Treatment of small intestinal neuroendocrine tumors: is an extended multimodal approach justified?

Neuroendocrine tumors (NETs) of the small bowel are known for their low malignant behavior. Although most cases are diagnosed in an advanced stage, natural life expectancy is significantly higher than with intestinal carcinomas. The question arises if there are any benefits to combining extended (radical or debulking) surgery, interventional treatment, and medical treatment with respect to life expectancy, and quality of life. A series of 58 patients (34 men, 24 women; mean age 61 +/- 12 years, range 37-87 years) with NETs of the small bowel were retrospectively reviewed and prospectively followed over 63 +/- 53 months. Clinical presentation, tumor characteristics, and postoperative medical treatment were documented. Quality of life was additionally analyzed using a questionnaire. Survival probability and quality of life were compared for tumor stages and type of treatment performed. In 47 of 58 (81%) patients the NET was diagnosed based on the presence of intestinal stenosis or endocrine symptoms. Of 16 patients without liver metastases, 15 (94%) were cured by radical surgery. Multiple liver metastases were evident in 40 of 58 (69%) patients and decreased the 5- and 10-year cumulative survival to 64% +/- 10% and 22% +/- 10% (M0 vs. M1: p <0.05). The 5- and 10-year survival rates after multimodal treatment (surgery, bio/immunotherapy, transarterial embolization of liver metastases) were 64% +/- 11% and 28% +/- 12% compared to 61% +/- 15% and 0% in patients without (p = NS). In patients with small intestinal NETs, a consistent multimodal treatment helps to improve the overall survival and, in most patients, the quality of life.