Optimizing the surgical effort in patients with advanced neuroendocrine neoplasm hepatic metastases: a critical analysis of 40 patients treated by hepatic resection and cryoablation. Am J Clin Oncol. 2012;35:439-445. [PMID: 21654315 DOI: 10.1097/coc.0b013e31821bc8dd]

Liver Resection for Gastroenteropancreatic Neuroendocrine Tumors with Extrahepatic Disease

Background: Although survival outcomes for neuroendocrine liver metastases (NETLM) are improved with liver-direct therapies (LDT), including hepatic debulking and nonsurgical trans-arterial embolization, the benefit is less established in the setting of concurrent extrahepatic disease (EHD). We performed a population-based study to characterize the rates of LDT being performed for NETLM with EHD patients and whether LDT is associated with survival outcomes. Methods: Patients with NETLM and EHD were identified using the California Cancer Registry database merged with data from the California Office of Statewide Health Planning and Development between 2000 and 2012. Demographics, clinical characteristics, and survival outcomes were analyzed for these patients with and without LDT. Results: 327 NETLM patients with EHD were identified. EHD sites included lung, peritoneum, bone, and brain. A total of 71 (22%) of these patients underwent LDT. Compared to NETLM with EHD patients who did not undergo LDT, patients who received LDT had longer median overall survival (27 vs. 16 months, p = 0.006). Within the LDT group, 23 patients underwent liver resection. Liver resection was associated with longer median overall survival compared to nonsurgical LDT (138 vs. 13 months, p < 0.001). Conclusions: LDT candidacy should be determined for patients on a case-by-case basis, but the presence of EHD should not preclude LDT with appropriate patient selection.

Microwave ablation combined with hepatectomy for treatment of neuroendocrine tumor liver metastases

BACKGROUND

Hepatectomy is the first choice for treating neuroendocrine tumor liver metastases. However, most patients with neuroendocrine tumor liver metastases are not suitable for hepatectomy. Ablation combined with hepatectomy can be an alternative to liver resection.

AIM

To explore the clinical effect of microwave ablation combined with hepatectomy for the treatment of neuroendocrine tumor liver metastases.

METHODS

In this study, the data of patients who underwent microwave ablation combined with hepatectomy for the treatment of neuroendocrine tumor liver metastases from June 2015 to January 2018 were reviewed. Before the operation, the patients did not receive any treatment for liver neuroendocrine tumors. After a multidisciplinary expert group discussion, all patients were deemed unsuitable for liver resection. All patients were diagnosed with neuroendocrine tumors by pathology. The overall survival time and progression-free survival time were followed by telephone calls and outpatient visits after surgery.

RESULTS

Eleven patients with neuroendocrine tumor liver metastases were treated by microwave ablation combined with hepatectomy between June 2015 and January 2018. The median number of liver metastatic nodules was 4 (range, 2 to 43). The median number of lesions resected was 1 (range, 1 to 18), and the median number of lesions ablated was 3 (range, 1 to 38). The mean operation time was 405.6 (± 39.4) min. The median intraoperative blood loss was 600 mL (range, 50 to 3000). Ten patients had a fever after surgery. The median duration of fever was 3 d (range, 0 to 21). Elevated bilirubin levels occurred in all patients after surgery. The median bilirubin on the first day after surgery was 28.5 (range, 10.7 to 98.9) µmol/L. One patient developed respiratory failure, renal insufficiency, and pneumonia after the operation. No patient died postoperatively during hospitalization. The mean overall survival time after surgery was 34.1 (± 3.7) mo, and the median progression-free survival time was 8 (range, 2 to 51) mo. One year after surgery, ten patients survived and five patients survived without progression. Three year after surgery, eight patients survived and two patients survived without progression.

CONCLUSION

Microwave ablation combined with hepatectomy not only makes the patients obtain a survival rate similar to that of patients undergoing hepatectomy, but also has a low incidence of postoperative complications.

Effects of low-dose aspirin on clinical outcome and disease progression in patients with gastroenteropancreatic neuroendocrine neoplasm

