine neoplasms (NEN), and minimally invasive, liver-directed therapies are gaining increasing interest. Catheter-based treatments are used in disseminated disease, whereas ablation techniques are usually indicated when the number of LM is limited. Although radiofrequency ablation (RFA) is by far the most used ablative technique, the goal of this opinion review is to explore the potential role of laser ablation (LA) in the treatment of LM from NEN. LA uses thinner needles than RFA, and this is an advantage when the tumors are in at-risk locations. Moreover, the multi-fiber technique enables the use of one to four laser fibers at once, and each fiber provides an almost spherical thermal lesion of 12-15 mm in diameter. Such a characteristic enables to tailor the size of each thermal lesion to the size of each tumor, sparing the liver parenchyma more than any other liver-directed therapy, and allowing for repeated treatments with low risk of liver failure. A recent retrospective study reporting the largest series of LM treated with LA documents both safety and effectiveness of LA, that can play a useful role in the multimodality approach to LM from NEN.
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Affiliation(s)
- Sergio Sartori
- Department of Internal Medicine, Section of Interventional Ultrasound, St. Anna Hospital, Ferrara 44100, Italy
| | - Lara Bianchi
- Department of Internal Medicine, Section of Interventional Ultrasound, St. Anna Hospital, Ferrara 44100, Italy
| | - Francesca Di Vece
- Department of Internal Medicine, Section of Interventional Ultrasound, St. Anna Hospital, Ferrara 44100, Italy
| | - Paola Tombesi
- Department of Internal Medicine, Section of Interventional Ultrasound, St. Anna Hospital, Ferrara 44100, Italy
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Abstract
OPINION STATEMENT Carcinoid syndrome (CS) is a complex disorder caused by functional neuroendocrine tumors (NETs). This debilitating disease is characterized by hyper-secretion of biologically active substances eliciting major hormonal symptoms burden and fibrotic changes that are often challenging for management. There have been a number of insights that have substantially advanced treatments since the introduction of somatostatin analogs (SSAs). Second-line treatments are needed in a substantial proportion of patients with advanced disease that have uncontrolled hormone secretion on the highest labeled doses of SSAs. International guidelines suggest several available options including dose escalation of SSAs, interferon alpha, everolimus, radionuclide therapy, liver-directed therapies, and the novel tryptophan hydroxylase 1 inhibitor, telotristat ethyl. The clear preference of one second-line therapy over the other is not stated since their relative and long-term efficacy are largely unknown, and standardized approach of hormonal response assessment is lacking in the literature. In the clinical setting, the treatment of CS is guided in conjunction with patients' performance status, tumor origin, grade, stage, and growth rate, with regard to both anti-hormonal, as well as anti-proliferative effect. There is an unmet need for further well-designed randomized placebo-controlled and head-to-head studies that systematically assess CS symptom control and biochemical response following a specific intervention.
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13
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Frilling A, Clift AK, Braat AJAT, Alsafi A, Wasan HS, Al-Nahhas A, Thomas R, Drymousis P, Habib N, Tait PN. Radioembolisation with 90Y microspheres for neuroendocrine liver metastases: an institutional case series, systematic review and meta-analysis. HPB (Oxford) 2019; 21:773-783. [PMID: 30733049 DOI: 10.1016/j.hpb.2018.12.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 12/03/2018] [Accepted: 12/11/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neuroendocrine liver metastases are clinically challenging due to their frequent disseminated distribution. This study aims to present a British experience with an emerging modality, radioembolisation with yttrium-90 labelled microspheres, and embed this within a meta-analysis of response and survival outcomes. METHODS A retrospective case series of patients treated with SIR-Spheres (radiolabelled resin microspheres) was performed. Results were included in a systematic review and meta-analysis of published results with glass or resin microspheres. Objective response rate (ORR) was defined as complete or partial response. Disease control rate (DCR) was defined as complete/partial response or stable disease. RESULTS Twenty-four patients were identified. ORR and DCR in the institutional series was 14/24 and 21/24 at 3 months. Overall survival and progression-free survival at 3-years was 77.6% and 50.4%, respectively. There were no grade 3/4 toxicities post-procedure. A fixed-effects pooled estimate of ORR of 51% (95% CI: 47%-54%) was identified from meta-analysis of 27 studies. The fixed-effects weighted average DCR was 88% (95% CI: 85%-90%, 27 studies). CONCLUSION Current data demonstrate evidence of the clinical effectiveness and safety of radioembolisation for neuroendocrine liver metastases. Prospective randomised studies to compare radioembolisation with other liver directed treatment modalities are needed.
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Affiliation(s)
- Andrea Frilling
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Ashley K Clift
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Arthur J A T Braat
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, 3508, GA Utrecht, the Netherlands
| | - Ali Alsafi
- Department of Imaging, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Harpreet S Wasan
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Adil Al-Nahhas
- Department of Nuclear Medicine, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Robert Thomas
- Department of Imaging, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Panagiotis Drymousis
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Nagy Habib
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
| | - Paul N Tait
- Department of Imaging, Imperial College London, Hammersmith Hospital, London, W12 0HS, United Kingdom
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14
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Abstract
With the increasing incidence of hepatocellular carcinoma (HCC) and its high mortality rates, effective treatment options are of urgent need, preferably in a multidisciplinary setting. In the management of those patients, interventional radiologists play a key role. In this article, we reviewed the current literature for regional, intraarterial treatment strategies of advanced-stage HCC including conventional transarterial chemoembolization, transarterial embolization, transarterial embolization with drug-eluting beads, and selective internal radiation therapy.
