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Management of Neuroendocrine Tumors James R. Howe, M.D. Director, Surgical Oncology and Endocrine Surgery University of Iowa College of Medicine
Management of
Neuroendocrine Tumors
James R. Howe, M.D.
Director, Surgical Oncology
and Endocrine Surgery
University of Iowa College of Medicine
Stage at Diagnosis
Localized Regional Distant
Yao et al. J. Clin. Oncology 26:3063, 2008
85%
nodes
77%
liver
51%
nodes
37%
liver
SEER vs. University of Iowa
Small Bowel Neuroendocrine
Tumors (SBNETs)
SBNETs
Most common GI site
Incidence 12 per million
50% multicentric
Well-differentiated
Indolent but present late
Work-UpHistory and Physical
Imaging
CT---best overall test
MRI---better for liver mets
68Ga-DOTATATE-PET---
functional testing; mets
18FDG-PET---high-grade
Blood Tests
Typical SBNET Patient
Exploration
Howe, J.R. in Atlas of Endocrine and Neuroendocrine Surgery
(Howe, J.R. ed.) Springer-Verlag (2017)
Locations of SBNETs: Unifocal and Multifocal
Keck, K.J. and Howe, J.R. Ann Surg Oncol 25:3207 (2018)
Locoregional Spread
www.lilienthenthalusa.com
Nodal Dissection
Howe, J.R. in Atlas of Endocrine and Neuroendocrine Surgery
(Howe, J.R. ed.) Springer-Verlag (2017)
Lymphadenopathy
SMV
SMA
Nodes
Open Approach with Small
Incision
Enlarged
Node
Cholecystectomy at Exploration
Somatostatin analogues lead
to gallstones
Hepatic embolization can result
in GB necrosis
Pancreatic Neuroendocrine
Tumors (PNETs)
Pancreatic Neuroendocrine Tumor
J. Howe, ed. Atlas of Endocrine and Neuroendocrine Surgery, Springer-Verlag 2017
PNET
Normal
Pancreas
Stomach
Halfdanarsan, TR et al.
Ann. Oncol. 19:1727, 2008
General Facts
About PNETs
Familial PNETs
A. Pea et al. Expert Rev Gastroenterol Hepatol 9:1407, 2015
Pancreatic Neuroendocrine Tumors
Non-functional
Insulinoma
Gastrinoma
VIPoma
Glucagonoma
Somatostatinoma
Pancreatic Polypeptide?
Diagnosis of PNETs
Symptoms
Imaging Tests
Biochemical testing
Biopsy: Endoscopic US or CT
When to Resect PNETs
Functional lesions
>2 cm
Not < 1 cm
Controversy in 1-2 cm1-3
>3 cm in VHL5
>2 cm in MEN14
1. L.C. Lee et al. Surgery 152:965, 2012
2. E.J. Kuo et al. Ann. Surg. Onc. 20:2815, 2013
3. S.M. Sharpe et al. J. Gastrointest. Surg 19:117, 2015
5. S.K. Libutti et al. Surgery 124:1153, 1998
4. F. Triponez et al. Ann. Surg. 243:265, 2006
Surgical Treatment Options
Enucleation
Distal Pancreatectomy
Pancreaticoduodenectomy (Whipple)
Laparoscopic distal pancreatectomy
Enucleation
J. Howe, ed. Atlas of Endocrine and Neuroendocrine Surgery, Springer-Verlag 2017
Enucleation
Hepatic
Artery
Splenic
Artery
SMV Splenic
Vein
Tumor
Pancreatic
Neck/Body
Surgical Treatment of Pancreatic
Body/Tail Lesions
CT: Pancreatic Body/Tail Mass
Tumor
Spleen
Tail of
PancreasTumor
Splenic
Artery
Distal Pancreatectomy/Splenectomy
J. Howe, ed. Atlas of Endocrine and Neuroendocrine Surgery, Springer-Verlag 2017
Pathology Specimen: Distal Pancreas and Spleen
SpleenTumor
Pancreatic
Margin
>1 cm
Surgical Treatment of Pancreatic
Head Lesions
PNET in Pancreatic Head
Primary Node
Tumor
thrombus
DuodenumDuodenum
TumorNode
Cameron JL Atlas of Surgery BC Decker, Inc. 1990
Pancreatic Anastomosis
J. Howe, ed. Atlas of Endocrine and Neuroendocrine Surgery, Springer-Verlag 2017
Bile Duct Anastomosis
J. Howe, ed. Atlas of Endocrine and Neuroendocrine Surgery, Springer-Verlag 2017
Gastrojejunal Anastomosis
J. Howe, ed. Atlas of Endocrine and Neuroendocrine Surgery, Springer-Verlag 2017
The Role of Laparoscopy for PNETs
Especially good for small, distal lesions
Can also enucleate
Well-suited for distal
pancreatectomy/splenectomy
J. Howe, ed. Atlas of Endocrine
and Neuroendocrine Surgery,
Springer-Verlag (in press)
Liver Metastases
Transverse View
Sagittal View
Options for Liver Metastases
Embolization
Radioembolization
Peptide Receptor Radiotherapy (PRRT)
Somatostatin analogues
Systemic therapy
Resection, enucleation, ablation
Microwave Ablation
Ultrasound with needle guide (black)
Aculis probe (white)
Ultrasound view of probe
traversing lesion
Microwave Ablation
30 seconds at 100W 60 seconds at 100W
● Not Just for Symptoms
● Improves Survival
● Parenchymal Sparing reasonable
● <10 lesions do better
● Cytoreduction target: >70-90%
Hepatic Cytoreduction
● <25% replacement do better
High Recurrence Rates in the liver---94% at 5 yrs.
Summary: Optimal Surgical
Approach to NETs
Remove the primary
Resect regional nodes
*when other options not feasible or at progression
Cytoreduce liver metastases
Use Somatostatin analogues
Use systemic therapy*
Cholecystectomy
Overall Survival
5 yr. OS=79.3% 10 yr. OS=57.4%
Median not
reached
SEER 88 mos.
10 yr. OS=52.9%
Median 126 mos.
SEER 42 mos.
5 yr. OS=79.9%
SK Sherman et al. Ann. Surg. Oncol. 21:2971, 2014
University of Iowa
NeuroEndocrine Cancer Clinic
Thomas O’Dorisio-Endocrinology
James Howe-Surgical Oncology
Sue O’Dorisio-Pediatric Oncology
Yusuf Menda, Dave Bushnell-Nuc. Med.
C. Chandrasekharan-Medical Oncology
Andrew Bellizzi-Pathology
Jackie Sexton, Kim Miller-Nursing
Joseph Dillon-Endocrinology
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