Objective: The chemopreventive effect of aspirin (ASA) has been observed in the setting of colorectal cancer and other solid neoplasms. Recently, ASA has demonstrated a promising anti-proliferative effect on GEP-NENs in vitro. However, the direct anti-neoplastic impact of ASA on GEP-NEN clinical outcome is yet to be clarified. Materials and methods: All the GEP-NEN patients followed up in three European Centers from January 2005 to September 2016 were retrospectively enrolled. Patients taking ASA in doses of 75-100 mg daily for cardiovascular prevention for at least six months were evaluated. The possible association between ASA and disease grading, staging, primary site, OS and PFS were evaluated. Results: Two hundred fifty one patients were included (117 males, median age 63 years). Of these, 64 patients were prescribed with ASA. No clear impact on OS or PFS was observed in GEP-NEN patients taking ASA compared to those not taking it. ASA intake was related with the patients' older age. At Cox multivariate analysis, stage IV and Ki-67 resulted independent predictors for OS and PFS. In the setting of intestinal NENs, a suggestive, but not statistically significant, protective role of ASA on PFS was observed [HR 0.41 (95% CI: 0.13-1.29)]. Conclusions: Despite ASA showed promising anti-proliferative effects in vitro and a chemopreventive action in NENs has been reported, a clear impact of ASA on survival in NENs has not emerged from the present study. However, in the subgroup of patients with small-intestine NENs, ASA showed a trend toward a protective role.

Predictive Value of Chromogranin A and a Pre-Operative Risk Score to Predict Recurrence After Resection of Pancreatic Neuroendocrine Tumors

INTRO

Chromogranin A (CgA) may be prognostic for patients with neuroendocrine tumors; however, the clinical utility of this test is unclear.

METHODS

Patients undergoing resection for pancreatic neuroendocrine tumors (pNET) were selected from the eight institutions of the US Neuroendocrine Tumor Study Group database. Cox regression was used to identify pre-operative variables that predicted recurrence-free survival (RFS), and those with p < 0.1 were included in a risk score. The risk score was tested in a unique subset of the overall cohort.

RESULTS

In the entire cohort of 287 patients, median follow-up time was 37 months, and 5-year RFS was 73%. Cox regression analysis identified four variables for inclusion in the risk score: CgA > 5x ULN (HR 4.3, p = 0.01), tumor grade 2/3 (HR 3.7, p = 0.01), resection for recurrent disease (HR 6.2, p < 0.01), and tumor size > 4 cm (HR 4.5, p = 0.1). Each variable was assigned 1 point. Risk-score testing in the unique validation cohort of 63 patients revealed a 95% negative predictive value for recurrence in patients with zero points.

DISCUSSION

This simple pre-operative risk scoring system resulted in a high degree of specificity for identifying patients at low-risk for tumor recurrence. This test can be utilized pre-operatively to aid informed decision-making.

Early recurrence of well-differentiated (G1) neuroendocrine liver metastasis after curative-intent surgery: Risk factors and outcome

BACKGROUND

The objective of the current study was to identify the risk of early vs late recurrence of well-differentiated (G1) neuroendocrine liver metastasis (NELM) after curative-intent resection.

METHODS

Patients who underwent curative-intent resection for well-differentiated NELM were identified from a multi-institutional database. Clinicopathological details, as well as the long-term overall (OS) and recurrence free survival (RFS) were obtained and compared. The optimal cutoff value to differentiate early and late recurrence was determined to be 1 year based on trend curve analysis.

RESULTS

Among the 548 patients undergoing curative resection for NELM, 162 patients had a well-differentiated NELM. After a median follow-up of 69 months, 59 (36.4%) patients had tumor recurrence; 23 (39.0%) patients recurred within 1 year (early recurrence) after surgery, while 36 (61.0%) recurred after 1 year (late recurrence). Early recurrence was associated with worse outcome vs late recurrence (5-year OS, 72.4% vs 92.0%; P = 0.020) and no recurrence (5-year OS, 72.4% vs 100.0%; P < 0.001). In addition, postrecurrence survival was worse within 36 months after recurrence among patients who recurred early compared with patients who recurred late (survival after recurrence at 36 months: early recurrence, 71.6% vs late recurrence, 91.4%; P = 0.047), although survival was comparable at 60 months (early recurrence, 71.6% vs late recurrence, 70.0%; P = 0.304). On multivariable analysis, nonfunctional neuroendocrine tumors (hazard ratio [HR], 4.4; 95% confidence interval [CI], 1.2-16.7; P = 0.029) and lymph node metastasis (HR, 3.6; 95% CI, 1.1-11.1; P = 0.028) were independent risk factors for early recurrence, whereas lymph node metastasis (HR, 3.0; 95% CI, 1.2-7.8; P = 0.020) and R1 resection (HR, 3.9; 95% CI, 1.4-10.5; P = 0.008) were independently associated with late recurrence.

CONCLUSIONS

Roughly, one-third of patients with well-differentiated NELM experienced a recurrence following curative-intent surgery. Among patients who recurred, two out of five patients recurred within 1 year after surgery. Early recurrence of well-differentiated NELM was associated with the hormone functional status and lymph node metastasis.