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Affiliation(s)
- Thomas J Vogl
- Institute for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Tatjana Gruber-Rouh
- Institute for Diagnostic and Interventional Radiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
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15
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Nigri G, Petrucciani N, Debs T, Mangogna LM, Crovetto A, Moschetta G, Persechino R, Aurello P, Ramacciato G. Treatment options for PNET liver metastases: a systematic review. World J Surg Oncol 2018; 16:142. [PMID: 30007406 PMCID: PMC6046097 DOI: 10.1186/s12957-018-1446-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 07/05/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic neuroendocrine tumors (PNETs) are rare pancreatic neoplasms. About 40-80% of patients with PNET are metastatic at presentation, usually involving the liver (40-93%). Liver metastasis represents the most significant prognostic factor. The aim of this study is to present an up-to-date review of treatment options for patients with liver metastases from PNETs. METHODS A systematic literature search was performed using the PubMed database to identify all pertinent studies published up to May 2018. RESULTS The literature search evaluated all the therapeutic options for patients with liver metastases of PNETs, including surgical treatment, loco-regional therapies, and pharmacological treatment. All the different treatment options showed particular indications in different presentations of liver metastases of PNET. Surgery remains the only potentially curative therapeutic option in patients with PNETs and resectable liver metastases, even if relapse rates are high. Efficacy of medical treatment has increased with advances in targeted therapies, such as everolimus and sunitinib, and the introduction of radiolabeled somatostatin analogs. Several techniques for loco-regional control of metastases are available, including chemo- or radioembolization. CONCLUSIONS Treatment of patients with PNET metastases should be multidisciplinary and must be personalized according to the features of individual patients and tumors.
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Affiliation(s)
- Giuseppe Nigri
- Department of Medical and Surgical Science and Translational Medicine, St. Andrea Hospital Rome, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Niccolò Petrucciani
- Digestive Surgery, Hepatobiliopancreatic Surgery and Liver Transplantation, UPEC University, Henri Mondor Hospital, Creteil, France
| | - Tarek Debs
- Department of Digestive Surgery and Liver Transplantation, Nice University Hospital, Nice, France
| | - Livia Maria Mangogna
- Department of Medical and Surgical Science and Translational Medicine, St. Andrea Hospital Rome, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Anna Crovetto
- Department of Medical and Surgical Science and Translational Medicine, St. Andrea Hospital Rome, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Giovanni Moschetta
- Department of Medical and Surgical Science and Translational Medicine, St. Andrea Hospital Rome, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Raffaello Persechino
- Department of Medical and Surgical Science and Translational Medicine, St. Andrea Hospital Rome, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Paolo Aurello
- Department of Medical and Surgical Science and Translational Medicine, St. Andrea Hospital Rome, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Giovanni Ramacciato
- Department of Medical and Surgical Science and Translational Medicine, St. Andrea Hospital Rome, Sapienza University of Rome, Via di Grottarossa 1035, 00189 Rome, Italy
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16
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Uri I, Grozinsky-Glasberg S. Current treatment strategies for patients with advanced gastroenteropancreatic neuroendocrine tumors (GEP-NETs). Clin Diabetes Endocrinol 2018; 4:16. [PMID: 30009041 PMCID: PMC6042326 DOI: 10.1186/s40842-018-0066-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 06/21/2018] [Indexed: 12/13/2022] Open
Abstract
Background Neuroendocrine tumors (NETs) are rare neoplasms, with an estimated annual incidence of ~ 6.9/100,000. NETs arise throughout the body from cells of the diffuse endocrine system. More than half originate from endocrine cells of the gastrointestinal tract and the pancreas, thus being referred to as gastroenteropancreatic NETs (GEP NETs). The only treatment that offers a cure is surgery, however most patients are diagnosed with metastatic disease, and curative surgery is usually not an option.Since the majority of patients are not candidate for curative surgery, they can be offered long-term systemic treatment, for both symptomatic relief and tumor growth suppression. Evidence based treatment options include somatostatin analogues, everolimus (an mTOR inhibitor), sunitinib (a tyrosine kinase inhibitor), peptide receptor radionuclide therapy (PRRT), chemotherapy, etc., alone or combined with cytoreductive procedures (surgery or liver directed procedures). However, there is an increasing need for novel therapies. Other treatment options being investigated are immunotherapy and epigenetic assessment that may lead to more personalized interventions. Following first line therapy with somatostatin analogues, there is no clear information to date indicating a preferred treatment sequence, and therefore the treatment approach should be individualized based on each NET patient characteristics. Conclusions NET patients are increasingly diagnosed throughout the world, usually with metastatic disease and requiring systemic therapy. We believe that each patient should be therefore thoroughly evaluated and individually discussed by a multidisciplinary and dedicated NET-expert team, updated with all treatment options including ongoing clinical trials, and before selecting the proper treatment sequence.
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Affiliation(s)
- Inbal Uri
- Neuroendocrine Tumor Unit, Endocrinology and Metabolism Department, Division of Medicine, Hadassah-Hebrew University Medical Center, P.O.B. 12000, 91120 Jerusalem, Israel
| | - Simona Grozinsky-Glasberg
- Neuroendocrine Tumor Unit, Endocrinology and Metabolism Department, Division of Medicine, Hadassah-Hebrew University Medical Center, P.O.B. 12000, 91120 Jerusalem, Israel
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