Management of Neuroendocrine Tumors - gildasclubqc.org · Management of Neuroendocrine Tumors James R. Howe, M.D. Director, Surgical Oncology and Endocrine Surgery University of Iowa

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

NIH SPORE P50 CA174521-01

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Old Capitol

Undergraduate Campus

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Medical School

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