Management Options for Advanced Low or Intermediate Grade Gastroenteropancreatic Neuroendocrine Tumors: Review of Recent Literature

Our understanding of the biology, genetics, and natural history of neuroendocrine tumors (NETs) of the gastrointestinal tract and pancreas has improved considerably in the last several decades and the spectrum of available therapeutic options is rapidly expanding. The management of patients with metastatic low or intermediate grade NETs has been revolutionized by the development of new treatment strategies such as molecular targeting therapies with everolimus and sunitinib, somatostatin analogs, tryptophan hydroxylase inhibitors, and peptide receptor radionuclide therapy that can be used alone or as a multimodal approach with or without surgery. To further define and clarify the utility, appropriateness, and the sequence of the growing list of available therapies for this patient population will require more high level evidence; however, data from well-designed randomized phase III clinical trials is rapidly accumulating that will further stimulate development of new management strategies. It is therefore important to thoroughly review emerging evidence and report major findings in frequent updates, which will expand our knowledge and contribute to a better understanding, characterization, and management of advanced NETs.

Mutation-targeted therapy with sunitinib or everolimus in patients with advanced low-grade or intermediate-grade neuroendocrine tumours of the gastrointestinal tract and pancreas with or without cytoreductive surgery: protocol for a phase II clinical trial

INTRODUCTION

Finding the optimal management strategy for patients with advanced, metastatic neuroendocrine tumours (NETs) of the gastrointestinal tract and pancreas is a work in progress. Sunitinib and everolimus are currently approved for the treatment of progressive, unresectable, locally advanced or metastatic low-grade or intermediate-grade pancreatic NETs. However, mutation-targeted therapy with sunitinib or everolimus has not been studied in this patient population.

METHODS AND ANALYSIS

This prospective, open-label phase II clinical trial was designed to determine if mutation-targeting therapy with sunitinib or everolimus for patients with advanced low-grade or intermediate-grade NETs is more effective than historically expected results with progression-free survival (PFS) as the primary end point. Patients ≥18 years of age with progressive, low-grade or intermediate-grade locally advanced or metastatic NETs are eligible for this study. Patients will undergo tumour biopsy (if they are not a surgical candidate) for tumour genotyping. Patients will be assigned to sunitininb or everolimus based on somatic/germline mutations profile. Patients who have disease progression on either sunitinib or everolimus will crossover to the other drug. Treatment will continue until disease progression, unacceptable toxicity, or consent to withdrawal. Using the proposed criteria, 44 patients will be accrued within each treatment group during a 48-month period (a total of 88 patients for the 2 treatments), and followed for up to an additional 12 months (a total of 60 months from entry of the first patient) to achieve 80% power in order to test whether there is an improvement in PFS compared to historically expected results, with a 0.10 α level one-sided significance test.

ETHICS AND DISSEMINATION

The study protocol was approved by the institutional review board of the National Cancer Institute (NCI-IRB Number 15C0040; iRIS Reference Number 339636). The results will be published in a peer-reviewed journal and shared with the worldwide medical community.

TRIAL REGISTRATION NUMBER

NCT02315625.

When should a liver resection be performed in patients with liver metastases from neuroendocrine tumours? A systematic review with practice recommendations

AIM

To determine the benefits and risks of hepatic resection versus non-resectional liver-directed treatments in patients with potentially resectable neuroendocrine liver metastases.

METHODS

A systematic review identified 1594 reports which alluded to a possible liver resection for neuroendocrine tumour metastases, of which 38 reports (all retrospective), comprising 3425 patients, were relevant.

RESULTS

Thirty studies reported resection alone, and 16 studies reported overall survival (OS). Only two studies addressed quality-of-life (QoL) issues. Five-year overall survival was reported at 41-100%, whereas 5-year progression-free survival (PFS) was 5-54%. We identified no robust evidence that a liver resection was superior to any other liver-directed therapies in improving OS or PFS. There was no evidence to support the use of a R2 resection (debulking), with or without tumour ablation, to improve either OS or QoL. There was little evidence to guide sequencing of surgery for patients presenting in Stage IV with resectable disease, and none to support a resection of asymptomatic primary tumours in the presence of non-resectable liver metastases.

CONCLUSION

Low-level recommendations are offered to assist in the management of patients with neuroendocrine liver metastases, along with recommendations for future studies.

Curative versus palliative surgical resection of liver metastases in patients with neuroendocrine tumors: a meta-analysis of observational studies

BACKGROUND

The role of surgical therapy in patients with liver metastases from neuroendocrine tumors (NETs) is unclear. In this study, the results obtained with curative or palliative resection, by reviewing recent literature and performing a meta-analysis, were examined.

MATERIALS AND METHODS

A systematic review and meta-analysis of observational studies published between January 1990 and October 2013 were performed. Studies that evaluated the different survival between patients treated by curative or palliative surgical resection of hepatic metastases from NETs were considered. The collected studies were evaluated for heterogeneity, publication bias, and quality. To calculate the pooled hazard ratio (HR) estimate and the 95% confidence interval (95% CI), a fixed-effects model was applied.

