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Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction
Published on: January 3, 2020
Neoadjuvant peptide receptor radionuclide therapy and modified multivisceral transplantation for an advanced small
Ashley K Clift1, Henk Giele2, Srikanth Reddy3
1Department of Surgery and Cancer, Imperial College London, London, UK.
Abstract:
Small intestinal neuroendocrine neoplasms (SI-NEN) frequently metastasise to regional lymph nodes, and surgery is the mainstay of therapy for such patients. However, despite the possible use of advanced surgical techniques, the resection of both primary and locoregional diseases is not always attainable. Intestinal and multivisceral transplantation has been performed in a small number of patients with conventionally nonresectable, slow-growing tumours threatening the mesenteric root but has remained controversial. The use of donor skin in "sentinel flaps" in transplantation theoretically offers advantages in tailoring immunosuppression and monitoring for rejection. We represent (with extended follow-up) the first case of a patient with inoperable extensive mesenteric metastases from SI-NEN, who underwent neoadjuvant peptide receptor radionuclide therapy before a modified multivisceral transplant with a concomitant vascularised sentinel forearm flap. At 48 months after transplantation, our patient remained at full physical activity with no evidence of disease recurrence on either tumour biochemistry or radiological imaging.
Insights
Multivisceral transplant with a sentinel flap offers a potential solution for inoperable small intestinal neuroendocrine neoplasms (SI-NEN) with extensive mesenteric metastases. This approach, combined with neoadjuvant therapy, showed no disease recurrence at 48 months post-transplant.
Area of Science:
- Oncology
- Transplantation Surgery
- Nuclear Medicine
Background:
- Small intestinal neuroendocrine neoplasms (SI-NEN) often present with metastatic disease, posing challenges for surgical resection.
- Multivisceral transplantation is a complex procedure for conventionally unresectable tumors, with its efficacy remaining debated.
- Sentinel flaps using donor skin are a novel approach to monitor rejection and tailor immunosuppression in transplantation.
Observation:
- A patient with inoperable, extensive mesenteric metastases from SI-NEN was treated with neoadjuvant peptide receptor radionuclide therapy.
- The patient subsequently underwent a modified multivisceral transplant that included a vascularized sentinel forearm flap.
- This represents the first reported case of this combined therapeutic strategy.
Findings:
- The patient experienced no evidence of disease recurrence at 48 months post-transplantation.
- Tumor biochemistry and radiological imaging confirmed the absence of recurrence.
- The patient maintained full physical activity, indicating a successful functional outcome.
Implications:
- This case highlights the potential of combining neoadjuvant peptide receptor radionuclide therapy with modified multivisceral transplantation and sentinel flaps for advanced SI-NEN.
- The sentinel flap approach may offer a valuable method for monitoring rejection and guiding immunosuppression in complex transplant cases.
- Further research is warranted to explore the broader applicability and long-term outcomes of this innovative treatment paradigm for neuroendocrine neoplasms.
