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Liver-directed surgery of neuroendocrine metastases: What is the optimal strategy?
Jessica E Maxwell1, Scott K Sherman1, Thomas M O'Dorisio2
1Department of General Surgery, University of Iowa Carver College of Medicine, Iowa City, IA.
Introduction:
Neuroendocrine tumors (NETs) frequently metastasize to the liver. Operative debulking offers symptomatic relief and improved survival; however, the frequent presence of multifocal, bilobar disease and high recurrence rates introduces doubt regarding their optimal management. Parenchyma-sparing debulking (PSD) procedures (ablation, enucleation, wedge resections) may offer similar survival improvements as resection while minimizing morbidity and preserving functional liver tissue.
Methods:
Clinicopathologic variables from 228 patients with small bowel or pancreatic NETs managed operatively at one institution were collected. Liver-directed surgery was carried out when substantial debulking was deemed feasible. Survival was assessed by use of the Kaplan-Meier method.
Results:
A total of 108 patients with pancreatic NET or small bowel NET underwent liver-directed surgery with primarily PSD procedures. Nearly two-thirds of patients achieved 70% cytoreduction and 84% had concurrent resection of their primary. The median number of lesions treated was 6 (range, 1-36). There were no 30-day operative mortalities. The 30-day major complication rate was 13.0%. Patients who achieved 70% cytoreduction enjoyed improved progression free (median 3.2 years) and overall survival (median not reached).
Conclusion:
PSD procedures are safe and can achieve significant cytoreduction, which is associated with improved survival. Lowering the debulking target threshold to 70% may benefit NET patients by increasing eligibility for cytoreduction.
Insights
Parenchyma-sparing debulking (PSD) safely treats liver metastases from neuroendocrine tumors (NETs), achieving significant cytoreduction and improving patient survival. Lowering the debulking goal to 70% expands eligibility for this beneficial procedure.
Area of Science:
- Hepatobiliary Surgery
- Surgical Oncology
- Neuroendocrine Tumor Management
Background:
- Neuroendocrine tumors (NETs) commonly metastasize to the liver, posing management challenges due to multifocal disease and high recurrence rates.
- While operative debulking improves survival, traditional resection can be morbid and may not preserve functional liver tissue.
- Parenchyma-sparing debulking (PSD) procedures offer a less invasive alternative, potentially achieving similar survival benefits with reduced morbidity.
Purpose of the Study:
- To evaluate the safety and efficacy of parenchyma-sparing debulking (PSD) for liver metastases from neuroendocrine tumors (NETs).
- To determine if achieving a 70% cytoreduction threshold is associated with improved patient survival outcomes.
- To assess the feasibility of PSD in managing multifocal, bilobar liver disease in NET patients.
Main Methods:
- A retrospective review of 228 patients with pancreatic or small bowel NETs who underwent operative management.
- Analysis of 108 patients who underwent liver-directed surgery, primarily utilizing PSD procedures (ablation, enucleation, wedge resections).
- Kaplan-Meier survival analysis to assess outcomes based on clinicopathologic variables and cytoreduction rates.
Main Results:
- 108 patients underwent liver-directed PSD for NET metastases, with a median of 6 lesions treated.
- Nearly two-thirds (66.7%) achieved ≥70% cytoreduction; 84% had concurrent primary tumor resection.
- No 30-day operative mortalities; 13.0% major complication rate. Patients with ≥70% cytoreduction had improved progression-free survival (3.2 years median) and overall survival.
Conclusions:
- Parenchyma-sparing debulking (PSD) is a safe and effective approach for managing liver metastases from neuroendocrine tumors.
- Significant cytoreduction, particularly achieving ≥70% debulking, is strongly associated with improved progression-free and overall survival.
- Lowering the cytoreduction target threshold to 70% may increase patient eligibility for beneficial surgical intervention.