RESULTS

After the literature search, 2,546 studies were found and, among 38 potentially eligible studies, 3 were considered. We did not find a significant longer survival in patients treated with curative surgical resection of hepatic metastases when compared to palliative hepatic resection HR 0.40 (95% CI: 0.14-1.11). In one study, palliative resection of hepatic metastases significantly increased survival when compared to embolization.

CONCLUSIONS

Curative and also palliative surgery of NETs liver metastases may improve survival outcome. However, further randomized clinical trials are needed to elucidate this argument.

Small bowel neuroendocrine tumors: the benefits of surgical intervention

Well-differentiated SI NETs are on the rise. Due in part to the indolent nature of these tumors, patients typically have a delay in diagnosis and present with metastatic disease. Surgeries for symptoms of either chronic intermittent small bowel obstruction and/or ischemia or from carcinoid syndrome have proven to provide excellent palliation. Most recently, several series have demonstrated an improved survival in those patients in whom the primary, locoregional disease has been resected. Several newer adjuncts have been developed to aid in the hepatic directed therapies such as ablation therapies, embolization and Y spheres. The ability to cytoreduce 70% or more of the hepatic tumor burden has been shown to not only to provide a biochemical and as such a clinical response, but also appears to prolong survival. All patients with SI NETs should be assessed in a multidisciplinary clinic and the first line of therapy should always be to assess surgical resectabilty.

Treatment of liver metastases in patients with digestive neuroendocrine tumors

BACKGROUND

Liver metastases are a strong prognostic indicator in patients with gastro-entero-pancreatic neuroendocrine tumors (GEP-NETs). Therapeutic options for metastatic NETs are expanding and not mutually exclusive.

AIMS

This paper reviews the literature relating to multidisciplinary approach towards GEP-NET metastases, to highlight advances in knowledge regarding these tumors, and to understand the interdisciplinary management of individual patients.

METHODS

A PubMed search was performed for English-language publications from 1995 through 2012. Reference lists from studies selected were manually searched to identify further relevant reports. Manuscripts comparing different therapeutic options and advances for GEP-NET-related liver metastases were selected.

RESULTS

There is considerable controversy regarding the optimal management of GEP-NET metastases. Although radical surgery still remains the gold standard, a variety of other therapeutic options are available for metastatic GEP-NETs, including loco-regional chemotherapy/radiotherapy, radioembolization, systemic peptide receptor radionuclide therapy, biotherapy, and chemotherapy. In selected patients, liver transplantation should also be considered. Systemic somatostatin analogues and/or interferon show anti-proliferative effects, representing an appropriate first-line treatment for most patients. In advanced metastatic NETs, recent options include targeted therapies (i.e., everolimus and sunitinib).

CONCLUSIONS

It is evident that multidisciplinary care and multimodality treatments remain the cornerstone of management of NET patients. Since NETs often show a more indolent behavior compared to other malignancies, physicians should aim to preserve a satisfactory quality of life for the patient by personalizing the therapeutic approach according to the tumor's features and prognostic factors.

Treatment of neuroendocrine tumor liver metastases

In the care of patients with hepatic neuroendocrine metastases, medical oncologists should work in multidisciplinary fashion with surgeons, interventional radiologists, and radiation oncologists to assess the potential utility of liver-directed and systemic therapies. This paper addresses the various roles and evidence basis for cytoreductive surgery, thermal ablation (radiofrequency, microwave, and cryoablation), and embolization (bland embolization (HAE), chemoembolization (HACE), and radioembolization) as liver-directed therapies. Somatostatin analogues, cytotoxic chemotherapy, and the newer agents everolimus and suntinib are discussed as a means for controlling intra- and extrahepatic disease, along with peptide receptor radiotherapy (PRRT). Finally, the experience with orthotopic liver transplant for neuroendocrine tumors is described.

Multimodal liver-directed management of neuroendocrine hepatic metastases

A preponderance of patients with neuroendocrine tumors (NETs) will experience hepatic metastases during the course of their disease. Many diagnoses of NETs are made only after the neoplasms have spread from their primary gastroenteropancreatic sites to the liver. This paper reviews current evidence-based treatments for neuroendocrine hepatic metastases, encompassing surgery, hepatic artery embolization (HAE) and chemoembolization (HACE), radioembolization, hepatic artery infusion (HAI), thermal ablation (radiofrequency, microwave, and cryoablation), alcohol ablation, and liver transplantation as therapeutic modalities. Consideration of a multidisciplinary approach to liver-directed therapy is strongly encouraged to limit morbidity and mortality in this patient population.